WSR 00-03-075

PROPOSED RULES

DEPARTMENT OF HEALTH


[ Filed January 19, 2000, 9:56 a.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 96-21-118.

Title of Rule: WAC 246-976-001 to 246-976-450 and 246-976-910 to 246-976-990, excluding 246-976-935, rules pertaining to emergency medical and trauma prevention including training, certification, licensure, verification, trauma registry and system administration.

Purpose: Research has shown that a system approach to the prehospital delivery of EMS and trauma care and the subsequent provision of definitive care at facilities equipped to handle such patients reduces death and disability. These rules provide for a consistent, coordinated and preplanned response by quality trained, certified prehospital provider agencies, and definitive care facilities to the needs of the ill and injured patient.

Statutory Authority for Adoption: Chapters 18.71, 18.73, and 70.168 RCW.

Statute Being Implemented: Chapters 18.71, 18.73, and 70.168 RCW.

Summary: These rules identify the duties and responsibilities of the secretary of the Department of Health and his/her delegates, so as to maintain a state-wide program of emergency medical care. They establish the minimum standards and training for first responders, emergency medical technicians, IV technicians, airway technicians, intermediate life support technicians and paramedics, and minimum standards for ambulance services, ambulances, aid vehicles, aid services, and emergency medical equipment.

Reasons Supporting Proposal: The WAC revisions will address: (a) Correcting some education inconsistencies in the curriculum between the various levels, (b) reviewing and updating the curriculum, (c) reviewing certification requirements, (d) review trauma registry and system administration and their responsibilities, and (e) housekeeping problems that improve the structure, grammar, organization and unnecessary repetition of the WAC or statute.

Name of Agency Personnel Responsible for Drafting: Shane Sanderson, 2725 Harrison Avenue N.W., Olympia, WA, (360) 705-6727; Implementation and Enforcement: Steve Bowman, Rick Buell, Jack Cvitanovic, 2725 Harrison Avenue N.W., Olympia, WA, (360) 705-6700.

Name of Proponent: Department of Health, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: These rules provide for a consistent, coordinated and preplanned response by quality trained, certified prehospital provider agencies, and definitive care facilities to the needs of the ill and injured patient. Chapters 18.71, 18.73 and 70.168 require the department to establish these rules. Prior to this no standards were defined in statute. These rules are the only way to establish standards for the response to and delivery of the ill and injured patient to the appropriate definitive care facility.

Proposal Changes the Following Existing Rules: The WAC revisions will address: (a) Correcting some educational inconsistencies in the curriculum between the various levels, (b) reviewing and updating the curriculum, (c) reviewing certification requirements, (d) review trauma registry and system administration and their responsibilities, and (e) housekeeping problems that improve the structure, grammar, organization and unnecessary repetition of the WAC or statute.

No small business economic impact statement has been prepared under chapter 19.85 RCW. According to RCW 19.85.020, "small business" means any business entity, including a sole proprietorship, corporation, partnership, or other legal businesses, that has the purpose of making a profit, and has fifty or fewer employees. All agencies that these rules pertain to have fifty or more employees, or are a nonprofit organization.

RCW 34.05.328 applies to this rule adoption. These rules are legislatively significant because: (1) They subject program ineligibility for not complying with the rule (i.e. prehospital agencies may not respond and/or transport trauma patients unless licensed as a verified agency) and (2) the rule establishes qualifications or processes for program eligibility.

Hearing Location: Department of Health, Office of EMS and Trauma, Large Training Room, 2725 Harrison Avenue N.W., Suite 500, Olympia, WA 98504, on February 23, 2000, at 9:00 a.m.

Assistance for Persons with Disabilities: Contact Tami Schweppe by February 14, 2000, TDD (800) 833-6388, or (360) 705-6748.

Submit Written Comments to: Janet Griffith, Director, P.O. Box 47853, Olympia, WA 98504-7853, fax (360) 705-6706, by February 14, 2000.

Date of Intended Adoption: March 21, 2000.

January 18, 2000

M. C. Selecky

Secretary

OTS-3487.3


AMENDATORY SECTION(Amending Order 323, filed 12/23/92, effective 1/23/93)

WAC 246-976-001
((Declaration of)) Purpose.

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/TC personnel and services.

(1) ((This chapter sets forth standards governing the state-wide emergency medical services and trauma care (EMS/TC) system in order to:

(a) Prevent unnecessary death and disability from trauma and emergency illness;

(b) Provide optimal care for the trauma patient;

(c) Contain costs of EMS/TC, and EMS/TC system implementation; and

(d) Pursue trauma prevention activities to decrease the incidence of trauma.

(2))) This chapter establishes criteria for:

(a) ((Basic life support training and certification;

(b) Advanced life support training and certification;

(c) Ambulance licensing and inspection;

(d) The verification process for prehospital services/agencies providing EMS/TC;

(e) The)) Training and certification of basic, intermediate and advanced life support technicians;

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

(c) Verification of prehospital trauma services;

(d) Development and operation of a state-wide trauma registry;

(((f))) (e) The designation process ((of health care facilities to provide)) and operating requirements for designated trauma care services;

(((g) Operation requirements for all levels of trauma care facilities;

(h))) (f) A state-wide emergency medical communication system;

(((i))) (g) Administration of the state-wide EMS/TC system ((administration)).

(3) This chapter ((is not intended to constitute)) does not contain detailed procedures ((for implementation of)) to implement the state EMS/TC system. Request procedures ((and)), guidelines ((are available on request)), or any publications referred to in this chapter from the Office of ((EMS and Trauma Systems)) Emergency Medical and Trauma Prevention, Department of Health, Olympia, WA 98504-7853 or on the internet at www.doh.wa.gov.

[Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-001, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending WSR 96-03-052, filed 1/12/96, effective 2/12/96)

WAC 246-976-010
Definitions.

((Unless a different meaning is plainly required by the context)) Definitions in RCW 18.71.200, 18.71.205, 18.73.030, and 70.168.015 apply to this chapter. In addition, unless the context plainly requires a different meaning, the following words and phrases used in this chapter ((shall have the meanings indicated)) mean:

"ACLS" means advanced cardiac life support, a course developed by the American Heart Association.

"Activation of the trauma system" means ((a process whereby a prehospital provider identifies the major trauma patient by using the prehospital trauma triage procedures, and notifies from the field both dispatch and medical control, who mobilize)) mobilizing resources to care for ((the)) a trauma patient in accordance with regional patient care procedures. When the prehospital provider identifies a major trauma patient, using approved prehospital trauma triage procedures, he or she notifies both dispatch and medical control from the field.

(("Advanced life support" means invasive emergency medical services requiring advanced medical treatment skills as defined in chapter 18.71 RCW.)) "Adolescence" means the period of physical and psychological development from the onset of puberty to maturity, approximately twelve to eighteen years of age.

"Advanced first aid," for the purposes of RCW 18.73.120, 18.73.150, and 18.73.170, means a course of at least twenty-four hours of instruction, which includes at least:

CPR;

Airway management;

Trauma/wound care;

Immobilization.

"Agency response time" means the ((time)) interval from agency notification to arrival on the scene. It is the ((same as the)) combination of activation and enroute times defined under system response times in this section.

"Aid service" means an agency((, public or private, that operates)) licensed by the department to operate one or more aid vehicles, consistent with regional and state plans.

(("Aid vehicle" means a vehicle used to carry aid equipment and individuals trained in first aid or emergency medical procedure.

"Air ambulance" means a fixed or rotary-winged aircraft that is configured to accommodate a minimum of one litter and two medical attendants with sufficient space to provide intensive life-saving care without interfering with the performance of the flight crew, and has been inspected and licensed by the department as an air ambulance.

"Airway technician" means a person certified to provide mobile airway management as defined in this chapter.

"Ambulance" means a ground or air vehicle designed and used to transport the ill and injured and to provide personnel, facilities, and equipment to treat patients before and during transportation.)) "Airway technician" means a person who:

Has been trained in an approved program to perform endotracheal airway management and other authorized aids to ventilation under written or oral authorization of an MPD or approved physician delegate; and

Has been examined and certified as an airway technician by the department or by the University of Washington's school of medicine.

"ALS" means advanced life support.

"Ambulance service" means an agency((, public or private, that operates)) licensed by the department to operate one or more ground or air ambulances. Ground ambulance service operation must be consistent with regional and state plans. Air ambulance service operation must be consistent with the state plan.

"Approved" means approved by the department of health.

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

"Attending surgeon" means a physician who is board-certified ((or board-eligible)) 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.

"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.

"BLS" means basic life support.

"Basic life support" means noninvasive emergency medical services requiring basic medical treatment skills as defined in chapter 18.73 RCW.

"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 have graduated less than five years previously from a residency program accredited for the appropriate specialty by the Accreditation Council for Graduate Medical Education.

"BP" means blood pressure.

"Certification" means ((recognition by the department of the competence of an individual who)) the department recognizes that an individual has met predetermined qualifications, and ((the authorization of)) authorizes the individual to perform certain procedures ((for which they have been trained or are otherwise qualified)).

"CME" means continuing medical education.

(("Communications system" means a radio and landline network which provides rapid public access, coordinated central dispatching of services, and coordination of personnel, equipment, and facilities in an EMS/TC system.))

"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, licensing and certification committee, or regional or local EMS/TC councils.

"Continuing medical education (CME)" means ongoing education after initial certification ((for the purpose of maintaining and enhancing)) to maintain and enhance skill and knowledge.

(("Council" means the local or regional EMS/TC council as authorized under chapter 70.168 RCW.

"Course coordinator" means an individual who has overall administrative responsibility for coordinating an EMS/TC course or program of continuing education.))

"CPR" means cardiopulmonary resuscitation.

(("Department" means the department of health.

"Designated trauma care service" means a level I, II, III, IV, or V trauma care service, or level I, II, or III pediatric trauma care service, or level I, I-pediatric, II, or III trauma-related rehabilitative service.

"Designation" means a formal determination by the department that a hospital or health care facility is capable of providing designated trauma care services as authorized in RCW 70.168.070.))

"Dispatch" means to ((designate)) identify and direct an emergency response unit to ((a service)) an incident location.

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

"ED" means emergency department.

(("Emergency medical dispatch (EMD)" means provision of special procedures and trained personnel to ensure the efficient handling of medical emergencies and dispatch of aid. It includes prearrival instructions for CPR and other verbal aid to callers.

"Emergency medical service (EMS)" means medical treatment and care which may be rendered at the scene of any medical emergency or while transporting any patient in an ambulance to an appropriate medical facility, including ambulance transportation between medical facilities.

"Emergency medical services and trauma care (EMS/TC) planning and services regions" means geographic areas established by the department in accordance with RCW 70.168.110.))

"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 service and trauma care system includes prevention activities, prehospital care, hospital care, and rehabilitation. ((The components of an EMS and trauma care system include:

Provision of manpower;

Training of personnel;

Communications;

Transportation;

Facilities;

Critical care units;

Use of public safety agencies;

Use of private agencies;

Consumer participation;

Accessibility to care;

Transfer of patients;

Standard medical recordkeeping and reporting;

Consumer information and education;

Independent review and evaluation, including formal quality assurance programs;

Disaster linkage; and

Mutual aid agreements.

"Emergency medical services and trauma care system plan (EMS/TC plan)" means a plan that identifies state-wide EMS/TC objectives and priorities and identifies equipment, facility, personnel, training, and other needs required to create and maintain a state-wide EMS/TC.

"Emergency medical technician (EMT)" means a person who is authorized by the secretary to render emergency medical care pursuant to RCW 18.73.081.)) "EMS" means emergency medical services.

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

"EMT" means emergency medical technician.

(("Facility patient care protocols" means the written procedures adopted by the medical staff that direct the care of the patient. These procedures shall be based upon the assessment of the patient's medical needs. The procedures shall follow minimum state-wide standards for trauma care service.

"First responder" means a person who is authorized by the secretary to render emergency medical care as defined by RCW 18.73.081.

"HIV/AIDS" means human immunodeficiency virus/acquired immunodeficiency syndrome.

"Hospital" means a facility licensed under chapter 70.41 RCW, or comparable health care facility operated by the federal government or located and licensed in another state.

"Hospital trauma service" means a service designed by the hospital within state guidelines for the treatment of trauma patients, including a formal commitment by the hospital and medical staff to an organized trauma care system and to participation in the regional/state system.)) "General surgeon" means a licensed physician who has completed a residency program in surgery and who has surgical privileges delineated by the facility.

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

(("ICU" means intensive care unit.

"Indicator" means a quality improvement tool or performance measure used to monitor the quality of important governance, management, clinical, and support processes and outcomes.

"Indicator monitoring system" means a method in which indicators are used to monitor important processes or outcomes of care or service, and indicator data are used to evaluate that care.)) "ILS" means intermediate life support.

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

(("Intermediate life support technician" means a person certified to provide levels of intermediate support skills as defined in this chapter.

"IV technician" means a person certified to provide mobile intravenous therapy as defined in this chapter.

"L&C" means licensing and certification.

"Legend drug" means any drug which is required by state law or regulation by the state board of pharmacy to be dispensed on prescription only, or is restricted to use by practitioners only.

"Level I pediatric rehabilitative services" means rehabilitative services as defined by RCW 70.168.015. Facilities providing level I pediatric rehabilitative services provide the same services as facilities authorized to provide level I rehabilitative services, except these services are exclusively for children under the age of fifteen years.

"Level I pediatric trauma care services" means pediatric trauma care services as defined by RCW 70.168.015. Hospitals providing level I services shall provide definitive, comprehensive, specialized care for pediatric trauma patients and shall also provide ongoing research and health care professional education in pediatric trauma care.

"Level II pediatric trauma care services" means pediatric trauma care services as defined by RCW 70.168.015. Hospitals providing level II services shall provide initial stabilization and evaluation of pediatric trauma patients and provide comprehensive general medical and surgical care to pediatric patients who can be maintained in a stable or improving condition without the specialized care available in the level I hospital. Complex surgeries and research and health care professional education in pediatric trauma care activities are not required.

"Level III pediatric trauma care services" means pediatric trauma care services as defined by RCW 70.168.015. Hospitals providing level III services shall provide initial evaluation and stabilization of patients. The range of pediatric trauma care services provided in level III hospitals is not as comprehensive as level I and II hospitals.

"Level I rehabilitative services" means rehabilitative services as defined by RCW 70.168.015. Facilities providing level I rehabilitative services provide rehabilitative treatment to patients with traumatic brain injuries, spinal cord injuries, complicated amputations, and other diagnoses resulting in functional impairment, with moderate to severe impairment or complexity. These facilities serve as referral facilities for facilities authorized to provide level II and III rehabilitative services.

"Level II rehabilitative services" means rehabilitative services as defined by RCW 70.168.015. Facilities providing level II rehabilitative services treat individuals with musculoskeletal trauma, peripheral nerve lesions, lower extremity amputations, and other diagnoses resulting in functional impairment in more than one functional area, with moderate to severe impairment or complexity.

"Level III rehabilitative services" means rehabilitative services as defined by RCW 70.168.015. Facilities providing level III rehabilitative services provide treatment to individuals with musculoskeletal injuries, peripheral nerve injuries, uncomplicated lower extremity amputations, and other diagnoses resulting in functional impairment in more than one functional area but with minimal to moderate impairment or complexity.

"Level I trauma care services" means trauma care services as defined by RCW 70.168.015. Hospitals providing level I services shall have specialized trauma care teams and provide ongoing research and health care professional education in trauma care.

"Level II trauma care services" means trauma care services as defined by RCW 70.168.015. Hospitals providing level II services shall be similar to those provided by level I hospitals, although complex surgeries and research and health care professional education activities are not required to be provided. This does not exclude education or training of prehospital providers.

"Level III trauma care services" means trauma care services as defined by RCW 70.168.015. The range of trauma care services provided by level III hospitals are not as comprehensive as level I and II hospitals.

"Level IV trauma care services" means trauma care services as defined by RCW 70.168.015.

"Level V trauma care services" means trauma care services as defined by RCW 70.168.015. Facilities providing level V services shall provide stabilization and transfer of all patients with potentially life-threatening injuries.)) "Interfacility transport" means medical transport of a patient between recognized medical treatment facilities requested by a licensed health care provider.

"Intermediate life support (ILS) technician" means a person who:

Has been trained in an approved program to perform specific phases of advanced cardiac and trauma life support as specified in this chapter, under written or oral direction of an MPD or approved physician delegate; and

Has been examined and certified as an ILS technician by the department or by the University of Washington's school of medicine.

"Intravenous therapy technician" means a person who:

Has been trained in an approved program to initiate IV access and administer intravenous solutions under written or oral authorization of an MPD or approved physician delegate; and

Has been examined and certified as an intravenous therapy technician by the department or by the University of Washington's school of medicine.

"IV" means intravenous.

"Licensing and certification committee (L&C committee)" means the emergency medical services licensing and certification advisory committee created by RCW 18.73.040.

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

"Local medical community" means the organized local medical society existing in a county or counties; or in the absence of an organized medical society, majority physician consensus in the county or counties.

"Medical control" means MPD authority to direct the medical care provided by ((all)) certified EMS personnel ((involved in patient care)) in the prehospital EMS system.

"Medical control agreement" means a written agreement between two or more MPDs, using similar protocols that are consistent with regional plans, to assure continuity of patient care between counties, and to facilitate assistance.

(("Medical program director (MPD)" means an approved emergency medical services medical program director as defined by RCW 18.71.205(4).))

"MPD" means medical program director.

(("Name code" means the first four letters of the last name, followed by the first and middle initials.

"National uniform data set" means a coding system which describes the functional abilities and disabilities of the disabled person, published by the State University of New York, Buffalo, NY.

"Ongoing training and evaluation" means a course of education as authorized in RCW 18.73.081 (3)(b).)) "Must" means shall.

"PALS" means pediatric advanced life support, a course developed by the American Heart Association.

"Paramedic" means a person ((certified to provide mobile intensive care paramedic services as defined in RCW 18.71.200(3))) 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; and

Has been examined and certified as a paramedic by the department or by the University of Washington's school of medicine.

(("Patient care procedures" means written operating guidelines adopted by the regional EMS/TC council, in consultation with local EMS/TC councils, emergency communications centers and the MPDs, in accordance with state-wide minimum standards. The patient care procedures 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 to first receive the patient, and the name and location of other trauma care facilities to receive the patient should an interfacility transfer be necessary. Procedures on interfacility transfer of patients shall be consistent with the transfer procedures in chapter 70.170 RCW.

"Pediatric trauma patient" means trauma patients known or estimated to be less than fifteen years of age.))

"Physician" means an individual licensed under the provisions of chapters 18.71 or 18.57 RCW((, Physicians, or under the provisions of chapter 18.57 RCW, Osteopathy -- Osteopathic medicine and surgery)).

"Practical examination" means a test ((which is)) conducted in ((the)) an initial course, or a test or series of evaluations during a recertification period, ((wherein the competency of a person is determined on)) to determine competence in each of the practical skills specified by the department.

(("Prehospital" means emergency medical care or transportation rendered to patients prior to hospital admission or during interfacility transfer by licensed ambulance or aid service under chapter 18.73 RCW, by personnel certified to provide emergency medical care under chapters 18.71 and 18.73 RCW, or by facilities providing level V trauma care services as provided for in chapter 18.71 RCW.))

"Prehospital agencies" means ((both public and private)) providers of prehospital care or interfacility transport.

"Prehospital index" means a scoring system ((for hospital trauma team activation, incorporating)) used to activate a hospital trauma resuscitation team. It incorporates assessment of systolic blood pressure, pulse, respiratory status, and level of consciousness, as described in "Prehospital Index: A scoring system for field triage of trauma victims," Koehler, John J., M.D. et al. Annals of Emergency Medicine 1986; 15:178-182.

"Prehospital patient care protocols" means the written procedures adopted by the MPD under RCW 18.73.030(13) and 70.168.015(26) which direct the out-of-hospital emergency care of the emergency patient which includes the trauma care patient. These protocols are related only to direct hands-on patient care.

"Prehospital trauma care services" means ((both public and private)) agencies that are verified to provide prehospital trauma care.

"Prehospital trauma triage procedures" means the method used by prehospital providers to evaluate injured patients and determine whether to activate the trauma system. It is described in WAC 246-976-930(2).

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

"Quality assurance (QA)" means an organized ((method of auditing and evaluating care provided within EMS/TC systems.

"Reciprocity" means the process by which an individual certified in another state, or certified by the University of Washington's school of medicine as authorized by RCW 18.71.200, is certified by the department.

"Region" means a geographic area used for EMS/TC planning, designated by the department in accordance with RCW 70.168.110)) quality assessment and improvement program to audit and evaluate care provided in EMS/TC systems, with the goal of improving patient outcomes.

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

"Regional patient care procedures (RPCP)" means procedures adopted by a regional council under RCW 18.73.030(14) and 70.168.015(23), and approved by the department. Regional patient care procedures do not relate to hands-on patient care.

"Regional plan" means the ((approved plan that identifies region-wide EMS/TC objectives and prioritizes and identifies equipment, facilities, personnel, training, and other needs required to create and maintain a region-wide EMS/TC system. The plan includes a strategy of implementation that identifies regional and local activities to create, operate, maintain, and enhance the system)) plan defined in WAC 246-976-960 (1)(b) that has been approved by the department.

"Registered nurse" means an individual licensed under the provisions of chapter ((18.88)) 18.79 RCW.

(("Rehabilitative services" means a formal program of multidisciplinary, coordinated, and integrated services for evaluation, treatment, education, and training to help individuals with disabling impairments achieve and maintain optimal functional independence in physical, psychosocial, social, vocational, and avocational realms.

"Reinstatement" means the process by which an individual whose EMS certification has expired can be recertified.))

"Response area" means a service coverage zone identified in an approved regional plan.

"Rural" means unincorporated or incorporated areas with total populations less than ten thousand people, or with a population density of less than one thousand people per square mile.

"Senior EMT instructor (SEI)" means an individual approved to be responsible for the quality of instruction ((of an initial EMS training course)) and the conduct of basic life support training courses.

"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:

For physicians, by the facility's medical staff;

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

For physician assistants and advanced registered nurse practitioners, as defined in the facility's bylaws.

"Specialized training" means approved training of certified EMS personnel to use a skill, technique, or equipment that is not included in the standard course curriculum.

(("State trauma registry" means data collected for examining the entire spectrum of trauma patients and their care, regardless of injury, hospital, or outcome.)) "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).

"Steering committee" means the EMS/TC steering committee created by RCW 70.168.020.

"Suburban" means an incorporated or unincorporated area with a population of ten thousand to twenty-nine thousand nine hundred ninety nine or any area with a population density of one thousand to two thousand people per square mile.

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

"Discovery time": The interval from injury to discovery of the injury;

"System access time": The ((time)) interval from discovery to call received;

"911 time": The interval from call received to dispatch notified, including the time it takes the call answerer to:

Process the call, including citizen interview; and

Give the information to the dispatcher;

"Dispatch time": The ((time)) interval from call received by the dispatcher to ((the time the agency is notified)) agency notification;

"Activation time": The ((time)) interval from agency notification to start of response;

"Enroute time": The ((time)) interval from the end of activation time to the beginning of on-scene time;

"Patient access time": The interval from the end of enroute time to the beginning of patient care;

"On scene time": The ((time the unit is on the scene with the patient)) interval from arrival at the scene to departure from the scene. This includes extrication, resuscitation, treatment, and loading;

"Transport time": The ((time)) interval from leaving the scene to arrival at a health care facility;

"Training agency" means an organization or individual((, which may include local or regional EMS/TC councils, that is approved to train EMS personnel for initial certification)) that is approved to be responsible for specified aspects of training of EMS personnel.

"Training physician" means a physician delegated by the MPD and approved by the department to be responsible for specified aspects of training of EMS personnel.

(("Trauma" means a major single or multisystem injury requiring immediate medical or surgical intervention or treatment to prevent death or permanent disability.

"Trauma care system" means an organized approach to providing care to trauma patients that provides personnel, equipment, and facilities for effective and coordinated trauma care. The trauma care system includes: Prevention, prehospital care, triage of trauma victims from the scene to designated trauma services, facilities with specific capabilities to provide trauma care, acute hospital care, and rehabilitation services.))

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

(("Trauma surgeon" means a physician who is board certified or board eligible in general surgery, and who has trauma surgery privileges delineated by the facility's medical staff.

"Triage" means the sorting of patients in terms of disposition, destination, or priority. Triage of prehospital trauma victims requires identifying injury severity so that the appropriate care level can be readily assessed according to patient care guidelines.

"Unit of learning" means a method of meeting the CME requirements of this chapter, which includes:

Approved learning objectives that reflect a complete patient care approach and to a topic or group of related topics; and

Measures a student's comprehension of the subject matter by written testing and demonstration of skills.))

"Urban" means:

An incorporated area over thirty thousand; or

An incorporated or unincorporated area of at least ten thousand people and a population density over two thousand people per square mile.

(("Verification" means the identification of prehospital providers capable of providing verified trauma care services, and is part of the licensure process described in chapter 18.73 RCW.

"Verified trauma care service" means prehospital services as provided for in RCW 70.168.080, and identified in the regional EMS/TC plan as required by RCW 70.168.100, whose capabilities have been verified by the department.))

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

[Statutory Authority: Chapter 18.71 RCW. 96-03-052, 246-976-010, filed 1/12/96, effective 2/12/96. Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-010, filed 12/23/92, effective 1/23/93.]

((CERTIFICATION)) TRAINING
NEW SECTION
WAC 246-976-021
Training course requirements.

(1) Department responsibilities: The department will publish procedures for agencies to conduct EMS training courses, including:

(a) The registration process;

(b) Requirements, functions, and responsibilities of course instructional and administrative personnel;

(c) Necessary information and administrative forms to conduct the course;

(2) Training agency responsibilities:

(a) General. Agencies providing initial training of certified EMS personnel at all levels (except advanced first aid) must:

(i) Have MPD approval for the course content;

(ii) Have MPD approval for all instructional personnel, who must be experienced and qualified in the area of training;

(iii) Have local EMS/TC council recommendation for each course;

(iv) Have written approval from the department to conduct each course;

(v) Approve or deny applicants for training consistent with the prerequisites for applicants in WAC 246-976-041 and 246-976-141.

(b) Basic life support (first responder, EMT). Agencies providing initial training of basic life support personnel must identify a senior EMS instructor to be responsible for the quality of instruction and the conduct of the course.

(c) Intermediate life support (IV, airway and ILS technicians). Agencies providing initial training of intermediate life support personnel must:

(i) Have a written agreement with the clinical facility, if it is separate from the academic facility;

(ii) Ensure that clinical facilities provide departments or sections, personnel, and policies, including:

(A) Written program approval from the administrator and chief of staff;

(B) A written agreement to participate in continuing education;

(C) Supervised clinical experience for students during the clinical portion of the program;

(D) An orientation program.

(d) Paramedics. Agencies training paramedics must be accredited by a national accrediting organization approved by the department.

(3) Course curriculum. The department recognizes the following National Standard EMS training courses published by the United States Department of Transportation as amended by the department:

(a) First responder: The first responder training course published 1996, amended by the department March 1998;

(b) EMT: The emergency medical technician -- Basic training course published 1994, amended by the department February 1999;

(c) IV technician: Those parts of the emergency medical technician -- Intermediate course published 1999 which relate to intravenous therapy lessons 1-1, 1-2, 1-3, 2-1, 2-2, 2-3, 2-6, 2-7, 3-2, 3-3, 4-1, and 4-2; amended by the department February 1999;

(d) Airway technician: Those parts of the emergency medical technician -- Intermediate course published 1999 which relate to airway management lessons 1-1, 1-2, 1-3, 2-1, 2-2, 2-3, 2-5, 3-2, 3-3, 4-1, and 4-2; amended by the department February 1999;

(e) ILS technician: Those parts of the emergency medical technician -- Intermediate course published 1999 which relate to IV therapy and intraosseous infusion, the use of multi-lumen airway adjuncts, and the following medications:

(i) Epinephrine for anaphylaxis administered by a commercially preloaded measured-dose device;

(ii) Albuterol administered by inhalation;

(iii) Dextrose 50% and 25%;

(iv) Nitroglycerine, sublingual and/or spray;

(v) Naloxone;

(vi) Aspirin PO (oral), for suspected myocardial infarction lessons 1-1, 1-2, 1-3, 2-1, 2-2, 2-3, 2-4, 2-6, 2-7, 3-1, 3-2, 3-3, 4-1, and 4-2; amended by the department February 1999;

(f) Paramedic: The emergency medical technician --Paramedic training course published 1995.

(4) Initial training for first responders and EMTs must also include approved infectious disease training that meets the requirements of chapter 70.24 RCW.

(5) Specialized training. The department, in conjunction with the advice and assistance of the L&C committee, may approve specialized training for certified EMS personnel to use skills, techniques, or equipment that is not included in standard course curricula. Agencies providing specialized training must have MPD and department approval of:

(a) Course curriculum;

(b) Lesson plans;

(c) Course instructional personnel, who must be experienced and qualified in the area of training;

(d) Student selection criteria;

(e) Criteria for satisfactory completion of the course, including student evaluations and/or examinations;

(f) Prehospital patient care protocols that address the specialized skills.

(6) Local government agencies: The department recognizes county agencies established by ordinance and approved by the MPD to coordinate EMS training. These agencies must comply with the requirements of this section.

[]


NEW SECTION
WAC 246-976-031
Senior EMS instructor (SEI).

(1) Responsibilities. The SEI is responsible for the overall instructional quality of the course, under the general supervision of the MPD. The SEI must conduct courses following department-approved curricula, and follow the department's policies, procedures and administrative requirements.

(2) Qualifications. The department will publish procedures to recognize senior EMS instructors (SEIs).

(3) Initial recognition. To apply for initial recognition as a SEI, submit to the department:

(a) Proof of high school graduation, GED or equivalent;

(b) Proof of current Washington certification as an EMT or above;

(c) Proof of at least three years prehospital EMS experience at the EMT level or above;

(d) Proof of at least one recertification;

(e) Proof of current recognition as a CPR instructor for health care providers by the American Heart Association, the American Red Cross, the National Safety Council, or other nationally recognized organization with substantially equivalent standards to any of the above mentioned;

(f) Successful completion of an approved instructor workshop;

(g) Experience assisting with two EMT courses, performing a minimum of three hours of lectures and six hours of practical skills in each course;

(h) Recommendation by the local EMS/TC council;

(i) Recommendation by the MPD.

(4) Renewal of recognition. Recognition as a SEI is for three years. To renew recognition, submit to the department:

(a) Proof of current Washington state EMS certification as an EMT or above;

(b) Proof of current or previous recognition as a senior EMS instructor;

(c) Proof of current recognition as a CPR instructor for health care providers by a nationally recognized organization approved by the department;

(d) Recommendation by the local EMS/TC council;

(e) Recommendation by the MPD.

[]


NEW SECTION
WAC 246-976-041
To apply for training.

(1) You must meet all requirements for certification, EXCEPT that current membership in an EMS/TC agency is not required for acceptance into an initial training course.

(2) You must be at least eighteen years old at the beginning of the course.

(3) For training at the intermediate (IV, airway and ILS technicians) and advanced life support (paramedic) levels, you must have completed at least one year as a certified EMT or above.

[]

CERTIFICATION
NEW SECTION
WAC 246-976-141
To apply for certification.

(1) Department responsibilities. The department will publish procedures for initial certification which include:

(a) Examinations. An applicant may have up to three attempts within six months after course completion to successfully complete the examinations;

(b) The process for administration of examinations; and

(c) Administrative requirements and the necessary forms.

(2) Applicant responsibilities. To apply for initial certification, submit to the department:

(a) An application for certification on forms provided by the department;

(b) Proof of identity: An official photo identification (which may be state, federal or military identification, drivers' license, or passport);

(c) Proof of age;

(d) Proof of completion of an approved course or courses for the level of certification sought;

(e) Proof of completion of approved infectious disease training to meet the requirements of chapter 70.24 RCW;

(f) Proof of successful completion of an approved examination within eighteen months prior to application;

(g) Proof of active membership, paid or volunteer, in one of the following EMS/TC organizations:

(i) Licensed provider of aid or ambulance services;

(ii) Law enforcement agency; or

(iii) Other affiliated EMS/TC service;

(h) The MPD's recommendation for certification;

(i) For EMTs, proof of high school graduation, GED, or equivalent;

(j) Other information required by this chapter.

(3) Certification is effective on the date the department issues the certificate, and will be valid for three years except as extended by the department for the efficient processing of license renewals. The expiration date will be indicated on the certification card.

(4) Certification of intermediate level technicians and paramedics is valid only:

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

(b) In other counties where formal EMS/TC medical control agreements are in place; or

(c) In other counties when accompanying a patient in transit from a county meeting the criteria in (a) or (b) of this subsection.

[]


NEW SECTION
WAC 246-976-151
Reciprocity, challenges, reinstatement and other actions.

(1) The department will publish procedures for:

(a) Reciprocal certification of individuals with current EMS certification in another state, or who are currently recognized by a national accrediting agency approved by the department.

(i) All applicants must pass an approved examination;

(ii) Paramedics whose training started after June 30, 1996, must have successfully completed a course accredited by a national accrediting organization approved by the department, and be currently recognized by a national accrediting agency approved by the department;

(b) Reinstatement of individuals whose Washington state EMS/TC certification has lapsed, or been suspended or revoked;

(c) Challenge of prerequisites for certification examinations by individuals who have not completed the course work and practical training required by this chapter, but who document equivalent EMS training and/or experience;

(d) Voluntary reversion from a level of certification to a lower level of certification.

(2) Before granting reciprocity, reinstatement, or challenge, the department will verify that infectious disease training required for EMS/TC personnel by chapter 70.24 RCW has been accomplished.

[]


NEW SECTION
WAC 246-976-161
Continuing medical education (CME) and skills maintenance.

(1) General requirements. See Tables A and B. You must document your annual CME and skills maintenance requirements, as indicated in the tables. You must complete all CME and skills maintenance requirements for your current certification period to be eligible for recertification.

(2) You must complete the number of MPD-approved CME hours appropriate to your level of certification, as indicated in Table A.

(3) You must demonstrate proficiency in certain critical skills, indicated in Table B, to the satisfaction of the MPD:

(4) IV starts.

(a) During your first year of certification as an IV technician, combined IV/airway technician, ILS technician, or paramedic, you must perform a minimum of thirty-six successful IV starts. EXCEPTION: If you have completed a certification period as an IV or ILS technician, you do not need to meet this requirement during your first year of certification as a paramedic.

(b) By the end of your initial certification period, you must perform a minimum of one hundred eight successful IV starts.

(5) Intubations.

(a) During your first year of certification as an airway technician, combined IV/airway technician, combined ILS/airway technician or paramedic, you must perform a minimum of twelve successful endotracheal intubations. EXCEPTION: If you have completed a certification period as an airway technician, you do not need to meet this requirement during your first year of certification as a paramedic.

(b) By the end of your initial certification period, you must perform a minimum of thirty-six successful endotracheal intubations.

(6) Description of selected terms used in the table:


TABLE A:

CME REQUIREMENTS

Basic Life Support
Intermediate Life Support
Paramedic
FR
EMT
IV
Air
IV/Air
ILS
ILS/Air
Paramedic
Annual
CPR & Airway X X X X X X X
Spinal Immobilization X X X X X X X
Patient Assessment
X
X
X
X
X
X
X

Certification Period
Infectious Disease X X X X X X X X
Trauma X X X X X X X
Pharmacology X X X X X X
Pediatrics X 2 hrs 2 hrs 2 hrs 2 hrs 2 hrs 2 hrs 6 hrs
Other CME, for a total of: 15 hrs 30 hrs 45 hrs 45 hrs 60 hrs 60 hrs 75 hrs 150 hrs

TABLE B:

SKILLS MAINTENANCE REQUIREMENTS

Intermediate Life Support
Paramedic
IV
Air
IV/Air
ILS
ILS/Air
Paramedic
First Certification Period
First Year of Certification
IV Starts - may not be averaged (see par 4) 36 36 36 36 36
Endotracheal intubations - may not be averaged (see par 5) 12 12 12 12
Demonstrate intraosseous infusion proficiency X X X X X
Second and Third Years of Certification
IV Starts - average (see par 4) 36 36 36 36 36
Endotracheal intubations - average (see par 5) 12 12 12 12
Demonstrate intraosseous infusion proficiency X X X X X
During the Certification Period
Demonstrate pediatric airway proficiency X X X X
Multi-Lumen Airway per MPD per MPD
Defibrillation
per MPD
per MPD
Later Certification Periods
Annual Requirements
IV Starts - demonstrate proficiency X X X X X
Endotracheal intubations - average (see par 4) 4 4 4 4
Demonstrate intraosseous infusion proficiency X X X X X
During the Certification Period
Demonstrate pediatric airway proficiency X X X X
Multi-Lumen Airway per MPD per MPD
Defibrillation per MPD per MPD

Infectious disease: Infectious disease training must meet the requirements of chapter 70.24 RCW and WAC 296-62-08001 (7) and (8).

CPR includes the use of airway adjuncts appropriate to the level of certification.

Pharmacology: Pharmacology specific to the medications approved by your MPD (NOT REQUIRED FOR FIRST RESPONDERS).

Pediatrics: This includes patient assessment, CPR and airway management, and spinal immobilization and packaging.

"IV starts": Proficiency in catheter-around-needle insertions performed on sick, injured, or preoperative adult and pediatric patients. With written authorization of the MPD, IV starts may be performed on artificial training aids.

Endotracheal intubation: Proficiency in endotracheal intubations, at least half of which must be performed on human subjects. With written authorization of the MPD, up to half of the intubations may be performed on artificial training aids.

Intraosseous infusion: Proficiency in intraosseous line placement in pediatric patients.

Proficiency: Ability to perform a skill properly, demonstrated to the satisfaction of the MPD.

Pediatric airway: Proficiency in pediatric airway management.

[]


NEW SECTION
WAC 246-976-171
Recertification.

(1) The department will publish procedures for renewal of certification, including:

(a) An ongoing training and evaluation program (OTEP) of skills as authorized in RCW 18.73.081 (3)(b) for first responders and EMTs; or

(b) Examinations for renewal of certification.

(2) To apply for renewal of certification, submit to the department on approved forms:

(a) All the information identified in WAC 246-976-141(2); EXCEPT current certification is considered proof of course completion, age, and initial infectious disease training;

(b) Proof of completion of CME and skills maintenance required for the level of certification sought, as defined in this chapter and identified on the table above. For first responders and EMTs, this includes proof of successful demonstration of skills, by:

(i) Successfully completing an approved OTEP; or

(ii) Passing an approved practical examination within the six months prior to application. An applicant changing from the ongoing training and evaluation program to the practical examination program must take the practical examination prior to the end of the certification period.

[]


NEW SECTION
WAC 246-976-182
Authorized care.

(1) Certified EMS/TC personnel are only authorized to provide patient care that is:

(a) Included in the approved curriculum for the individual's level of certification;

(b) Included in approved specialized training; and

(c) That is included in approved MPD protocols.

(2) When a patient is identified as needing care which is not authorized for the providers, the certified person in charge of that patient must consult with medical control as soon as possible, if protocols and regional patient care procedures do not provide adequate off-line direction for the situation.

(3) For trauma patients, all prehospital providers must follow the approved trauma triage procedures, regional patient care procedures and MPD patient care protocols.

[]


NEW SECTION
WAC 246-976-191
Disciplinary actions.

(1) The department will publish procedures for modification, suspension, revocation, or denial of certification. The procedures will be consistent with the requirements of the Administrative Procedure Act (chapter 34.05 RCW), the Uniform Disciplinary Act (chapter 18.130 RCW), and practice and procedure (chapter 246-10 WAC).

(2) The department will publish procedures:

(a) To investigate complaints and allegations against certified personnel;

(b) For MPDs to recommend corrective action regarding certified individuals.

(3) Before recommending revocation, suspension, modification, or denial of a certificate, the MPD must initiate corrective action with the certified individual, consistent with department procedures.

(4) The MPD may request the department to summarily suspend certification of an individual if the MPD believes that continued certification will be detrimental to patient care.

(5) In cases where the MPD recommends denial of recertification, the department will investigate the individual, and may revoke his or her certification.

(6) If an employing or sponsoring agency disciplines a certified individual for conduct or circumstances as described in RCW 18.130.070, the Uniform Disciplinary Act, the agency must report the cause and the action taken to the department.

[]

LICENSURE AND VERIFICATION
AMENDATORY SECTION(Amending Order 323, filed 12/23/92, effective 1/23/93)

WAC 246-976-260
Licenses required.

(((1) The department shall:

(a) Establish and publish procedures for licensure of ambulance and aid services and ambulance and aid vehicles, consistent with the state plan and approved regional plans;

(b) Not allow the transfer of licenses issued under this chapter.

(2) Applicants for licensure as ambulance or aid services shall submit application to the department following department procedures, including:

(a) Evidence of ability to comply with standards, rules, and regulations of this chapter;

(b) Evidence of operation that is consistent with the state-wide and regional EMS/TC plans and prehospital patient care procedures;

(c) Evidence of liability insurance coverage;

(d) Description of the general area to be served and the number of vehicles to be used.

(3) Licensees shall submit application for renewal of licensure to the department at least thirty days before the expiration of the current license.)) (1) The department will publish procedures to license 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 application forms to the department, including:

(a) A declaration that the service is able to comply with standards, rules, and regulations of this chapter;

(b) A declaration that staffing will meet the personnel requirements of RCW 18.73.150 and 18.73.170;

(c) A declaration that operation will be consistent with the state-wide and regional EMS/TC plans and approved patient care procedures;

(d) Evidence of liability insurance coverage;

(e) A description of the general area to be served and the number of vehicles to be used. The description includes:

(i) The services to be offered (e.g., emergency response and/or interfacility transports);

(ii) The dispatch process, including a backup plan if the primary unit is unavailable;

(iii) A plan for tiered response that is consistent with approved regional patient care procedures;

(iv) A plan for rendezvous with other services that is consistent with approved regional patient care procedures;

(v) A map of the proposed response area;

(vi) The level of service to be provided: BLS, ILS, or paramedic; and the scheduled hours of operation; and

(vii) 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 the approved prehospital trauma triage procedures defined in WAC 246-976-010.

[Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-260, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending Order 323, filed 12/23/92, effective 1/23/93)

WAC 246-976-270
Denial, suspension, revocation of license(( -- Notice, hearing)).

(1) ((Under the provisions of the Administrative Procedure Act, chapter 34.05 RCW, and chapter 246-08 WAC, the department may suspend, modify, or revoke any ambulance or aid vehicle license issued under this chapter, or deny licensure to an applicant, when it finds failure to comply with the requirements of chapter 18.73 RCW, or other applicable laws or rules, or with this chapter.

(2) The Uniform Disciplinary Act, chapter 18.130 RCW, governs the unlicensed practice, the issuance and denial of licenses, and the disciplining of persons who hold licenses to operate ambulance or aid services under this chapter. The secretary is authorized by RCW 18.130.040 to be the disciplining authority under this chapter.)) The department may suspend, modify, or revoke any ambulance or aid service license issued under this chapter, or deny licensure to an applicant when it finds:

(a) Failure to comply with the requirements of chapters 18.71, 18.73, 18.130, or 70.168 RCW, or other applicable laws or rules, or with this chapter;

(b) ((False, fraudulent, or misleading advertising, or any public claim of authorization to provide a level of service for which the licensee is not authorized or licensed;

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

(((d))) (c) Failure to cooperate with the department in inspections or investigations;

(((e))) (d) Failure to supply data as required in chapter 70.168 RCW and this chapter.

(((3) Licensees or applicants may request a hearing to contest department decisions on license denial, suspension, modification, or revocation by filing a written application in accordance with WAC 246-08-020.

(4))) (2) Under the provisions of the Administrative Procedure Act, chapter 34.05 RCW, and the Uniform Disciplinary Act, chapter 18.130 RCW, the department may impose sanctions against a licensed service ((which has not been verified under this chapter, but which routinely responds to trauma incidents and/or renders care to patients of trauma in a manner that is not consistent with the approved regional plan . Such sanctions may include but are not limited to action under RCW 18.73.190 and this chapter which may lead to revocation of the service's license, assessment of fines, and/or filing of misdemeanor charges. (a))) as provided in chapter 18.130 RCW. The department ((shall)) 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.

(((b) This section shall not restrict the authority of a provider licensed under chapter 18.73 RCW to provide services which it has been authorized to provide by state law, except as addressed by chapter 70.168 RCW and specified in the approved regional plan.))

[Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-270, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending Order 323, filed 12/23/92, effective 1/23/93)

WAC 246-976-290
Ground ambulance vehicle standards.

(1) Ground ambulance vehicles purchased and placed into service after December 31, 2000, must meet Federal Specification KKK-A-1822D, published by the General Services Administration, Federal Supply Service Bureau, November 1, 1994, except for color and placarding. Ground ambulance vehicles must also meet all applicable state and federal regulations for emergency vehicles.

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

(3) Subsections (4) through (13) of this section are rescinded effective January 1, 2001.

(4) All ambulance vehicles ((shall)) must be clearly identified by appropriate emblems and markings on the front, side, and rear of the vehicle.

(((2) Tires, spare tire, tire changing tools shall meet the following requirements:

(a))) (5) Tires ((shall)) must be in good condition with not less than two-thirty-seconds inch useable tread, appropriately sized to support the weight of the vehicle when loaded((;

(b) One inflated spare tire shall be furnished and stored in a protected area which provides access without removal of the patient;

(c) Tire changing tools shall be furnished. Minimum tools shall include a jack, jack handle, and wheel-nut wrench. The jack shall be capable of raising any wheel of the loaded ambulance to an adequate height)).

(((3))) (6) The electrical system ((shall)) must meet the following requirements:

(a) Interior lighting in the driver compartment ((shall)) 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;

(b) Interior lighting in the patient compartment ((shall)) must be adequate throughout the compartment, and provide an intensity of twenty foot-candles at the level of the patient((. Lights should be controllable from the patient compartment and the driver compartment));

(c) Exterior lights ((shall)) must comply with the appropriate sections of Federal Motor Vehicle Safety Standards, and include body-mounted flood lights over the rear door which provide adequate loading visibility;

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

(((4))) (7) Windshield wipers and washers ((shall)) must be dual, electric, multispeed, and maintained in good condition.

(((5))) (8) Battery and generator system:

(a) ((The battery shall have)) Battery with a minimum seventy ampere hour rating. 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 ((shall be)) capable of supplying the maximum built-in DC electrical current requirements of the ambulance. Extra fuses ((shall)) must be provided.

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

(((7))) (10) Mirrors ((shall be provided)) on the left side and right side of the vehicle. The location of mounting must ((be such as to)) provide maximum rear vision from the driver's seated position. ((There may be an interior rear-view mirror to provide the driver with a view of occurrences in the patient compartment.

(8))) (11) One ABC two and one-half pound fire extinguisher ((shall be provided)).

(((9))) (12) Ambulance body:

(a) The length of the patient compartment ((shall)) must be at least one hundred twelve inches in length, measured from the partition to the inside edge of the rear loading doors((. This length shall provide at least twenty inches, and not more than thirty inches, of unobstructed space at the head of the primary patient, measured from the technician's seat back rest to the forward edge of the cot));

(b) The width of the patient compartment, after cabinet and cot installation, ((shall)) must provide at least nine inches of clear walkway between cots or the squad bench((. The department recommends at least twenty-five inches width of kneeling space alongside the primary cot be provided, measured at the floor for a height of nine inches, from the forward leading edge, half of the length back of the primary cot));

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

(d) There ((shall)) must be secondary egress from the curb side of the patient compartment;

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

(f) ((Steps may be provided at door openings if the floor is more than eighteen inches above the ground. Steps shall be of a design to prevent the accumulation of mud, ice, or snow, and shall have a nonskid surface;

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

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

(((i) The department recommends all interior fasteners, latches, hinges, etc., should be of a flush-type design. When doors are open, the hinges, latches, and door checks shall not protrude into the access area. All hangers or supports for equipment or other items should be flush with the surrounding surface when not in use.)) (h) The finish of the entire patient compartment ((shall)) must be impervious to soap and water and disinfectants to permit washing and sanitizing;

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

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

(((10))) (13) Vehicle brakes, tires, regular and special electrical equipment, windshield wipers, heating and cooling units, safety belts, and window glass, ((shall)) must be in good working order.

[Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-290, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending Order 323, filed 12/23/92, effective 1/23/93)

WAC 246-976-300
Ground ambulance and aid vehicles -- Equipment.

Ground ambulance and aid services ((shall)) must provide ((minimum)) equipment listed in Table C on each licensed vehicle, ((including:)) when available for service.


Note: "asst" means assortment
TABLE C: EQUIPMENT

AMBULANCE

AID

VEHICLE

AIRWAY MANAGEMENT
Airway Adjuncts
Oral airway (adult: sm, med, lg) 1ea 1ea
Oral airway (pediatric: 00, 0, 1,2,3,4) 1ea 1ea
Suction
Portable, manual 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
((Adult (14 Fr x 22") 4 2
Pediatric (6, 8, 10 Fr) 1ea 1ea
Rigid suction tips 2 1
Water, rinsing Yes 0
Oxygen delivery)) Water-soluble lubricant
Oxygen delivery system built in 1 0
3000L Oxygen cylinder, 500Lbs PSI minimum, or equivalent liquid oxygen system 1 0
300L Oxygen cylinder, 500Lbs PSI minimum, or equivalent liquid oxygen system 2 1
Regulator, oxygen (0-15+ Liter) 1 1
Cannula, nasal, adult 4 2
((O2 mask, adult 4 2
O2 mask, pediatric 2 1))
O2 mask, nonrebreather, adult 4 2
O2 mask, nonrebreather, pediatric 2 1
BVM, with O2 reservoir
-Adult 1 ((0)) 1
Pediatric (w/sizes neonatal to adult) 1 ((0)) 1
Pocket mask or equivalent ((0)) 1 1
PATIENT ASSESSMENT AND CARE
Assessment
Sphygmomanometer
Adult, large 1 0
Adult, regular 1 1
Pediatric 1 0
((Infant 1 0))
Stethoscope, adult 1 1
((Pediatric 1 0))
Thermometer, ((oral,)) hypothermia and hyperthermia 1ea 0
Flashlight, w/spare or rechargeable batteries & bulb 1 1
* Defibrillation capability appropriate to the level of personnel. (*Note: The requirement for defibrillation takes effect January 1, 2002.) 1 1
Personal infection control and protective equipment as required by the department of labor and industries
((Gloves, exam, nonsterile (box) 1 1
Other equipment per WISHA requirements Yes Yes
MEDICAL EMERGENCIES)) TRAUMA EMERGENCIES
Trauma registry identification bands Yes Yes
Triage identification for 12 patients Yes Yes
Wound care
Dressing, sterile asst asst
Dressing, sterile, trauma ((4)) 2 ((4)) 2
Roller gauze bandage asst asst
((Triangular bandage 4 4))
Medical tape asst asst
Self adhesive bandage strips asst asst
Cold packs 4 2
Occlusive dressings 2 2
Burn sheets 2 2
Scissors, bandage 1 1
Irrigation solution 2 1
Splinting
Backboard((, plywood or equiv)) with straps 2 1
((Backboard)) Head immobilizer 1 1
((Immobilizer board, pediatric capable)) Pediatric immobilization device 1 0
Extrication collars, rigid
Adult (small, medium, large) ((2ea)) asst ((1ea)) 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) 2ea 1ea
Splint, pediatric (arm and leg) 1ea 1ea
General
Litter, wheeled, collapsible 1 0
Pillows, plastic covered or disposable 2 0
Pillow case 4 0
Sheets 4 0
Blankets ((4)) 2 2
Towels, cloth 4 0
Emesis collection device 1 1
Urinal 1 0
Bed pan 1 0
OB kit 1 1
Extrication
Shovel 1 1
Hammer 1 1
Adjustable wrench, 8" 1 1
Hack saw, with blades 1 1
Crowbar, pinch point, ((40")) 36" minimum 1 1
Screwdriver, straight tip, 10" minimum 1 1
Screwdriver, 3 Phillips, 10" minimum 1 1
Wrecking bar, 3' minimum 1 1
Locking pliers 1 1
Bolt cutters, 1/2" min. jaw spread 1 1
Rope, utility, 50' x 3/8" 1 1

[Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-300, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending Order 323, filed 12/23/92, effective 1/23/93)

WAC 246-976-310
Ground ambulance and aid vehicles -- Communications equipment.

(1) ((Ground ambulance and aid services shall)) Licensed services must provide each licensed ambulance and aid vehicle with communication equipment which:

(a) Is consistent with state and ((approved)) regional plans;

(b) Is in good working order;

(c) Allows direct two-way communication between the vehicle and its ((system)) dispatch control point;

(d) Uses cellular phones only as a secondary means of communications; and

(e) Allows communication with ((the)) medical control ((system established in the state communication plan)).

(2) ((In addition to subsection (1) of this section, services shall)) Licensed services must provide each licensed ambulance with communication equipment which:

(a) Allows direct two-way communication((, from both the driver's and patient's compartments,)) with all hospitals in the service area of the vehicle, from both the driver's and patient's compartment;

(b) Incorporates appropriate encoding and selective signaling devices; and

(c) When transporting patients, allows communications with medical control and designated EMS/TC receiving facilities ((state-wide)).

[Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-310, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending Order 323, filed 12/23/92, effective 1/23/93)

WAC 246-976-320
Air ambulance services.

(1) ((The department shall:

(a) Issue licenses to air ambulance services and aircraft which meet standards described in this section;

(b) Exclude from licensure requirements those services operating aircraft for primary purposes other than civilian air medical transport, but which may be called into service to initiate an emergency air medical transport of a patient to the nearest available treatment facility or rendezvous point with other means of transportation. Examples of services fitting this description include, but are not limited to: United States Army Military Assistance to Safety and Traffic, United States Navy, United States Coast Guard, Search and Rescue, and the United States Department of Transportation.

(c) Establish and publish minimum standards for air ambulance services, medical transport aircraft, and medical equipment required for licensure. Standards for aircraft shall be consistent with federal aviation administration regulations.

(2))) Air ambulance services ((shall)) must:

(a) Comply with all regulations in this chapter pertaining to ambulance services and vehicles, except that WAC ((246-976-280,)) 246-976-290((,)) and 246-976-300 are replaced for air ambulance services by subsection (((3))) (2)(b) and (c) of this section;

(b) Comply with the standards in this section for all types of transports, including inter-facility and prehospital transports;

(c) ((Be currently certified as an air taxi under federal aviation regulations Part 135, Air Taxi Operators and Commercial Operators of Small Aircraft. Air ambulance services shall comply with applicable federal aviation regulations contained in Parts 91 and 135, and conduct all maintenance activities in accordance with Part 43. Air ambulance services shall comply with any additional federal aviation administration regulations specifically dealing with air ambulance services)) Be in current compliance with all state and Federal Aviation Administration statutes and regulations that apply to air carriers, including, but not limited to, those regulations that apply to certification requirements, operations, equipment, crew members, and maintenance, and any specific regulations that apply to air ambulance services.

(((3))) (2) Air ambulance services ((shall)) must provide:

(a) A physician director who is:

(i) Practicing medicine in the response area of the aircraft, as identified in the state EMS/TC plan;

(ii) Trained and experienced in emergency, trauma, and critical care;

(((ii))) (iii) Knowledgeable of the operation of air medical services; and

(((iii))) (iv) Responsible for supervising and evaluating the quality of patient care provided by the air medical flight personnel;

(b) Sufficient air medical personnel on each response to provide adequate patient care, specific to the mission, including:

(i) One specially trained, experienced registered nurse or paramedic; and

(ii) One other person who ((may)) must be a physician, nurse, physician's assistant, respiratory therapist, paramedic, EMT, or other appropriate specialist appointed by the physician director. If an air ambulance responds directly to the scene of an incident, at least one of the air medical personnel ((shall)) must be trained in prehospital emergency care;

(c) Aircraft that, when operated as air ambulances:

(i) Are configured ((in such a way)) so that the medical attendants ((have access to)) can access the patient ((in order)) to begin and maintain advanced life support and other treatment ((modalities));

(ii) Allow loading and unloading the patient without excessive maneuvering or tilting of the stretcher;

(iii) Have appropriate communication equipment to insure internal crew and air-to-ground exchange of information between flight personnel and hospitals, medical control, the flight operations center, and air traffic control facilities;

(iv) Are equipped with:

(A) Appropriate navigational aids;

(B) Airway management equipment, including:

(I) Oxygen;

(II) Suction;

(III) Ventilation and intubation equipment, adult and pediatric;

(C) Cardiac monitor/defibrillator;

(D) Supplies, equipment, and medication as required by the program physician director, for emergency, cardiac, trauma, pediatric care, and other missions; and

(E) The ability to maintain appropriate patient temperature; and

(v) Have adequate interior lighting for patient care arranged so as not to interfere with the pilot's vision;

(d) If using fixed-wing aircraft, pressurized, multi-engine aircraft when appropriate to the mission;

(e) If using helicopter aircraft:

(i) A protective barrier sufficiently isolating the cockpit, ((in order)) to minimize in-flight distraction or interference;

(ii) Appropriate communication equipment to communicate with ground EMS/TC services and public safety vehicles, in addition to the communication equipment specified in (c)(iii) of this subsection.

(((4))) (3) All air medical personnel ((shall)) must:

(a) Be certified in ACLS;

(b) Be trained in:

(i) Emergency, trauma, and critical care;

(ii) Altitude physiology;

(iii) EMS communications;

(iv) Aircraft and flight safety; and

(v) The use of all patient care equipment on board the aircraft;

(c) Be familiar with survival techniques appropriate to the terrain;

(d) Perform under protocols.

(((5) In instances where)) (4) Exceptions:

(a) If aeromedical evacuation of a patient is necessary because of a life threatening condition and a licensed air ambulance is not available, ((patient transportation may be accomplished by)) the nearest available aircraft that can accommodate the patient may transport. The physician ordering the transport ((shall)) must justify the need for air transport of the patient in writing to the department within thirty days after the incident.

(b) Excluded from licensure requirements those services operating aircraft for primary purposes other than civilian air medical transport, but which may be called into service to initiate an emergency air medical transport of a patient to the nearest available treatment facility or rendezvous point with other means of transportation. Examples are: United States Army Military Assistance to Safety and Traffic, United States Navy, United States Coast Guard, Search and Rescue, and the United States Department of Transportation.

(5) Air ambulance services licensing or relicensing after December 31, 2000, must have and maintain accreditation by the Commission on Accreditation of Medical Transport Services (CAMTS, Box 1305, Anderson SC 29622) for aeromedical transport.

(6) Subsections (2), (3) and (4) of this section are rescinded effective January 1, 2001, except that subsection (3)(a)(i) of this section remains in effect, requiring a physician director practicing medicine in the response area of the aircraft.

[Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-320, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending Order 323, filed 12/23/92, effective 1/23/93)

WAC 246-976-330
Ambulance and aid services -- Record requirements.

(1) Each ambulance and aid ((vehicle)) service ((shall)) must maintain a record of:

(a) Current certification levels of all personnel;

(b) Make, model, and license number of all vehicles; and

(c) Each patient contact with at least the following information:

(i) Names and certification levels of all personnel;

(ii) Date and time of medical emergency;

(iii) Age of patient;

(iv) Applicable components of system response time as defined in this chapter;

(v) Patient vital signs;

(vi) Procedures performed on the patient;

(vii) Mechanism of injury or type of illness;

(viii) Patient destination;

(ix) For trauma patients, other data points identified in ((this chapter)) WAC 246-976-430 for the trauma registry.

(2) Transporting agencies ((shall)) must leave a copy of the patient care record at the receiving facility.

(3) ((Patient records are confidential. Disclosure of patient information shall be governed by applicable state and federal regulations on confidentiality.

(4))) Licensed services ((shall)) must make all records available for inspection and duplication upon request of the department.

[Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-330, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending Order 323, filed 12/23/92, effective 1/23/93)

WAC 246-976-340
Ambulance and aid services -- Inspections and investigations.

(1) The department ((shall)) 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 ((shall)) will include a review for compliance with verification standards as part of the inspections described in this section.

(3) 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.

[Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-340, filed 12/23/92, effective 1/23/93.]

((VERIFICATION))
AMENDATORY SECTION(Amending Order 323, filed 12/23/92, effective 1/23/93)

WAC 246-976-390
Verification of trauma care services.

(1) The department ((shall)) will:

(a) ((Develop and provide)) Publish procedures ((and application forms)) for verification. Verification will expire with the period of licensure. The application for verification will be incorporated in the application for licensure;

(b) ((Establish and publish standards for verification of)) Verify prehospital trauma care services in the following categories:

(i) Aid service((,)): Basic, intermediate and advanced (paramedic) life support;

(ii) Ground ambulance service((,)): Basic, intermediate and advanced (paramedic) life support;

(iii) ((Aid service, intermediate life support;

(iv) Ambulance service, intermediate life support;

(v) Aid service, paramedic;

(vi) Ambulance service, paramedic;)) Air ambulance service. After December 31, 2000, the department will consider that a service accredited by CAMTS meets the requirements of subsections (5), (7) and (10) of this section;

(c) Review the minimum response times for verified prehospital trauma services at least biennially, considering data available from the trauma registry and with the advice of the steering committee;

(d) Forward applications for verification to the appropriate regional council for review and comment;

(e) Approve an applicant to provide verified prehospital trauma care, based on satisfactory evaluations as described in this section;

(((e))) (f) Notify the regional council and the MPD in writing of the name, location, and level of verified services;

(((f))) (g) Renew approval of a verified service upon reapplication, if the service continues to meet standards established in this chapter and ((the needs identified in)) verification remains consistent with the regional ((EMS/TC)) plan.

(2) ((For licensed aid services, the department shall:

(a) Establish and review biennially the minimum number of aid services needed to provide verified nontransport trauma care services based upon distribution and level of service identified for each response area in the approved regional plan;

(b) Evaluate applicants for aid service trauma verification based upon demonstrated ability of the provider to meet standards defined in this section.

(3) For licensed ambulance services, the department shall:

(a) Establish and review biennially the minimum and maximum number of verified ambulance services needed in the state and within each region to assure adequate availability and avoid inefficient duplication and lack of coordination of verified transport trauma care service based upon distribution and level of service identified for each response area identified in the approved regional plan;

(b) Evaluate applicants for ambulance trauma service verification based upon:

(i) Demonstrated ability of the provider to meet standards defined in this section;

(ii) The maximum number of ambulance services for each response area identified in the approved regional plans;

(iii) Preference for verification of existing licensed EMS/TC agencies, until January 1, 1995;

(iv) Recommendations from:

(A) EMS systems established by ordinance, resolution, interlocal agreement, or contract;

(B) Local government; and

(C) Local and regional EMS/TC councils;

(v) Verification shall be renewed upon reapplication, if the service continues to meet standards established in this chapter, and the needs identified in the regional plan.

(4) The regional councils shall:

(a) Identify the need for and distribution of verified aid services needed to assure adequate availability of prehospital aid service within the region for each response area, based upon agency response time standards, geography, topography, and population density for:

(i) Aid service, basic life support;

(ii) Aid service, intermediate basic life support;

(iii) Aid service, advanced life support;

(b) Identify the need for and distribution of verified ambulance services needed to assure adequate availability and avoid inefficient duplication and lack of coordination of prehospital ambulance service within the region for each response area based upon agency response time standards, geography, topography, and population density for:

(i) Ambulance, basic life support;

(ii) Ambulance, intermediate life support;

(iii) Ambulance, advanced life support.

(5) Licensed ambulance and aid services applying to become verified prehospital trauma care services shall)) The department will identify the need for and recommend distribution and level of care of prehospital services to assure adequate availability and avoid inefficient duplication and lack of coordination of prehospital services within the region. The department will identify minimum and maximum numbers of prehospital services, based on the approved regional and state plans. The department will:

(a) Establish and review biennially the minimum and maximum number of prehospital services based upon distribution and level of service identified for each response area in the approved regional plan.

(b) Evaluate an applicant for trauma verification based upon demonstrated ability of the provider to meet standards defined in this section 24-hours every day.

(c) Verify the trauma capabilities of a licensed prehospital service if it determines that the applicant:

(i) Proposes services that are identified in the regional plan for ground services, or the state plan for air ambulance services, in the proposed response areas.

(ii) Agrees to operate under approved regional patient care procedures and prehospital patient care protocols.

(3) Regional council responsibilities regarding verification are described in WAC 246-976-960.

(4) To apply for verification, a licensed ambulance or aid service must submit application on forms provided by the department, including:

(a) Documentation required for licensure specified by WAC 246-976-260(2);

(b) ((By July 1, 1995,)) A policy that a trauma training program is required for all personnel responding to trauma incidents. The program ((shall)) must meet learning objectives established by the department and be approved by the MPD;

(c) Documentation that the provider has the ability twenty-four hours every day to deliver personnel and equipment required for verification to the scene of a trauma ((injury)) within the agency response times identified in this section; and

(d) ((By July 1, 1995,)) Documentation that the provider ((is participating)) will participate in an approved regional quality assurance program.

(((6))) (5) Verified aid services ((shall)) must provide personnel to attend the patient on each trauma response including:

(a) ((Aid service,)) Basic life support: At least one individual, first responder or above;

(b) ((Aid service,)) Intermediate life support: ((At least one IV/airway technician; or two individuals, one IV technician and one airway technician;))

(i) At least one ILS technician; or

(ii) At least one IV/airway technician; or

(iii) At least two individuals, one IV technician and one airway technician.

(c) ((Aid service,)) Advanced life support - Paramedic: At least one paramedic.

(((7))) (6) Verified ambulance services ((shall)) must provide personnel to attend the patient on each trauma response including:

(a) ((Ambulance,)) Basic life support: At least two certified individuals -- one EMT plus one first responder;

(b) ((Ambulance,)) Intermediate life support:

(i) One ILS technician, plus one EMT; or

(ii) One IV/airway technician, plus one EMT; or

(((ii))) (iii) One IV technician and one airway technician((, both of whom shall be in attendance in the patient compartment, plus a driver));

(c) ((Ambulance,)) Advanced life support - Paramedic: At least two certified individuals -- one paramedic and one EMT.

(((8) Minimum equipment standards for licensure of basic life support (BLS) units as identified in WAC 246-976-300 shall be the minimum standards for verified BLS units.

(9))) (7) Verified BLS vehicles must carry equipment identified in WAC 246-976-300, Table C.

(8) Verified ((aid and ground ambulance services shall)) ILS and paramedic vehicles must provide equipment ((on each vehicle, including for intermediate life support (ILS) and paramedic (PAR) level of service)) identified in Table D, in addition to meeting the requirements of WAC 246-976-300:

TABLE D: EQUIPMENT FOR VERIFIED TRAUMA SERVICES

(NOTE: "ASST" MEANS ASSORTMENTS)

AMBULANCE AID VEHICLE
PAR ILS PAR ILS
AIRWAY MANAGEMENT
Airway Adjuncts
((Oral airway (adult: sm, med, lg) 1ea 1ea 1ea 1ea
Oral airway (pediatric: 00,0,1,2,3,4) 1ea 1ea 1ea 1ea))
Adjunctive airways, per protocol ((0)) 1 1 ((0)) 1 1
Laryngoscope handle, spare batteries 1 1 1 1
Adult blades, set 1 1 1 1
Pediatric blades, straight (0,1,2) 1ea 1ea 1ea 1ea
Pediatric blades, curved (2) 1ea 1ea 1ea 1ea
McGill forceps, adult & pediatric 1 1 1 1
ET tubes, adult (1/2 mm) 1ea 1ea 1ea 1ea
ET tubes, pediatric, with stylet
Uncuffed (2.5 - 5.0 mm) 1ea 1ea 1ea 1ea
Cuffed or uncuffed (6.0 mm) 1ea 1ea 1ea 1ea
End-tidal CO2 detector 1ea 1ea 1ea 1ea
Oxygen saturation monitor 1ea 1ea 1ea 1ea
Suction
Portable, ((manual and)) powered 1 1 1 1

((Vehicle mounted and powered; providing: Minimum of 30 L/min.& vacuum > 300 mm Hg 1 1 0 0
Tubing, suction 1 1 1 1
Bulb syringe, pediatric 1 1 1 1
Catheters, suctions
Adult (14 Fr x 22") 4 4 2 2
Pediatric (6,8,10 Fr) 1ea 1ea 1ea 1ea
Rigid suction tips 2 2 1 1
Water, rinsing Yes Yes 0 0
Oxygen delivery
Oxygen delivery system, built in 1 1 0 0
3000L Oxygen cylinder, 500Lbs PSI minimum 1 1 0 0

300L Oxygen cylinder, 500Lbs PSI minimum 2 2 1 1
Regulator, oxygen (0-15+Liter) 1 1 1 1
Cannula, nasal, adult 4 4 2 2
O2 mask, adult 4 4 2 2
O2 mask, pediatric 2 2 1 1
O2 mask, nonrebreather, adult 4 4 2 2
O2 mask, nonrebreather, pediatric 2 2 1 1
BVM, w/O2 reservoir
Adult 1 1 1 1
Pediatric, (w/sizes neonatal to adult) 1 1 1 1))
PATIENT ASSESSMENT AND CARE
((Assessment))
Sphygmomanometer
Adult, large 1 1 1 1
((Adult, regular 1 1 1 1))
Pediatric 1 1 1 1
((Infant 1 1 1 1
Stethoscope
Adult 1 1 1 1
Pediatric 1 1 1 1
Thermometer, oral and hypothermia 1ea 1ea 0 0
Flashlight, w/spare or rechargeable batteries & bulb 1 1 1 1
Personal infection control
Gloves, exam, nonsterile (box) 1 1 1 1
Other equipment per WISHA requirements Yes Yes Yes Yes
MEDICAL EMERGENCIES
Wound care
Dressing, sterile asst asst asst asst
Dressing, sterile, trauma 4 4 4 4
Roller gauze bandage asst asst asst asst
Triangular bandage 4 4 4 4
Medical tape asst asst asst asst
Self adhesive bandage strips asst asst asst asst
Cold packs 4 4 2 2
Occlusive dressings 2 2 2 2
Burn sheets 2 2 2 2
Scissors, bandage 1 1 1 1
Irrigation solution 2 2 1 1
Splinting
Backboard, plywood or equiv with straps 2 2 1 1
Backboard head immobilizer 1 1 1 1
Immobilizer board, pediatric capable 1 1 1 1
Extrication collars, rigid
Adult (small, medium, large) 2ea 2ea 1ea 1ea
Pediatric asst asst asst asst
Extrication device (immobilizer) adult

1

1

1

1

Splint, traction, adult with straps 1 1 1 1
Splint, traction, pediatric, w/straps 1 1 1 1
Splint, adult (arm and leg) 2ea 2ea 1ea 1ea
Splint, pediatric (arm and leg) 1ea 1ea 1ea 1ea))
TRAUMA EMERGENCIES
IV access
((Isotonic solution 4L 4L 2L 2L))
Administration sets
Adult 1 1 1 1
Pediatric, w/volume control 4 4 2 2
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 ((0)) Yes Yes ((0)) Yes
Pressure infusion device 1 1 1 1
((Cardiac care
Monitor/defibrillator (manual capable) with necessary supplies 1 0 1 0
General
Litter, wheeled, collapsible, w/straps 1 1 0 0
Pillows (plastic cover or disposable) 2 2 0 0
Pillow case 4 4 0 0
Sheets 4 4 0 0
Blankets 4 4 2 2
Towels, cloth 4 4 0 0
Emesis collection device 1 1 1 1
Urinal 1 1 0 0
Bed pan 1 1 0 0
OB kit 1 1 1 1
Extrication
Shovel 1 1 1 1
Hammer 1 1 1 1
Adjustable wrench, 8" 1 1 1 1
Hack saw, with blades 1 1 1 1
Crowbar, pinch point, 40" minimum 1 1 1 1
Screwdriver, straight tip, 10" minimum 1 1 1 1
Screwdriver, 3 Phillips, 10" minimum 1 1 1 1
Wrecking bar, 3' minimum 1 1 1 1
Locking pliers 1 1 1 1
Bolt cutters, 1/2" min. jaw spread 1 1 1 1
Rope, utility, 50' x 3/8" 1 1 1 1))
Medications according to local patient care protocols

(9) Verified air ambulance services ((shall)) must meet equipment requirements described in WAC 246-976-320.

(10) ((By January 1994, all verified trauma services shall participate in the regional quality assurance program established by RCW 70.168.090(2).

(11))) Verified aid services ((shall)) must meet the following minimum agency response times for response areas as defined by the department and identified in the ((approved)) 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;

(c) To rural response areas: Forty-five minutes or less, eighty percent of the time;

(d) To wilderness response areas: As soon as possible.

(((12))) (11) Verified ground ambulance services ((shall)) must meet the following minimum agency response times for response areas as defined by the department and identified in the ((approved)) 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;

(c) To rural response areas: Forty-five minutes or less, eighty percent of the time;

(d) To wilderness response areas: As soon as possible.

(((13) A verified prehospital trauma care service, or an applicant for verification, may request a variance from the requirements of this section.

(14) The department may:

(a) Grant a variance from ambulance and aid service verification requirements for a period not to exceed one year if the department determines:

(i) No detriment to public health and safety will result from the variance; and

(ii) Compliance with the provisions of this section will cause a reduction or loss of existing prehospital services;

(b) Renew a variance. If a renewal is granted, the verified service shall prepare a plan to bring the provider or region into compliance and the expected date of compliance, consistent with the regional EMS/TC plan.)) (12) Verified air ambulance services must meet minimum agency response times as identified in the state plan.

[Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-390, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending Order 323, filed 12/23/92, effective 1/23/93)

WAC 246-976-400
Verification -- Noncompliance with standards.

If the department finds that a verified prehospital trauma care service is out of compliance with verification standards:

(1) The department shall promptly notify in writing: The service, the MPD, the local and regional EMS/TC councils.

(2) ((The service shall,)) Within thirty days of the department's notification ((by the department)), the service must submit a corrective plan to the department, the MPD and the regional council outlining proposed action to ((bring the service into)) return to compliance.

(3) ((The MPD and the regional council shall, within thirty days of receipt of the service's corrective plan, forward their recommendations on the plan to the department.

(4) The department shall, within thirty days, review the plan and recommendations of the regional council and MPD, and notify the service of acceptance or rejection.

(5) The regional council may:

(a) Seek assistance and funding from the department and others to provide training or grants necessary to bring the verified prehospital trauma service into compliance; and/or

(b) Appeal to the department for modification of the regional plan if it is unable to assure continued compliance with the regional plan.

(6) The department shall monitor the service's progress in fulfilling the terms of the approved plan.

(7) If the service is either unable or unwilling to comply with the verification standards, under the provisions of chapter 34.05 RCW, the department may suspend or revoke the verification. The department shall promptly notify the regional council and the MPD of any revocation or suspension of verification.)) If the MPD or the regional council receive information that a service is out of compliance with the regional plan, they may forward their recommendations for corrections to the department.

(4) The department will review the plan within thirty days, including consideration of any recommendations from the MPD or regional council. The department will notify the service whether the plan is accepted or rejected.

(5) The department will monitor the service's progress in fulfilling the terms of the approved plan.

[Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-400, filed 12/23/92, effective 1/23/93.]

TRAUMA REGISTRY
AMENDATORY SECTION(Amending Order 323, filed 12/23/92, effective 1/23/93)

WAC 246-976-420
Trauma registry -- Department responsibilities.

((The department shall:

(1) Establish a state-wide data registry to collect and analyze data on the incidence, severity, and causes of trauma, including traumatic brain injury for the purposes of:

(a) Monitoring and providing information necessary to evaluate major trauma patient care and outcome;

(b) Assessing compliance of prehospital providers, health care facilities, hospitals, and rehabilitation services with the standards of state trauma system operation and designation;

(c) Providing information necessary for resource planning and management;

(d) Providing data for injury surveillance, analysis, and prevention programs; and

(e) Providing a resource for research and education.

(2) Establish criteria to identify patients to be included in the state trauma registry by:

(a) All licensed prehospital providers;

(b) Health care facilities, both designated (all levels) and nondesignated;

(c) Designated trauma rehabilitation services;

(d) Medical examiner reports;

(e) Other sources outside of the EMS/TC system which may include but not be limited to:

(i) Death certificates;

(ii) Washington Fire Incident Report System;

(iii) Commission's Hospital Abstract Reporting System (CHARS); and

(iv) Law enforcement agency records.

(3) Establish, publish, and periodically review the required data elements to be submitted to provide information regarding injury, trauma care, and system operation, in the following categories:

(a) Demographic;

(b) Anatomic;

(c) Physiologic;

(d) Severity;

(e) Epidemiologic;

(f) Resource utilization;

(g) Quality assurance;

(h) Outcome; and

(i) Financial.

(4) Require a case specific patient identifier common to all data sources used in the registry;

(5) Provide procedures for electronic submission of data, including specifications for necessary software; or provide paper forms for manual submission of data;

(6) For data quality assurance:

(a) Develop detailed protocols for quality control, consistent with the department's most current data quality guidelines;

(b) Perform validity studies to assess the completeness and accuracy of case identification and data collection;

(c) Provide a report on completeness and accuracy of data submitted for each provider submitting data to the registry.

(7) Conclude a pilot of the trauma registry by July 1993, which assesses the impact of data reporting on hospital and prehospital participants, and evaluates the appropriateness of the inclusion criteria and required data elements; and

(8) Evaluate requests from regional EMS/TC councils for collection of voluntarily submitted additional data elements from agencies and facilities in that region.)) (1) Purpose: The department maintains a trauma registry, as required by RCW 70.168.060 and 70.168.090. The purpose of this registry is to:

(a) Provide data for injury surveillance, analysis, and prevention programs;

(b) Monitor and evaluate the outcome of care of major trauma patients, in support of state-wide and regional quality assurance and system evaluation activities;

(c) Assess compliance with state standards for trauma care;

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

(e) Provide a resource for research and education.

(2) Confidentiality: It is essential for the department to protect information regarding specific patients and providers. Data elements related to the identification of individual patient's, provider's, and facility's care outcomes shall be confidential, shall be exempt from RCW 42.17.250 through 42.17.450, and shall not be subject to discovery by subpoena or admissible as evidence.

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

(b) The department may approve requests for trauma registry data from qualified agencies or individuals, consistent with applicable statutes and rules. The department may charge reasonable costs associated with such requests.

(c) The data elements indicated as confidential in Tables E, F and G below are considered confidential.

(d) The department will establish criteria defining situations in which additional registry information is confidential, in order to protect confidentiality for patients, providers, and facilities.

(e) This paragraph does not limit access to confidential data by approved regional quality assurance programs established under chapter 70.168 RCW and described in WAC 246-976-910.

(3) Inclusion criteria: The department will establish inclusion criteria to identify those injured patients that providers must report to the trauma registry.

(a) For all licensed prehospital providers these criteria will include injured patients:

(i) Who were dead at the scene;

(ii) Who died enroute; or

(iii) Who met the criteria of the prehospital trauma triage (destination) procedures.

(b) For designated trauma services these criteria will include all patients who were discharged with ICD diagnosis codes of 800.0 - 904.99, 910 - 959.9 (injuries), 994.1 (drowning), 994.7 (asphyxiation), or 994.8 (electrocution) and:

(i) For whom the hospital trauma resuscitation team was activated;

(ii) Who were dead on arrival at your facility;

(iii) Who were dead at discharge from your facility;

(iv) Who were transferred into your facility from another facility;

(v) Who were transferred out of your facility to another acute care facility; or

(vi) Who were admitted as inpatients to your facility and have a length of stay greater than two days or forty-eight hours.

(c) For all licensed rehabilitation services, these criteria will include all patients who were included in the trauma registry for acute care.

(4) Other data: The department and regional quality assurance programs may request data from medical examiners and coroners in support of the registry.

(5) Data linking: To link data from different sources, the department will establish procedures to assign a unique identifying number (trauma band number) to each trauma patient. All providers reporting to the trauma registry must include this trauma number.

(6) Data submission: The department will establish procedures and format for providers to submit data electronically. These will include a mechanism for the reporting agency to check data for validity and completeness before data is sent to the registry.

(7) Data quality: The department will establish mechanisms to evaluate the quality of trauma registry data. These mechanisms will include at least:

(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. The department will report quarterly on the timeliness, accuracy and completeness of data.

(8) Registry reports:

(a) Annually, the department will report:

(i) Summary statistics and trends for demographic and related information about trauma care, for the state and for each EMS/TC region;

(ii) Outcome measures, for evaluation of clinical care and system-wide quality assurance and quality improvement programs.

(b) Semiannually, the department will report:

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

(ii) On all patient data entered into the trauma registry during the reporting period;

(iii) Aggregate regional data to the regional EMS/TC council, excluding any confidential or identifying data.

(c) The department will provide:

(i) Provider-specific raw data to the provider that originally submitted it;

(ii) Periodic reports on financial data;

(iii) Registry reports to all providers that have submitted data;

(iv) For the generation of quarterly reports to all providers submitting data to the registry, for the purpose of planning, management, and quality assurance.

[Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-420, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending Order 323, filed 12/23/92, effective 1/23/93)

WAC 246-976-430
Trauma registry -- Provider responsibilities.

(((1) All licensed prehospital services shall:

(a) Use the following criteria for inclusion of patient data in the trauma registry:

(i) Trauma victims dead at scene; and

(ii) All patients meeting trauma triage criteria who are transported to a health care facility;

(b) Submit required registry data via electronic transfer; or, if authorized in writing by the department, on approved paper forms.

(2) The first licensed service on the scene shall be responsible for submitting the following data on all patients identified in subsection (1) of this section, treated during each calendar quarter. Data shall arrive at the registry in an approved format no later than ninety days after the end of the quarter:

(a) Run sheet number;

(b) Name or name code, when available;

(c) Date of birth when available;

(d) Age;

(e) Sex;

(f) Agency incident number;

(g) Patient's trauma identification number;

(h) Agency identification number;

(i) First agency on scene (yes/no);

(j) Transporting agency identification;

(k) Level of transporting agency (BLS/ALS);

(l) Incident county code;

(m) Response area code of incident (urban, suburban, rural, wilderness);

(n) Date of incident;

(o) Time:

(i) Call received;

(ii) Dispatched;

(iii) Arrived at scene;

(p) First scene:

(i) Systolic blood pressure;

(ii) Respiratory rate;

(iii) Pulse;

(q) Glasgow coma score - eye, verbal, and motor;

(r) Systolic blood pressure less than ninety mm Hg in field (yes/no);

(s) Mechanism of injury;

(t) Prehospital trauma system activation (yes/no);

(u) Extrication required;

(v) Patient entrapped (yes/no);

(w) Safety restraint or device used;

(x) Field interventions done; and

(y) Additional information if patient died at scene:

(i) Patient home zip code;

(ii) Patient race and ethnicity when available.

(3) The transporting service shall be responsible for submitting the following data on all patients identified in subsection (1) of this section, treated during each calendar quarter. Data shall arrive at the registry in an approved format no later than ninety days after the end of the quarter:

(a) Run sheet number or file number;

(b) Name or name code;

(c) Date of birth, when available;

(d) Age;

(e) Sex;

(f) Agency incident number;

(g) Patient's trauma identification number;

(h) Agency identification number;

(i) First agency on scene identification number;

(j) Transporting agency identification;

(k) Level of transporting agency (BLS/ALS);

(l) Intra-facility transport;

(m) Incident county code;

(n) Response area code of incident (urban, suburban, rural, wilderness);

(o) Date of incident;

(p) First hospital transported to (code);

(q) Second hospital transported to (code);

(r) Intra-field rendezvous transport agency identification number;

(s) Time of:

(i) Call received;

(ii) Dispatch;

(iii) Arrival at scene;

(iv) Departure from scene;

(v) Arrival at intra-field destination or rendezvous;

(vi) Arrival at first hospital;

(vii) Departure from first hospital;

(viii) Arrival at second hospital;

(t) First:

(i) Systolic blood pressure;

(ii) Respiratory rate;

(iii) Pulse;

(iv) Glasgow coma score - eye, verbal, and motor;

(u) Systolic blood pressure less than ninety mm Hg in field;

(v) Mechanism of injury;

(w) Trauma triage criteria met;

(x) Prehospital trauma system activation (yes/no);

(y) Extrication required;

(z) Patient entrapped (yes/no);

(aa) Safety restraint/device used;

(bb) Field interventions done;

(cc) Receiving hospital contacted (code);

(dd) Diverted;

(ee) Mode of transport; and

(ff) Additional information if patient dies in route:

(i) Patient home zip code;

(ii) Patient race and/or ethnicity, when available.

(4) Licensed ambulance services transporting patients between facilities shall be responsible for submitting the following data on all patients identified in subsection (1) of this section, treated during each calendar quarter. Data shall arrive at the registry in an approved format no later than ninety days after the end of the quarter:

(a) Run sheet number;

(b) Patient's trauma identification number;

(c) Agency identification number;

(d) Inter-facility transfer (yes/no);

(e) Mode of transport;

(f) Level of transport (BLS/ALS);

(g) Time:

(i) Call received;

(ii) Arrived at hospital;

(h) Originating facility (code);

(i) Destination facility (code).

(5) Designated trauma care facilities at all levels shall:

(a) Use the following criteria for inclusion of patient data in the trauma registry:

(i) All trauma patients dead on arrival at health care facility;

(ii) All trauma patients discharged deceased from health care facility;

(iii) All trauma patients transferred to another facility;

(iv) Other patients with all three of the following:

(A) Emergency admit, UB-82; and

(B) Length of stay greater than two days or forty-eight hours; and

(C) Discharge diagnosis ICD-9-CM codes of 800 - 904.99 or 910 - 959.9;

(b) Submit required registry data via electronic transfer; or, if authorized in writing by the department, on approved paper forms;

(c) Submit the following data for patients identified in (a) of this subsection, who were discharged during each calendar quarter. Data shall arrive at the registry in an approved format no later than ninety days after the end of the quarter:

(i) Identification of facility;

(ii) Unique patient identification number assigned to the patient by the facility;

(iii) Arrival via EMS system;

(iv) Prehospital run sheet number, when available;

(v) Date of ED arrival;

(vi) Time of ED arrival;

(vii) Date of incident;

(viii) Initial hospital;

(ix) Facility patient was transferred from;

(x) Patient information:

(A) Name or name code;

(B) Date of birth;

(C) Sex;

(D) Race and ethnicity;

(E) Patient's trauma identification number;

(F) Social Security number;

(G) Home zip code number;

(H) Organ donor;

(xi) Mechanism of injury;

(xii) Safety restraint/device used;

(xiii) Prehospital index score on admission;

(xiv) Time of first contact with ED physician;

(xv) Trauma team activated (yes/no);

(xvi) Time of call to surgeon;

(xvii) Time of arrival of surgeon in ED;

(xviii) First systolic blood pressure in ED;

(xix) First temperature in ED;

(xx) First pulse rate in ED;

(xxi) First spontaneous respiration rate in ED;

(xxii) Lowest systolic blood pressure in ED;

(xxiii) Glasgow coma score in ED - eye, verbal, and motor;

(xxiv) Patient intubated at first GCS;

(xxv) Patient pharmacologically paralyzed at first GCS;

(xxvi) ED procedures performed;

(xxvii) Time of ED discharge;

(xxviii) ED discharge disposition;

(xxix) Admitting service;

(xxx) CT scan of head done (yes/no);

(xxxi) Date of head CT scan;

(xxxii) Time of head CT scan;

(xxxiii) For each operation:

(A) Date and time patient arrived in operating room;

(B) Date and time operation started;

(C) Most recent ICD codes;

(xxxiv) Length of primary stay in intensive care unit;

(xxxv) Length of readmission stay in intensive care unit;

(xxxvi) Co-morbidity complications;

(xxxvii) Physical therapy consult;

(xxxviii) Date of physical therapy consult;

(xxxix) Rehabilitation consult;

(xl) Date of rehabilitation consult;

(xli) Disability at acute care discharge:

(A) Feeding;

(B) Locomotion;

(C) Expression;

(xlii) Glasgow outcome score at discharge;

(xliii) Date of facility discharge;

(xliv) Time of facility discharge;

(xlv) Discharge disposition;

(xlvi) Rehabilitation facility identification number;

(xlvii) Autopsy done (yes/no);

(xlviii) Date of death;

(il) Time of death;

(l) Most recent ICD diagnosis codes/discharge codes;

(li) E-code;

(lii) Occupational injury;

(liii) Safety restraint/device used; and

(liv) Payer source;

(d) Submit reimbursement information on trauma registry patients annually, including:

(i) Total billed charges;

(ii) Remitted reimbursement by each payer category; and

(iii) Ratio of cost to charges, by department.

(6) Designated rehabilitation facilities shall:

(a) Inclusion patient data for the trauma registry on all patients whose primary admission diagnosis is trauma, including ICD diagnosis codes of 800 - 904.99 or 910 - 959.9;

(b) Submit the following data for patients identified in (a) of this subsection, who were discharged during each calendar quarter. Data shall arrive at the registry in an approved format no later than ninety days after the end of the quarter:

(i) Rehabilitation facility identification number;

(ii) Trauma tag/identification number;

(iii) Name or name code;

(iv) Social Security number;

(v) Sex;

(vi) Date of birth;

(vii) Date of admission to rehabilitation;

(viii) First admit (yes/no);

(ix) Continuing admit (yes/no);

(x) Impairment code, from the national uniform data set;

(xi) Source of admission;

(xii) Level of cognitive function on admission (Rancho scale);

(xiii) Tracheostomy;

(xiv) Ventilator dependent;

(xv) Feeding tube;

(xvi) Admission functional independence measure, from the national uniform data set (FIM or WEE FIM);

(xvii) Complications;

(xviii) Premorbid physiological, cognitive, and mental conditions;

(xix) Highest grade completed;

(xx) Level of cognitive function on discharge (Rancho scale);

(xxi) Functional independence measure on discharge, from the national uniform data set (FIM or WEE FIM score);

(xxii) Discharged with tracheostomy;

(xxiii) Discharged ventilator dependent;

(xxiv) Discharged with feeding tube;

(xxv) Discharge due to medical problem (yes/no);

(xxvi) Date of discharge due to medical problem;

(xxvii) Readmitted after medically required interruption;

(xxviii) Date of readmission after interruption;

(xxix) Patient did not return after interruption;

(xxx) Discharged to;

(xxxi) Social support system;

(xxxii) Discharge date from rehabilitation;

(xxxiii) Rehabilitation services ordered at discharge;

(xxxiv) Community support system; and

(xxxv) Payer source - primary and secondary;

(c) Submit reimbursement information on trauma registry patients annually, including:

(i) Total billed charges;

(ii) Remitted reimbursement by each payer category; and

(iii) Ratio of cost to charges, by department.

(7) Medical examiners and coroners may:

(a) Submit data to the registry on all patients with injury listed as an underlying cause or contributing factor to death on the death certificate;

(b) Submit the following data for all patients meeting the inclusion criteria identified in (a) of this subsection:

(i) Patient:

(A) Name or name code;

(B) Date of birth;

(C) Social Security number;

(D) Patient's trauma identification number;

(E) Gender;

(F) Race and/or ethnicity;

(G) Date of incident;

(H) Date of death; and

(I) Home zip code;

(ii) Medical examiner number/coroner identification number;

(iii) Medical examiner/coroner facility identification number;

(iv) Autopsy done;

(v) Mechanism of injury;

(vi) Organ donor;

(vii) Cause of death; and

(viii) Most recent ICD diagnosis code or equivalent description.)) (1) Trauma care providers, prehospital and hospital, must place a trauma ID band on trauma patients, if not already in place from another agency.

(2) All trauma care providers must submit required data to the trauma registry in an approved format.

(3) All trauma care providers must protect the confidentiality of data in their possession and as it is transferred to the department.

(4) All trauma care providers must correct and resubmit records which fail the department's validity tests described in WAC 246-976-420(6). You must send corrected records to the department within three months of notification.

(5) Licensed prehospital services must:

(a) Assure personnel use the trauma ID band.

(b) Report data as shown in Table E for trauma patients defined in WAC 246-976-420.

(c) Report incidents occurring in a calendar quarter by the end of the following quarter. The department encourages more frequent data reporting.

(6) Designated trauma services must:

(a) Assure personnel use the trauma ID band.

(b) Report data elements shown in Table F for all patients defined in WAC 246-976-420.

(c) Report patients discharged in a calendar quarter by the end of the following quarter. The department encourages more frequent data reporting.

(7) Designated trauma rehabilitation services must:

(a) Report data on all patients who were included in the trauma registry for acute care.

(b) Report either:

(i) Data elements shown in Table G; or

(ii) If the service submits data to the uniform data set for medical rehabilitation, provide a copy of the data to the department.


TABLE E: Prehospital Data Elements for the Washington Trauma Registry
Type of patient Pre-Hosp No-Trans Pre-Hosp Transport Inter-Facility
Data Element
Note: (C) identifies elements that are confidential. See WAC 246-976-420 (2)(c).
Incident Information
Agency identification number (C) X X X
Date of response (C - day only) X X X
Run sheet number (C) X X X
Agency incident number (C) X X X
First agency on scene identification number (C) X X
Transporting agency identification X X
Level of transporting agency X X X
Mode of transport X X X
Incident county code X X
Incident Zip Code X X
Incident location (type) X X
Incident response area type X X
Patient Information
Patient's trauma identification band number (C) X X X
Name (C) X X X
Date of birth (C), or Age X X X
Sex X X X
If patient died at scene: Patient home Zip Code X X
Mechanism of injury X X
Illness/Injury type code X X
Safety restraint or device used X X
Transportation
Transported from (code) (C - if hospital ID) X X
Transported to (code) (C - if hospital ID) X X
If rendezvous, assisting agency ID number X X
Reason for destination decision X X
Times
Call received X X X
Dispatched X X X
Code Response to scene? X X X
Arrived at scene X X X
Departed from scene X X
Code response to destination? X X
Arrival at destination X X
First Vital Signs
Time X X X
Systolic blood pressure X X X
Respiratory rate X X X
Pulse X X X
Glasgow coma score X X X
Trauma Triage Criteria
Vital signs, consciousness level X X
Anatomy of injury X X
Biomechanics of injury X X
Other risk factors X X
Gut feeling of medic X X
Prehospital trauma system activation? X X
Other Severity Measures
Blunt/Penetrating injury X X
Respiratory effort X X
Consciousness X X
Time (interval) for extrication X X
Treatment: EMS interventions X X X


TABLE F: Hospital Data Elements for the

Washington Trauma Registry

All licensed hospitals must submit the following data for patients identified in WAC 246-976-420(3):

Note: (C) identifies elements that are confidential. See WAC 246-976-420(2).



Record Identification

Identification of reporting facility (C);

Date and time of arrival at reporting facility (C - day only);

Unique patient identification number assigned to the patient by the reporting facility (C);

Patient's trauma identification band number (C);

Patient Identification

Name (C);

Date of birth (C - day only);

Sex;

Race;

Social Security number (C);

Home zip code;

Prehospital Incident Information

Date of incident (C - day only);

Arrival via EMS system?;

Transporting agency ID number;

Transporting agency run number (C);

Mechanism of injury;

City and county of incident;

If transfer in, facility patient was transferred from (C);

Occupational injury?;

Safety restraint/device used;

ED or Admitting Information

Time ED physician called;

ED physician called "code"?;

Time ED physician available for patient care;

Time trauma team activated;

Level of trauma team activation;

Time trauma surgeon called;

Time trauma surgeon available for patient care;

Vital Signs in ED

Patient dead on arrival at your facility?;

First and last systolic blood pressure;

First and last temperature;

First and last pulse rate;

First and last spontaneous respiration rate;

Lowest systolic blood pressure;

Glasgow coma scores (eye, verbal, motor);

Injury Severity scores

Prehospital Index (PHI) score;

Revised Trauma Score (RTS) on admission;

For pediatric patients:

Pediatric Trauma Score (PTS) on admission;

Pediatric Risk of Mortality (PRISM) score on admission;

Pediatric Risk of Mortality - Probability of Survival (PRISM P(s));

Pediatric Overall Performance Category (POPC);

Pediatric Cerebral Performance Category (PCPC):

ED procedures performed;

Time of ED discharge;

ED discharge disposition, including

If admitted, the admitting service;

If transferred out, ID of receiving hospital

Diagnostic and Consultative Information

Date and time of head CT scan;

Date of physical therapy consult;

Date of rehabilitation consult;

Blood alcohol content;

Toxicology screen results;

Co-morbid factors/Preexisting conditions;

Surgical Information

For the first operation:

Date and time patient arrived in operating room;

Date and time operation started;

OR procedure codes;

For later operations:

Date of operation

OR Procedure Codes

Critical Care Unit Information

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

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

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

Other procedures performed (not in OR)

Discharge Status

Date and time of facility discharge (C - day only);

Most recent ICD diagnosis codes/discharge codes, including nontrauma codes;

E-codes, primary and secondary;

Glasgow Score at discharge;

Disability at discharge (Feeding/Locomotion/Expression)

Discharge disposition

If transferred out, ID of facility patient was transferred to (C)

If patient died in your facility

Date and time of death (C - day only);

Was an autopsy done?;

Was case referred to coroner or medical examiner?

Did coroner or medical examiner accept jurisdiction?

Was patient evaluated for organ donation?

Financial Information (All Confidential)

For each patient

Total billed charges;

Payer sources (by category);

Reimbursement received (by payer category);

Annually, submit ratio-of-costs-to-charges, by department.


TABLE G: Data Elements for Designated Rehabilitation Services

Designated trauma rehabilitation services must submit the following data for patients identified in WAC 246-976-420(3).

Note: (C) identifies elements that are confidential. WAC 246-976-420(2)


Rehabilitation services, Levels I and II



Patient Information

Facility ID (C)

Facility Code

Patient Code

Trauma tag/identification Number (C)

Date of Birth (C - day only)

Social Security Number (C)

Patient Name (C)

Patient Sex

Care Information

Date of Admission (C - day only)

Admission Class

Date of Discharge (C - day only)

Impairment Group Code

ASIA Impairment Scale

Diagnosis (ICD-9) Codes

Etiologic Diagnosis

Other significant diagnoses

Complications/comorbidities

Diagnosis for transfer or death

Other Information

Date of onset

Admit from (Type of facility)

Admit from (ID of facility)

Acute trauma care by (ID of facility)

Prehospital living setting

Prehospital vocational category

Discharge-to-living setting

Functional Independence Measure (FIM) - One set on admission and one on discharge

Self Care

Eating

Grooming

Bathing

Dressing - Upper

Dressing - Lower

Toileting

Sphincter control

Bladder

Bowel

Transfers

Bed/chair/wheelchair

Toilet

Tub/shower

Locomotion

Walk/wheelchair

Stairs

Communication

Comprehension

Expression

Social cognition

Social interaction

Problem solving

Memory

Payment Information (all confidential)

Payer source - primary and secondary

Total Charges

Remitted reimbursement by category


Rehabilitation, Level III


Patient Information

Facility ID (C)

Patient number (C)

Trauma tag/identification Number (C)

Social Security Number (C)

Patient Name (C)

Care Information

Date of Admission (C - day only)

Impairment Group Code

Diagnosis (ICD-9) Codes

Etiologic Diagnosis

Other significant diagnoses

Complications/comorbidities

Other Information

Admit from (Type of facility)

Admit from (ID of facility) (C)

Acute trauma care given by (ID of facility) (C)

Inpatient trauma rehabilitation given by (ID of facility) (C)

Discharge-to-living setting

Payment Information (all confidential)

Payer source - primary and secondary

Total Charges

Remitted reimbursement by category

[Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-430, filed 12/23/92, effective 1/23/93.]

SYSTEM ADMINISTRATION
AMENDATORY SECTION(Amending WSR 98-04-038, filed 1/29/98, effective 3/1/98)

WAC 246-976-890
Interhospital transfer guidelines and agreements.

((Facilities providing)) Designated trauma ((care)) services ((shall)) must:

(1) Have written guidelines for the identification and transfer of patients with special ((trauma)) care needs exceeding the capabilities of the trauma ((care)) service.

(2) Have written transfer agreements with other designated trauma ((care)) services ((which include)). The agreements must address the responsibility of the transferring hospital ((and of)), the receiving hospital, and the prehospital transport agency, including a mechanism ((for assignment of)) to assign medical control during interhospital transfer.

(3) Have written guidelines to identify trauma patients who are transferred in from other facilities, whether admitted through the emergency department or directly into other hospital services.

(4) Use verified prehospital trauma services for interfacility transfer of trauma patients.

[Statutory Authority: Chapter 70.168 RCW. 98-04-038, 246-976-890, filed 1/29/98, effective 3/1/98. Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-890, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending Order 323, filed 12/23/92, effective 1/23/93)

WAC 246-976-910
((EMS and trauma care system)) Regional quality assurance and improvement program.

(((1) The department shall:

(a) Provide guidelines for regional EMS/TC system quality assurance to evaluate regional trauma care delivery, patient care outcomes, and compliance with the requirements of this chapter; and

(b) Review and approve regional quality assurance activities.

(2) Levels I, II, and III trauma care facilities shall establish and participate in regional EMS/TC systems quality assurance programs.

(3) The regional quality assurance program:

(a) Shall include at least one member of each designated facility's medical staff, an EMS provider, and a member of the EMS/TC regional council; and

(b) In regions with facilities jointly designated under WAC 246-976-470 (3)(b), shall include at least one member who does not reside or work in the region.

(4) The regional quality assurance program shall invite the MPD and all other health care providers and facilities providing trauma care in the region, including nondesignated facilities and nonverified prehospital services, to participate in the regional trauma quality assurance program.

(5) The regional quality assurance program shall include a written plan for implementation including:

(a) Scope of all services offered in the region;

(b) Ongoing assessment of performance of the regional EMS and trauma care system, based on data supplied by the trauma registry and other sources, including:

(i) Trauma care delivery;

(ii) Patient care outcomes, including pediatric and adult patient outcomes;

(iii) Unexpected deaths; and

(iv) Compliance with the requirements of chapter 70.168 RCW, and this chapter;

(c) Identification and analysis of trends, patient care outcomes, and other information, based on trauma registry data;

(d) Periodic assessment of data concerning aspects of patient care;

(e) Policies regarding confidentiality of data elements related to identification of provider's and facility's care outcomes, in accordance with chapter 70.168 RCW;

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

(g) Policies regarding confidentiality of documentation of the results of inquiries involving patient care issues; and

(h) Provision for feedback to the department and the regional council on identified EMS/TC issues and concerns.)) (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 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 state-wide 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.

[Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-910, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending Order 323, filed 12/23/92, effective 1/23/93)

WAC 246-976-920
Medical program director.

(((1) The department shall:

(a) In conjunction with the state EMS/TC committee, evaluate, certify, and terminate certification of MPDs for a county, group of counties, or cities with populations over four hundred thousand, in coordination with the recommendations of the local medical community and local EMS/TC council;

(b) Withdraw certification of MPDs on receipt of written resignation;

(c) Defend and hold harmless MPDs, delegates, or agents for any act or omission committed or omitted in good faith in the performance of his or her duties.

(2))) (1) The MPD ((shall)) must:

(a) Be knowledgeable in the administration and management of prehospital emergency medical care and services;

(b) Provide medical control and direction of EMS/TC certified personnel in their medical duties, by oral or written communication;

(c) Develop and adopt written prehospital patient care protocols to direct EMS/TC certified personnel in patient care. These protocols ((shall be based upon the assessment of the patients' medical needs. The protocols shall meet or exceed state-wide minimum standards for trauma and other prehospital care services)) may not conflict with regional patient care procedures or with the authorized care of the certified prehospital personnel as described in WAC 246-976-182;

(d) Establish protocols for storing, dispensing, and administering controlled substances, in accordance with state and federal regulations and guidelines;

(e) ((Consult)) Participate with the local and regional EMS/TC councils and emergency communications centers to develop and ((approve)) revise regional patient care procedures;

(f) Participate with the local and regional EMS/TC councils to develop and revise regional plans and make timely recommendations to the regional council;

(g) Work within the parameters of the approved regional patient care procedures and the regional plan;

(((g))) (h) Supervise training of all EMS/TC certified personnel;

(((h))) (i) Develop protocols for special training described in WAC ((246-976-040)) 246-976-021(5);

(((i))) (j) Periodically audit the ((educational)) medical care performance((, skill maintenance, and field performance)) of EMS/TC certified personnel((, for quality assurance purposes));

(((j))) (k) Recommend to the department certification, recertification, or denial of certification of EMS/TC personnel;

(((k))) (l) Recommend to the department disciplinary action to be taken against EMS/TC personnel, which may include modification, suspension, or revocation of certification;

(((l) Review and make recommendations)) (m) Recommend to the department ((for)) individuals applying for recognition ((or renewal of recognition)) as senior ((EMT)) EMS instructors.

(((3))) (2) In accordance with department policies and procedures, the MPD may:

(a) Delegate ((in writing any duties, other than those described above in subsection (2)(c), (j), and (k) of this section, to other physicians)) duties to other physicians, except for duties described in subsection (1)(c), (k), and (l) of this section. The delegation must be in writing;

(i) The MPD ((shall)) must notify the department in writing of the names and duties of individuals so delegated, within fourteen days;

(ii) The MPD may remove delegated authority at any time, which shall be effective upon written notice to the delegate and the department;

(b) Delegate ((in writing)) duties relating to training, evaluation, or examination of certified EMS/TC personnel, to qualified nonphysicians. The delegation must be in writing;

(c) Enter into EMS/TC medical control agreements with other MPDs;

(d) Recommend denial of certification to the department for any ((student)) applicant the MPD ((deems)) can document is unable to function as an EMS provider, ((despite)) regardless of successful completion of ((MPD-approved)) training, evaluation, or examinations; and

(e) ((Require)) Utilize examinations to determine the knowledge and abilities of IV technicians, airway technicians, intermediate life support technicians, or paramedics prior to recommending applicants for certification or recertification. ((If such examinations are required, the MPD shall conduct at least one examination annually, and may conduct examinations more often if necessary.

(4))) (3) The department may withdraw the certification of an MPD ((when:

(a) The MPD fails to maintain eligibility under this chapter;

(b) The MPD fails to perform the duties assigned under this chapter;

(c) The MPD demonstrates unwillingness or inability to perform duties under this chapter;

(d) The local EMS/TC council or the local medical community recommends revocation to the department)) for failure to comply with the Uniform Disciplinary Act (chapter 18.130 RCW) and other applicable statutes and regulations.

[Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-920, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending Order 323, filed 12/23/92, effective 1/23/93)

WAC 246-976-930
General responsibilities of the department.

(((1) The department shall establish:

(a) The minimum and maximum number of hospitals and health care facilities in the state and within each EMS/TC planning and service region that may provide designated trauma care services based upon approved regional EMS/TC plans;

(b) The minimum and maximum number of prehospital providers in the state and within each EMS/TC planning and service region that may provide verified trauma care services based upon approved regional EMS/TC plans.

(2) The department shall designate hospitals and health care facilities to provide designated trauma care services in accordance with needs identified in the state-wide EMS/TC plan.

(3) The department shall design and establish the state-wide trauma care registry as authorized in RCW 70.168.090.

(4) The department shall develop prehospital trauma triage procedures and interfacility transfer guidelines, for adult and pediatric patients, and review them biennially with the advice of the steering committee.

(5) The department shall create:

(a) An EMS/TC licensing and certification advisory committee of eleven members, and appoint members, including a balance of physicians, one of whom is an MPD, and individuals regulated under RCW 18.71.205 and 18.73.081, an administrator from a city or county EMS/TC system, a member of the steering committee, and one consumer. All members except the consumer shall be knowledgeable in specific and general aspects of EMS/TC. Members shall be appointed for a period of three years. The terms of those members representing the same field shall not expire at the same time;

(b) Regional EMS/TC councils and appoint members, including a balance of hospital and prehospital trauma care and EMS providers, local elected officials, consumers, local law enforcement representatives, local government agencies, physicians, EMS/TC educators, and prevention specialists involved in the delivery of EMS/TC services recommended by the local EMS/TC councils within the region.

(6) The department shall develop standards and a process and schedule for biennial update of regional and state-wide planning.

(7))) In addition to the requirements described in chapters 18.71, 18.73, and 70.168 RCW, and elsewhere in this chapter:

(1) The department shall review, recommend changes to, and approve regional plans and regional patient care procedures based on the requirements of this chapter and recommendations from the steering committee, and upon consideration of the needs of ((trauma)) patients ((whose care may require resources from more than one region and/or from adjacent states.

(8) The department shall develop and publish a state-wide EMS/TC plan that:

(a) Identifies state-wide EMS/TC objectives and priorities and identifies equipment, facility, personnel, training, prevention, and other needs required to create and maintain a state-wide EMS/TC system;

(b) Is formulated by incorporating the regional EMS/TC plans required under chapter 70.168 RCW;

(c) Shall be updated every two years and shall be made available to the state board of health in sufficient time to be considered in preparation of the biennial state health report required in RCW 43.20.050;

(d) Includes a state EMS/TC communication plan formulating the system based on regional plans and legislative intent. The communications system plan shall:

(i) Provide for a communication network to support medical control;

(ii) Establish guidelines for EMD training for all EMS dispatch personnel; and

(iii) Establish minimum communications equipment levels for licensed ambulance and aid vehicles;

(e) Provides for interagency coordination, administration, and regulation of the state-wide EMS/TC communications plan.

(9) From available funds, the department shall make EMS systems development grants to regional councils:

(a) To support regional EMS/TC council operations;

(b) To support regional council matching grant programs described in WAC 246-976-960 (1)(f), giving priority to achievement of minimum standards of this chapter, and other purposes and priorities established with the advice of the steering committee)).

(((10))) (a) The department may approve regional plans which include standards that are consistent with chapter 70.168 RCW and other state and federal laws, but which exceed the requirements of this chapter.

(b) The department will develop a process for biennial update of regional and state-wide planning. The process will include provisions to amend regional plans between biennial updates.

(2) The department will publish prehospital trauma triage procedures which include assessment of the patient's:

(a) Vital signs and level of consciousness;

(b) Anatomy of injury;

(c) Biomechanics of the injury; and

(d) Comorbid and associated risk factors.

(3) The department may approve pilot programs and projects which have:

(a) Stated objectives;

(b) A specified beginning and ending date;

(c) An identified way to measure the outcome;

(d) A review process;

(e) A work plan with a time line;

(f) If training of EMS/TC personnel is involved, consistency with the requirements of WAC 246-976-021(5).

(4) The department ((shall)) will review ((biennially)) at least every four years:

(a) Rules, policies, and standards for EMS/TC, with the advice of the steering committee;

(b) Rules and standards for licensure of services and vehicles, and for certification of EMS/TC personnel, with the advice of the L&C committee;

(((c) Minimum response times for verified prehospital trauma care services, considering data available from the trauma registry and with the advice of the steering committee.

(11) The department shall develop a format for evaluating the performance of MPDs consistent with WAC 246-976-920.

(12) The department shall develop and maintain the trauma prevention and education program as an integral component of the EMS/TC system.

(13) The department may:

(a) Recognize as an affiliated EMS services, those organizations which are not required to be licensed under chapter 18.73 RCW, but which are:

(i) Recommended for affiliation by the local EMS/TC council and the MPD;

(ii) Identified in the regional plan as part of the EMS/TC system;

(b) Approve pilot programs and projects which have:

(i) Stated objectives;

(ii) A specified beginning and ending date;

(iii) An identified way of measuring the outcome;

(iv) A review process;

(v) A work plan with a time line;

(vi) Consistency with regional and state plans;

(vii) If training of certified EMS/TC personnel involved, consistency with the requirements of WAC 246-976-040;

(c) Appoint a communications advisory committee, with members who are users of EMS/TC communications and providers of EMS/TC services.))

[Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-930, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending Order 323, filed 12/23/92, effective 1/23/93)

WAC 246-976-940
Steering committee.

In addition to the requirements of chapter 70.168 RCW and elsewhere in this chapter, the EMS/TC steering committee ((shall)) will:

(1) Review and comment on the department's rules, policies, and standards ((for EMS/TC at least biennially));

(2) ((Review and comment on rules proposed by the department for EMS/TC;

(3))) Review and comment on the department's budget for the EMS/TC system at least biennially;

(((4) Advise the department regarding EMS/TC needs and proposed funding throughout the state;

(5) Review the regional EMS/TC plans and recommend changes to the department before the department adopts the plans;

(6) Advise the department on disbursement of grants to regional councils and nonprofit agencies for the development, implementation, and enhancement of the EMS/TC system; and

(7) Review the department's prehospital triage guidelines and inter-facility transfer guidelines biennially.)) (3) Periodically review and recommend changes to:

(a) The department's prehospital triage procedures;

(b) Regional patient care procedures;

(c) Regional plans; and

(d) Inter-facility transfer guidelines.

[Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-940, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending Order 323, filed 12/23/92, effective 1/23/93)

WAC 246-976-950
Licensing and certification committee.

In addition to the requirements of RCW 18.73.050, the licensing and certification committee ((shall: (1) Review and comment on proposed licensing and certification rules under chapters 18.71 and 18.73 RCW;

(2))) will review and comment biennially on the department's EMS/TC rules and standards pertaining to licensure of vehicles and services, verification of services, and to certification of individuals((;

(3) Assist the department, at the department's request, to fulfill any duty or exercise any power under this chapter pertaining to EMS/TC licensing and certification)).

[Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-950, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending Order 323, filed 12/23/92, effective 1/23/93)

WAC 246-976-960
Regional emergency medical services and trauma care councils.

(((1) Regional councils shall:

(a) At least semiannually, identify and analyze trends and patient care outcomes, based on trauma registry data provided by the department, to evaluate the EMS/TC system and its component subsystems;

(b) Develop and submit to the department regional EMS/TC plans to:

(i) Assess and analyze regional EMS/TC needs;

(ii) Identify personnel, agencies, facilities, equipment, training, prevention programs, and education to meet regional and local needs;

(iii) Identify specific activities necessary to meet state-wide standards and patient care outcomes and develop a plan of implementation for regional compliance;

(iv) Establish and review agreements with regional providers necessary to meet state standards;

(v) Establish agreements with providers outside the region to facilitate patient transfer;

(vi) Include a regional budget identifying the amount, source, and purpose of all gifts and payments;

(vii) Establish the number and level of facilities to be designated, consistent with department guidelines and based on availability of resources and the distribution of trauma within the region;

(viii) Identify the need for and recommend distribution and level of care of prehospital services, to assure adequate availability and avoid inefficient duplication and lack of coordination of prehospital services within the region;

(ix) Include other specific elements defined by the department;

(x) Identify EMS/TC services and resources currently available within the region;

(xi) Describe how the roles and responsibilities of the MPD are coordinated with those of the regional EMS/TC council;

(xii) Describe and recommend improvements in medical control communications and EMS/TC dispatch, with at least the elements of the state communication plan described in WAC 246-976-930 (1)(l)(iv); and

(xiii) Include a schedule for implementation;

(c) In developing or updating its plan:

(i) Seek and consider the recommendations of:

(A) Local EMS/TC councils;

(B) Counties, cities, or other governmental bodies that have established an EMS/TC system by ordinance, resolution, interlocal agreement, or contract; and

(ii) Use the regional and state analyses provided by the department based on trauma registry data and other appropriate sources;

(d) Advise the department on matters relating to the delivery of EMS/TC within the region;

(e) Provide data required by the department to assess the effectiveness of the EMS/TC system;

(f) Provide matching grants from funds made available by the department. These funds shall:

(i) Not exceed fifty percent of the cost of the proposal for which the grant is made; except, the department may waive or modify the matching requirement if it determines insufficient local funding exists and the public health and safety would be jeopardized if the proposal were not funded;

(ii) Be made available to any public or private nonprofit agency which in the judgment of the council will best fulfill the purpose of the grant;

(iii) Be awarded to:

(A) Establish, develop, expand, and improve the EMS/TC system;

(B) Purchase EMS/TC equipment;

(C) Provide training and continuing education for EMS/TC personnel;

(D) Research and development activities pertaining to EMS/TC;

(E) Develop, implement, and evaluate prevention programs; or

(F) Accomplish other purposes as approved by the department;

(g) Adopt patient care procedures in consultation with the MPDs, local councils, and emergency communications centers. The patient care procedures shall 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 to first receive the patient, and the name and location of other trauma care facilities to receive the patient should an interfacility transfer be necessary. Procedures on interfacility transfer of patients shall be consistent with the transfer procedures in chapter 70.170 RCW, and:

(i) Identify types and expected volume of trauma that may exceed regional capabilities, taking into consideration resources available in other regions and adjacent states;

(ii) Include a description of activation of the trauma system.

(2) In areas where no local EMS/TC council exists, the regional EMS/TC council shall have all the authority, duties, and responsibilities of the local council, as described in WAC 246-976-970.

(3) Regional councils may:

(a) Apply for, receive, and accept gifts and other payments, including property and service, from any governmental or other public or private entity or person;

(b) Use these funds for any activities related to the design, maintenance, or enhancements of the EMS/TC system in the region; or

(c) Establish regional standards in the plan, including response times for verified services, which exceed the minimum requirements of this chapter.

(4) An EMS/TC provider who disagrees with the regional plan may appeal to the steering committee before the department approves the plan.)) (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) 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.

[Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-960, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending Order 323, filed 12/23/92, effective 1/23/93)

WAC 246-976-970
Local emergency medical services and trauma care councils.

(1) If a county or group of counties ((may)) creates a local EMS/TC council, it must be composed 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) In addition to meeting the requirements of chapter 70.168 RCW and this chapter, local EMS/TC councils ((shall)) must:

(a) ((Review, evaluate, and provide recommendations to the regional EMS/TC council regarding the provision of EMS/TC in the region, and provide recommendations on the regional EMS/TC plan;

(b) Recommend individuals to the department for membership on the regional EMS/TC council;

(c))) Participate with the MPD((,)) and emergency communication centers((, and the regional EMS/TC council)) in making recommendations to the regional council about the development of regional patient care procedures; and

(((d))) (b) Review senior EMS instructor applications and make recommendations to the department ((for individuals applying for recognition or renewal of recognition as senior EMT instructors)).

(c) Review applications for initial training classes and OTEP programs, and make recommendations to the department.

(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).

[Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-970, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending WSR 93-20-063, filed 10/1/93, effective 11/1/93)

WAC 246-976-990
Fees and fines.

(1) The department shall assess individual health care facilities submitting a proposal to be designated as a level I general trauma care facility a fee, not to exceed seven thousand dollars, to help defray the costs to the department of inspections and review of applications.

(2) The department shall assess individual health care facilities submitting a proposal to be designated as a level II general trauma care facility a fee, not to exceed six thousand dollars, to help defray the costs to the department of inspections and review of applications.

(3) The department shall assess individual health care facilities submitting a proposal to be designated as a level III general trauma care facility a fee, not to exceed one thousand nine hundred fifty dollars, to help defray the costs to the department of inspections and review of applications.

(4) The department shall assess individual health care facilities submitting a proposal to be designated as a level I pediatric trauma care facility a fee, not to exceed nine thousand two hundred dollars, to help defray the costs to the department of inspections and review of applications.

(5) The department shall assess individual health care facilities submitting a proposal to be designated as a level II pediatric trauma care facility a fee, not to exceed eight thousand dollars, to help defray the costs to the department of inspections and review of applications.

(6) The department shall assess individual health care facilities submitting a proposal to be designated as a level III pediatric trauma care facility a fee, not to exceed two thousand dollars, to help defray the costs to the department of inspections and review of applications.

(7) The department shall assess health care facilities submitting a joint proposal to be jointly designated as a level I general or pediatric trauma care facility a fee, of at least seven thousand dollars, and based upon a determined hourly rate and per diem expense per inspection team member, not to exceed fourteen thousand five hundred dollars to help defray the costs to the department of inspections and review of applications.

(8) The department shall assess health care facilities submitting a joint proposal to be jointly designated as a level II general or pediatric trauma care facility a fee, of at least six thousand dollars, and based upon a determined hourly rate and per diem expense per inspection team member, not to exceed twelve thousand five hundred dollars to help defray the costs to the department of inspections and review of applications.

(9) The department shall assess health care facilities submitting a joint proposal to be jointly designated as a level III general or pediatric trauma care facility a fee, of at least one thousand nine hundred fifty dollars, and based upon a determined hourly rate and per diem expense per inspection team member, not to exceed three thousand one hundred dollars to help defray the costs to the department of inspections and review of applications.

(10) The department shall assess health care facilities submitting a proposal to be designated at multiple levels to provide adult and pediatric care a fee, not to exceed nine thousand two hundred dollars to help defray the costs to the department of inspections and review of applications.

(11) The department shall not assess such fees to health care facilities applying to provide level IV and V trauma care services.

(12) ((The department may assess fines for ambulance or aid services failing to license within the specified periods. Delinquent fines shall be one hundred dollars for a service and twenty-five dollars per vehicle, and shall not exceed five hundred dollars.)) If an ambulance or aid service fails to comply with the requirements of chapters 18.71, 18.73, 70.168 RCW, the Uniform Disciplinary Act, or with the requirements of this chapter, the department may notify the appropriate local, state or federal agencies.

[Statutory Authority: Chapter 70.168 RCW. 93-20-063, 246-976-990, filed 10/1/93, effective 11/1/93. Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-990, filed 12/23/92, effective 1/23/93.]


REPEALER

     The following sections of the Washington Administrative Code are repealed:
WAC 246-976-020 First responder training -- Course contents, registration, instructor qualifications.
WAC 246-976-025 First responder -- Continuing medical education.
WAC 246-976-030 Emergency medical technician training -- Course content, registration, and instructor qualifications.
WAC 246-976-035 Emergency medical technician -- Continuing medical education.
WAC 246-976-040 Specialized training.
WAC 246-976-045 Levels of intermediate life support personnel and advanced life support paramedics.
WAC 246-976-050 Intravenous therapy technician training -- Course content, registration, instructor qualifications.
WAC 246-976-055 Intravenous therapy technicians -- Continuing medical education.
WAC 246-976-060 Airway technician training -- Course content, registration, instructor qualifications.
WAC 246-976-065 Airway technician -- Continuing medical education.
WAC 246-976-070 Combined intravenous therapy and airway technician training -- Course content, registration, instructor qualifications.
WAC 246-976-075 IV therapy/airway technician -- Continuing medical education.
WAC 246-976-076 Intermediate life support training -- Course content, registration, instructor qualifications.
WAC 246-976-077 Intermediate life support technicians -- Continuing medical education.
WAC 246-976-080 Paramedic training -- Course content.
WAC 246-976-085 Paramedic -- Continuing medical education.
WAC 246-976-110 Senior EMT instructor -- Qualifications and responsibilities.
WAC 246-976-120 Disciplinary action -- Training personnel.
WAC 246-976-140 Certification and recertification -- General requirements.
WAC 246-976-150 Certification and recertification -- First responder.
WAC 246-976-160 Certification and recertification -- Emergency medical technician.
WAC 246-976-165 Levels of certified intermediate life support personnel and paramedics.
WAC 246-976-170 Certification and recertification -- Intravenous therapy technicians.
WAC 246-976-180 Certification and recertification -- Airway technicians.
WAC 246-976-181 Certification and recertification -- Intermediate life support technician.
WAC 246-976-190 Recertification -- IV and airway technicians.
WAC 246-976-200 Certification and recertification -- Paramedics.
WAC 246-976-210 Certification -- Reciprocity, challenges, and reinstatement.
WAC 246-976-220 EMS personnel -- Scope of care authorized, prohibited.
WAC 246-976-230 Certification -- Reversion, revocation, suspension, modification, or denial.
WAC 246-976-240 Notice of decision and hearing.
WAC 246-976-280 Ground ambulance and aid services -- Personnel requirements.
WAC 246-976-350 Ambulance and aid services -- Variances from requirements.
WAC 246-976-370 Ambulance and aid services -- Prehospital trauma triage procedures.
WAC 246-976-440 Trauma registry -- Reports.
WAC 246-976-450 Access and release of trauma registry information.

Washington State Code Reviser's Office