Date of Adoption: October 24, 2000.

Purpose: The proposed rule change will require all air ambulance services to be accredited by the Commission on Accreditation of Medical Transport Services (CAMTS) or another accrediting organization approved by the department as having equivalent requirements as CAMTS before they are licensed and verified. A provisional license will be granted to those new services requesting licensure that are ineligible to apply for CAMTS accreditation based upon stated CAMTS requirements. The requirement will ensure public safety, meet patient's needs and assure conformity between Washington air ambulance standards and the current national standards.

Citation of Existing Rules Affected by this Order: Amending WAC 246-976-320 and 246-976-390.

Statutory Authority for Adoption: RCW 18.73.140.

Adopted under notice filed as WSR 00-17-181 on August 23, 2000.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 2, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 2, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 2, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 0, Repealed 0. Effective Date of Rule: Thirty-one days after filing.

October 31, 2000

Nancy Ellison

Deputy

for Mary C. Selecky

Secretary

OTS-4122.4

AMENDATORY SECTION(Amending WSR 00-08-102, filed 4/5/00, effective 5/6/00)

WAC 246-976-320
Air ambulance services.

(1) Air ambulance services must:

     (a) Comply with all regulations in this chapter pertaining to ambulance services and vehicles, except that WAC 246-976-290 and 246-976-300 are replaced for air ambulance services by subsection (((2))) (4)(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 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;

     (d) Air ambulance services must provide a physician director who is practicing medicine in the response area of the aircraft, as identified in the state EMS/TC plan.

     (2) Air ambulance services currently licensed or seeking relicensure after July 31, 2001, must have and maintain accreditation by the Commission on Accreditation of Medical Transport Services or another accrediting organization approved by the department as having equivalent requirements as CAMTS for aeromedical transport. Until August 1, 2001, subsections (4) and (5) of this section apply to air ambulance services currently licensed or seeking relicensure.

     (3) Air ambulance services requesting initial licensure that are ineligible to attain accreditation because they lack a history of operation at the site, must meet the criteria of subsections (4) and (5) of this section and within four months of licensure must have completed an initial consultation with CAMTS or another accrediting organization approved by the department as having equivalent requirements as CAMTS for aeromedical transport. A provisional license will be granted for no longer than two years at which time the service must provide documentation that it is accredited by CAMTS or another accrediting organization approved by the department as having equivalent requirements as CAMTS for aeromedical transport.

     (4) Air ambulance services 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;

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

     (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 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 must be trained in prehospital emergency care;

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

     (i) Are configured so that the medical attendants can access the patient to begin and maintain advanced life support and other treatment;

     (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, 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.

     (((3))) (5) All air medical personnel 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.

     (((4))) (6) Exceptions:

     (a) If aeromedical evacuation of a patient is necessary because of a life threatening condition and a licensed air ambulance is not available, the nearest available aircraft that can accommodate the patient may transport.      The physician ordering the transport 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.

[Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW.      00-08-102, § 246-976-320, filed 4/5/00, effective 5/6/00.      Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW.      93-01-148 (Order 323), § 246-976-320, filed 12/23/92, effective 1/23/93.]

(1) The department will:

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

     (b) 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) Air ambulance service: After July 31, 2001, the department will consider that an air ambulance service has met the requirements of subsections (4), (6), and (9) of this section if it has been accredited by CAMTS or another accrediting organization approved by the department as having equivalent requirements as CAMTS for aeromedical transport;

     (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 for aid and ground ambulance services 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;

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

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

     (2) 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) A policy that a trauma training program is required for all personnel responding to trauma incidents.      The program 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 within the agency response times identified in this section; and

     (d) Documentation that the provider will participate in an approved regional quality assurance program.

     (5) Verified aid services must provide personnel on each trauma response including:

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

     (b) Intermediate life support:

     (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) Advanced life support - Paramedic: At least one paramedic.

     (6) Verified ambulance services must provide personnel on each trauma response including:

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

     (b) Intermediate life support:

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

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

     (iii) One IV technician and one airway technician;

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

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

     (8) Verified ILS and paramedic vehicles must provide equipment 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
		Adjunctive airways, per protocol		1	1	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, powered		1	1	1	1
PATIENT ASSESSMENT AND CARE
		Sphygmomanometer
			Adult, large	1	1	1	1
			Pediatric	1	1	1	1
TRAUMA EMERGENCIES
	IV access
		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	Yes	Yes	Yes
		Pressure infusion device		1	1	1	1
		Medications according to local patient care protocols

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

     (10) Verified aid services must meet the following minimum agency response times for all major trauma responses to response areas as defined by the department and identified in the regional plan:

     (a) To urban response areas: Eight minutes or less, eighty percent of the time;

     (b) To suburban response areas: Fifteen minutes or less, eighty percent of the time;

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

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

     (11) Verified ground ambulance services must meet the following minimum agency response times for all major trauma responses to response areas as defined by the department and identified in the regional plan:

     (a) To urban response areas: Ten minutes or less, eighty percent of the time;

     (b) To suburban response areas: Twenty minutes or less, eighty percent of the time;

     (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) Verified air ambulance services must meet minimum agency response times as identified in the state plan.

[Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW.      00-08-102, § 246-976-390, filed 4/5/00, effective 5/6/00.      Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW.      93-01-148 (Order 323), § 246-976-390, filed 12/23/92, effective 1/23/93.]

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