Supplemental Notice to WSR 10-08-092.

     Preproposal statement of inquiry was filed as WSR 08-16-037.

     Title of Rule and Other Identifying Information: WAC 246-976-001 through 246-976-400, 246-976-890, 246-976-920 and 246-976-950, supplemental notice for emergency medical services (EMS) and trauma system (TS) prehospital rules and standards for training, licensure, and verification, and prehopsital [prehospital] system administration.

     Hearing Location(s): Washington State Department of Health, Town Center 1 Building, 101 Israel Road S.E., Room 163, Tumwater, WA 98501, on November 23, 2010, at 9:00 a.m.

     Date of Intended Adoption: November 30, 2010.

     Submit Written Comments to: Michael Lopez, P.O. Box 47853, Olympia, WA 98504-7853, web site http://www3.doh.wa.gov/policyreview/, fax (360) 236-2830, by November 23, 2010.

     Assistance for Persons with Disabilities: Contact Denece Thomas by November 22, 2010, TTY (800) 833-6388 or 711.

     Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The department determined that it would be beneficial to EMS licensees and stakeholders to restructure the format of the proposed rules filed April 6, 2010, to provide clarity of the requirements. The purpose of the proposed supplemental rules is to provide EMS stakeholders, licensees, and stakeholders an opportunity to review and comment on the proposed structure of the rules before adoption. The proposed rule language and intent has not changed substantively and new sections with tables have been added for clarity.

     Reasons Supporting Proposal: The proposed rules reflect changes in EMS industry standards and practice and objectives recommended by the governor's steering committee for EMS and TS in its 2006 strategic plan. The department also decided to restructure the format of the proposed rules in order to make the language clearer for stakeholders. In order for the stakeholders to have an opportunity to provide comments on the revised structure, the department will conduct a second public hearing prior to adopting the rules. Rules are needed to establish enforceable standards to reduce the risk of substandard care to the public.

     Statutory Authority for Adoption: RCW 70.168.050 and 70.168.060.

     Statute Being Implemented: Chapters 18.73, 18.71 RCW and RCW 70.24.260.

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

     Name of Proponent: Department of health, governmental.

     Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Michael Lopez, 243 Israel Road S.E., Tumwater, WA 98501, (360) 236-2841.

     No small business economic impact statement has been prepared under chapter 19.85 RCW. The proposed rule would not impose more than minor costs on businesses in an industry.

     A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Michael Lopez, P.O. Box 47853, Olympia, WA 98504-7853, phone (360) 236-2841, fax (360) 236-2830, e-mail michael.lopez@doh.wa.gov.

October 18, 2010

B. White

for Mary C. Selecky

Secretary

OTS-3038.10

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

WAC 246-976-001   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 establishes criteria for:

     (a) Training and certification of ((basic, intermediate and advanced life support technicians)) EMS providers;

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

     (c) Verification of prehospital trauma services;

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

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

     (f) A statewide emergency medical communication system;

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

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

[Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW. 00-08-102, § 246-976-001, 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), § 246-976-001, filed 12/23/92, effective 1/23/93.]

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

     (1) "Activation of the trauma system" means mobilizing resources to care for 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.))

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

     (3) "Advanced cardiac life support (ACLS)" means a course that includes the education and clinical interventions used to treat cardiac arrest and other acute cardiac related problems.

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

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

     (6) "Advanced life support (ALS)" means invasive emergency medical services requiring the advanced medical treatment skills of a paramedic.

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

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

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

     (("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.))

     (10) "Ambulance service" means an agency 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.))

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

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

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

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

     (("BLS" means basic life support.))

     (15) "Basic life support (BLS)" means emergency medical services requiring basic medical treatment skills as defined in chapter 18.73 RCW.

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

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

     (18) "BP" means blood pressure.

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

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

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

     (22) "County operating procedures" or "COPS" means the written operational procedures adopted by the county MPD and the local EMS council specific to county needs. COPS do not conflict with regional patient care procedures.

     (23) "CPR" means cardiopulmonary resuscitation.

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

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

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

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

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

     (29) "ED" means emergency department.

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

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

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

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

     (34) "EMS" means emergency medical services.

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

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

     (("EMT" means emergency medical technician.))

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

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

     (("ILS" means intermediate life support.))

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

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

     (41) "Intermediate life support (ILS)" means invasive emergency medical services requiring the advanced medical treatment skills of an advanced EMT (AEMT).

     (("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.))

     (42) "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)) a fluid or medication administered directly into the venous system.

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

     (44) "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)) it means the group of physicians in the county or counties.

     (45) "Medical control" means ((MPD authority to direct the)) oral or written direction of medical care ((provided by)) that certified prehospital EMS personnel ((in the prehospital EMS system)) provide to patients of all age groups. The oral or written direction is provided by the MPD or MPD delegate.

     (46) "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.

     (47) "Medical program director (MPD)" means ((medical program director.

     "Must" means shall.)) a person who meets the requirements of chapters 18.71 and 18.73 RCW and is certified by the department. The MPD is responsible for both the supervision of training and medical control of EMS providers.

     (48) "MPD delegate" means a physician appointed by the MPD and recognized and approved by the department. An MPD delegate may be:

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

     (b) A prehospital supervising physician who provides on-line medical control of EMS personnel.

     (49) "Ongoing training and evaluation program (OTEP)" ((or "ongoing training and evaluation program (OTEP)" or "OTEP" or "OTEP program" or "OTEP method" is)) means a continuous program of prehospital EMS education for EMS personnel ((that)) after completion of initial training. An OTEP is approved by the MPD and the department ((to)). An OTEP must meet the EMS education requirements and core topic content required for recertification. The OTEP method includes ((cognitive, affective and psychomotor)) evaluations of the knowledge and skills covered in the topic content following ((completion of)) each topic presentation ((to determine student competence of topic content)).

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

     (51) "Paramedic" or "physician's trained emergency medical service paramedic" means a person who((:

     • Has been trained in an approved program to perform all phases of prehospital emergency medical care, including advanced life support, under written or oral authorization of an MPD or approved physician delegate; and

     • Has been examined and certified as a paramedic by the department or by the University of Washington's school of medicine.)) has been trained in an approved program to perform all phases of prehospital emergency medical care, including advanced life support, under written or oral authorization of an MPD or approved physician delegate, examined and certified by the department under chapter 18.71 RCW.

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

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

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

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

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

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

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

     (("Prehospital agencies" means providers of prehospital care or interfacility ambulance transport.))

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

     (60) "Prehospital patient care protocols" means the department-approved, written ((procedures)) orders 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)) patients ((which includes the trauma care patient)). These protocols are related only to delivery and documentation of direct patient treatment. The protocols meet or exceed statewide minimum standards developed by the department in rule as authorized in chapter 70.168 RCW.

     (61) "Prehospital provider" means EMS provider.

     (62) "Prehospital trauma care service((s))" means ((agencies)) an agency that ((are)) is verified by the department to provide prehospital trauma care.

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

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

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

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

     (67) "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 direct patient care.)) department-approved written operating guidelines adopted by the regional emergency medical services and trauma care council, in consultation with the local emergency medical services and trauma care councils, emergency communication centers, and the emergency medical services medical program director, in accordance with statewide 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 are consistent with the transfer procedures in chapter 70.170 RCW. Patient care procedures do not relate to direct patient care.

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

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

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

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

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

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

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

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

     ((•)) (c) 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.))

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

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

     (75) "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 between one thousand ((to)) and two thousand people per square mile.

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

     (a) "Discovery time": The interval from injury to discovery of the injury((;)).

     (("System access time": The 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 interval from call received by the dispatcher to agency notification;

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

     • "En route time": The interval from the end of activation time to the beginning of on-scene time;

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

     • "On scene time": The interval from arrival at the scene to departure from the scene. This includes extrication, resuscitation, treatment, and loading;

     • "Transport time": The interval from leaving the scene to arrival at a health care facility;)) (b) "System access time": The interval from discovery of the injury to call received by 9-1-1 public safety answering point (PSAP).

     (c) "Call processing time": The interval from the time the PSAP answers the call and the time it takes the PSAP to:

     (i) Process the call, including caller interrogation; and

     (ii) Provide the call interrogation information to the EMS dispatcher.

     (d) "Dispatch time": The total time interval, including the call processing time, from when the call is received by the PSAP until the EMS agency is notified.

     (e) "En route time": The time interval from the time the agency is notified until the EMS vehicle is en route to the call.

     (f) "Arrival time": The time interval from when the EMS vehicle is en route until arrival at the incident scene.

     (g) "On scene time": The time interval from arrival at the scene until the EMS transport vehicle departs the incident scene.

     (h) "Transport time": The time interval from when the EMS transport vehicle leaves the incident scene until arriving at the health care facility.

     (77) "Training ((agency)) program" means an organization ((or individual)) that is approved by the department 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.))

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

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

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

     (81) "Urban" means:

     ((•)) (a) An incorporated area over thirty thousand; or

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

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

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

[Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW. 05-01-221, § 246-976-010, filed 12/22/04, effective 1/22/05; 00-08-102, § 246-976-010, filed 4/5/00, effective 5/6/00. 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.]

     (5) Discipline of EMS training programs.

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

     (i) Violations of chapter 246-976 WAC;

     (ii) Pending disciplinary actions;

     (iii) Falsification of EMS course documents; or

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

     (b) The training program may request a hearing to contest department decisions in regard to denial, suspension, modification, or revocation of training program approval in accordance with the Administrative Procedure Act (APA) (chapter 34.05 RCW) and associated administrative codes.

[]

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

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

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

     (4) Have written course approval from the department.

[]

     (a) The effectiveness of the training;

     (b) EMS provider knowledge and skills competency;

     (c) EMS provider ability to provide proper patient care after the training.

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

     (a) A needs statement describing what the proposed pilot will address;

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

     (c) The length of the pilot project;

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

     (e) Course curriculum/lesson plans;

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

     (g) Course prerequisites;

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

     (i) Prehospital patient care protocols for use in the pilot program.

     (3) The department will:

     (a) Review the request and training plan;

     (b) Consult with the prehospital technical advisory committee to determine the need for, and the benefits of the requested training throughout the state.

     (c) Based on recommendation of the prehospital TAC, approve or deny the request for the pilot program.

     (4) The MPD must report the results of the pilot training to the department and the prehospital TAC.

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

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

[]

     (b) The candidate or SEI may request a hearing to contest department decisions in regard to denial, suspension, modification or revocation of SEI recognition in accordance with the Administrative Procedure Act (APA) (chapter 34.05 RCW) and associated administrative codes.)) (1) Responsibilities and requirements.

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

     (b) The SEI must:

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

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

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

[Statutory Authority: RCW 18.73.081 and 70.168.120. 02-14-053, § 246-976-031, filed 6/27/02, effective 7/28/02. Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW. 00-08-102, § 246-976-031, filed 4/5/00, effective 5/6/00.]

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

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

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

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

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

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

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

[]

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

     (b) Failed to:

     (i) Maintain EMS certification;

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

     (A) Name;

     (B) Address;

     (C) Home and work phone numbers;

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

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

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

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

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

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

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

     (2) The candidate or SEI may request a hearing to contest department decisions in regard to denial, suspension, modification or revocation of SEI recognition in accordance with the Administrative Procedure Act (APA) (chapter 34.05 RCW) and associated administrative codes.

[]

     (2) An applicant for training at the intermediate (((IV, airway and ILS technicians)) AEMT) ((and advanced life support (paramedic) levels, you)) level, must ((have completed)) be currently certified as an EMT with at least one year ((as a certified EMT or above)) of experience.

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

[Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW. 00-08-102, § 246-976-041, filed 4/5/00, effective 5/6/00.]

     With approval of the MPD, a certified intermediate level technician or paramedic may function as an EMT in counties other than those described in (a) through (c) of this subsection.)) To apply for initial EMS provider certification following the successful completion of a Washington state approved EMS course, an applicant must submit to the department:

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

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

[Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW. 00-08-102, § 246-976-141, filed 4/5/00, effective 5/6/00.]

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

     (2) Proof of meeting the requirements identified in Table B.

[]

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

     (2) Proof of meeting the requirements identified in Table C.

[]

     (2) The department may extend the certification period to accommodate the efficient processing of recertification applications. The expiration date will be indicated on the certification card issued by the department.

     (3) Certification of AEMTs 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 medical control agreements are in place; or

     (c) In other counties when accompanying a patient in transit.

     (d) While responding to other counties for mutual aid purposes, mass care, or other incidents. In these situations, EMS provider will provide patient care following the prehospital patient care protocols of their supervising MPD.

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

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

[]

     (g) Education requirements for recertification - Table A:

((TABLE A: EDUCATION REQUIREMENTS FOR RECERTIFICATION	Basic Life Support		Intermediate Life Support (EMT-Intermediate Levels)					Paramedic (ALS)
	FR	EMT	IV	Air	IV/Air	ILS	ILS/Air	Paramedic
Annual Requirements
CPR & Airway	X	X	X	X	X	X	X
Spinal Immobilization	X	X	X	X	X	X	X
Patient Assessment	X	X	X	X	X	X	X
Certification Period Requirements
Infectious Disease	X	X	X	X	X	X	X	X
Trauma		X	X	X	X	X	X	X
Pharmacology		X	X	X	X	X	X
Other Pediatric Topics	X	X	X	X	X	X	X	X
*Additional education course hours totaling:	15 hrs	30 hrs	45 hrs	45 hrs	60 hrs	60 hrs	75 hrs	150 hrs))

	"X" indicates an individual must demonstrate knowledge and competency in the topic or skill.
	*Individuals obtaining education through the CME method must complete the total number of educational course hours indicated above. However, due to the competency-based nature of OTEP, fewer class hours may be needed to complete these requirements than the total course hours indicated above.

     (h) Skill maintenance requirements - Table B:

((TABLE B: SKILLS MAINTENANCE REQUIREMENTS		Intermediate Life Support (EMT-Intermediate Levels)					Paramedic (ALS)
		IV	Air	IV/Air	ILS	ILS/Air	Paramedic
First Certification Period
• First Year of Certification
IV Starts
	Continuing Education Method may not be averaged	36		36	36	36	36
	OTEP Method	12		12	12	12	12
Endotracheal intubations (4 must be performed on humans for each method)
	Continuing Education Method may not be averaged		12	12		12	12
	OTEP Method		4	4		4	4
Intraosseous infusion placement		X		X	X	X	X
• Second and Third Years of Certification
• Annual Requirements
IV Starts*
	Continuing Education Method	36		36	36	36	36
	OTEP Method	12		12	12	12	12
Endotracheal intubations* (4 per year must be performed on humans for each method)
	Continuing Education Method		12	12		12	12
	OTEP Method		4	4		4	4
Intraosseous infusion placement		X		X	X	X	X
• During the Certification Period
Pediatric airway management			X	X		X	X
Multi-lumen airway placement					X	X
Defibrillation					X	X
Later Certification Periods
• Annual Requirements
IV Starts		X		X	X	X	X
Endotracheal intubations (2 per year must be performed on humans for each method)
	Continuing Education Method		4	4		4	4
	OTEP Method		2	2		2	2
Intraosseous infusion placement		X		X	X	X	X
• During the Certification Period
Pediatric airway management			X	X		X	X
Multi-lumen airway placement					X	X
Defibrillation					X	X))

	"X" indicates an individual must demonstrate proficiency of the skill to the satisfaction of the MPD.
	*The second and third year requirements may be averaged over the two years.

     (i) Skill maintenance requirements for individuals requesting reciprocal certification:

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

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

     (iii) The county MPD may evaluate an individual's skills to determine if the individual is proficient in the application of those skills prior to recommending certification. The MPD may recommend an individual obtain specific training to become proficient in any skills deemed insufficient by the MPD or delegate.

     (j) Description of selected terms used in Tables A and B:

     (i) Class hours: Actual hours spent to become knowledgeable in a topic(s) or proficient in a skill(s).

     (ii) Course hours: The predetermined time scheduled to conduct a course or topic.

     (iii) CPR and airway management includes foreign body obstruction (FBAO) and the use of airway adjuncts appropriate to the level of certification, for adults, children and infants following national standards, assuring the following pediatric objectives are covered.

     Pediatric objectives - The EMS provider must be able to:

     (A) Identify and demonstrate airway management techniques for infants and children.

     (B) Demonstrate infant and child CPR.

     (C) Demonstrate FBAO technique for infants and children.

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

     (v) Infectious disease: Infectious disease training must meet the requirements of chapter 70.24 RCW.

     (vi) Intraosseous infusion: Proficiency in intraosseous line placement in pediatric patients.

     (vii) IV starts: Proficiency in intravenous catheterization performed on sick, injured, or preoperative adult and pediatric patients. With written authorization of the MPD, IV starts may be performed on artificial training aids.

     (viii) Multi-lumen airway placement: Proficiency includes the verification of tube placement and continued placement of the multi-lumen airway through procedures identified in county MPD protocols.

     (ix) Other pediatric topics: This includes anatomy and physiology and medical problems including special needs patients appropriate to the level of certification, assuring the following pediatric objectives are covered.

     (A) Anatomy and physiology - The EMS provider must be able to:

     (I) Identify the anatomy and physiology and define the differences in children of all ages.

     (II) Identify developmental differences between infants, toddlers, preschool, school age and adolescents, including special needs children.

     (B) Medical problems including special needs patients - The EMS provider must be able to:

     (I) Identify the differentiation between respiratory distress and respiratory failure.

     (II) Identify the importance of early recognition and treatment of shock in the infant and child patient.

     (III) Identify causes and treatments for seizures.

     (IV) Identify life-threatening complications of meningitis and sepsis.

     (V) Identify signs and symptoms of dehydration.

     (VI) Identify signs and symptoms of hypoglycemia.

     (VII) Identify how hypoglycemia may mimic hypoxemia.

     (VIII) Identify special needs pediatric patients that are technologically dependant (tracheotomy tube, central line, GI or feeding tubes, ventilators, community specific needs).

     (IX) Identify the signs and symptoms of suspected child abuse.

     (X) Identify the signs and symptoms of anaphylaxis and treatment priorities.

     (XI) Identify the importance of rapid transport of the sick infant and child patient.

     (x) Patient assessment: This includes adult, pediatric and geriatric patients appropriate to the level of certification, assuring the following pediatric objectives are covered.

     Pediatric objectives - The EMS provider must be able to:

     (A) Identify and demonstrate basic assessment skills according to the child's age and development.

     (B) Demonstrate the initial assessment skills needed to rapidly differentiate between the critically ill or injured and the stable infant and child patient.

     (C) Identify and demonstrate the correct sequence of priorities to be used in managing the infant and child patient with life threatening injury or illness.

     (D) Identify that the priorities for a severely injured and critically ill infant and child are:

     • Airway management,

     • Oxygenation,

     • Early recognition and treatment of shock,

     • Spinal immobilization,

     • Psychological support.

     (E) Demonstrate a complete focused assessment of an infant and a child.

     (F) Demonstrate ongoing assessment of an infant and a child.

     (G) Identify the differences between the injury patterns of an infant and a child compared to that of an adult.

     (H) Identify the psychological dynamics between an infant and a child, parent or caregiver and EMS provider.

     (xi) Pharmacology: Pharmacology specific to the medications approved by the MPD (not required for first responders).

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

     (xiii) Spinal immobilization and packaging: This includes adult, pediatric and geriatric patients appropriate to the level of certification, assuring the following pediatric objectives are covered.

     Pediatric objectives - The EMS provider must be able to:

     (A) Demonstrate the correct techniques for immobilizing the infant and child patient.

     (B) Identify the importance of using the correct size of equipment for the infant and child patient.

     (C) Demonstrate techniques for adapting adult equipment to effectively immobilize the infant and child patient.

     (xiv) Trauma: For adult, pediatric and geriatric patients appropriate to the level of certification, assuring the following pediatric objectives are covered.

     Pediatric objectives - The EMS provider must be able to:

     (A) Identify the importance of early recognition and treatment of shock in the infant and child patient.

     (B) Identify the importance of early recognition and treatment of the multiple trauma infant and child patient.

     (C) Identify the importance of rapid transport of the injured infant and child patient.)) (1) Education is required to recertify as an EMS provider.

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

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

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

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

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

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

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

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

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

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

     (5) Upon approval of the MPD, if an EMS provider is unable to complete the required endotracheal intubations as defined in WAC 246-976-162 or 246-976-163 the EMS provider may meet the endotracheal intubation requirements by completing an MPD and department-approved intensive airway management training program, covering all knowledge and skill aspects of emergency airway management.

[Statutory Authority: Chapters 18.71 and 18.73 RCW. 04-08-103, § 246-976-161, filed 4/6/04, effective 5/7/04. Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW. 00-08-102, § 246-976-161, filed 4/5/00, effective 5/6/00.]

     (1) Complete and document the requirements, indicated in Table A of this section, appropriate to the level of certification for each certification period.

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

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

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

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

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

     (iii) The care of cardiac and stroke patients.

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

     (c) Infectious disease: Infectious disease training must meet the requirements of chapter 70.24 RCW.

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

     (e) IV starts: Proficiency in intravenous catheterization performed on sick, injured, or preoperative adult and pediatric patients. With written authorization of the MPD, IV starts may be performed on artificial training aids.

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

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

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

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

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

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

     (l) Trauma: For adult, pediatric, and geriatric patients appropriate to the level of certification.

[]

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

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

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

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

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

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

     (i) Evaluators must:

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

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

     (C) Complete the evaluator application, DOH Form 530-012;

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

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

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

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

     (ii) Instructors must:

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

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

     (iii) Guest lecturers, when used, must have specific knowledge and experience in the skills of the prehospital emergency care field for the topic being presented and be approved by the county MPD to instruct EMS topics;

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

     (iii) The care of cardiac and stroke patients.

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

     (c) Infectious disease: Infectious disease training must meet the requirements of chapter 70.24 RCW.

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

     (e) IV starts: Proficiency in intravenous catheterization performed on sick, injured, or preoperative adult and pediatric patients. With written authorization of the MPD, IV starts may be performed on artificial training aids.

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

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

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

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

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

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

     (l) Trauma: For adult, pediatric, and geriatric patients appropriate to the level of certification.

[]

     (ii) Paramedics must successfully complete practical skills evaluations required by the MPD to determine ongoing competence.)) (1) To apply for recertification, an EMS provider must:

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

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

     (c) Submit to the department a completed certification application on forms provided by the department.

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

[Statutory Authority: Chapters 18.71 and 18.73 RCW. 04-08-103, § 246-976-171, filed 4/6/04, effective 5/7/04. Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW. 00-08-102, § 246-976-171, filed 4/5/00, effective 5/6/00.]

     (c) Within the scope of care that is:

     (((a))) (i) Included in the approved instructional guidelines/curriculum for the individual's level of certification; or

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

     (((c) That is)) (iii) Included in state approved county 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, the certified person in charge of the patient must consult with their on-line medical control as soon as possible. Medical control can only authorize a certified person to perform within their scope of practice.

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

[Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW. 00-08-102, § 246-976-182, filed 4/5/00, effective 5/6/00.]

     (2) 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)) (3) MPDs ((to recommend corrective action)) may perform counseling regarding the clinical practice of certified individuals.

     (((3))) (4) Before recommending ((revocation, suspension, modification, or denial of a certificate)) disciplinary action, the MPD must initiate ((corrective action)) protocol and procedural counseling with the certified individual, consistent with department ((procedures)) guidelines.

     (((4))) (5) 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)) is an immediate and critical threat to public health and safety.

     (((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)) The MPD may recommend denial or renewal of an individual's certification.

     (7) As required by RCW 18.130.080, 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)) is subject to the reporting requirements identified in chapter 246-16 WAC. An employing or sponsoring agency must report to the department the following:

     (a) When the certified individual's services have been terminated or restricted based upon a final determination that the individual has either committed an act or acts that may constitute unprofessional conduct; or

     (b) That the certified individual may not be able to practice his or her profession with reasonable skill and safety to consumers as a result of a mental or physical condition; or

     (c) When a certified individual is disciplined by an employing or sponsoring agency for conduct or circumstances that would be unprofessional conduct under RCW 18.130.180 of the Uniform Disciplinary Act.

[Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW. 00-08-102, § 246-976-191, filed 4/5/00, effective 5/6/00.]

     (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 statewide and regional EMS/TC plans and approved patient care procedures;

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

     (b) Proof of ((liability)) the following insurance coverage:

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

     (ii) Professional and general liability coverage;

     (((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))) (c) A map of the proposed response area;

     (((vi))) (d) The level of service to be provided: Basic life support (BLS), intermediate life support (ILS), or advanced life support (ALS) (paramedic); and the scheduled hours of operation((; and

     (vii))). Minimum staffing required for each level is as follows:

     (i) For aid service response:

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

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

     (C) An ALS level service will provide care with at least one paramedic.

     (ii) For ambulance services:

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

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

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

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

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

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

     (4) Licensed ambulance and aid services must comply with ((the)) department-approved prehospital ((trauma)) triage procedures ((defined in WAC 246-976-010)).

[Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW. 00-08-102, § 246-976-260, 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), § 246-976-260, filed 12/23/92, effective 1/23/93.]

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

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

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

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

     (2) 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 as provided in chapter 18.130 RCW. The department 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.

[Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW. 00-08-102, § 246-976-270, 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), § 246-976-270, filed 12/23/92, effective 1/23/93.]

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

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

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

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

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

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

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

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

     (6) Battery and generator system:

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

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

     (7) The ambulance must be equipped with:

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

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

     (((9))) (c) One ABC two and one-half pound fire extinguisher.

     (((10))) (8) Ambulance body requirements:

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

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

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

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

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

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

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

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

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

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

     (((11))) (9) Vehicle brakes, ((tires,)) regular and special electrical equipment, ((windshield wipers,)) heating and cooling units, safety belts, and window glass, must be ((in good working order)) functional at all times.

[Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW. 00-08-102, § 246-976-290, 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), § 246-976-290, filed 12/23/92, effective 1/23/93.]

Note: "asst" means assortment
TABLE ((C)) D: EQUIPMENT	AMBULANCE	AID VEHICLE
AIRWAY MANAGEMENT
Airway Adjuncts
Oral airway (((adult: sm, med, lg))) adult and pediatric	((1ea)) asst	((1ea)) asst
((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
Water-soluble lubricant	1	1
Oxygen delivery system built in	1	0
3000 L Oxygen ((cylinder)) supply, with regulator, 500 ((Lbs)) PSI minimum, or equivalent liquid oxygen system	1	0
300 L Oxygen ((cylinder)) supply, with regulator, 500 ((Lbs)) PSI minimum, or equivalent liquid oxygen system	2	1
((Regulator, oxygen (0-15+ Liter)	1	1))
Cannula, nasal, adult	4	2
O2 mask, nonrebreather, adult	4	2
O2 mask, nonrebreather, pediatric	2	1
BVM, with O2 reservoir
Adult, pediatric, infant	1 ea	1 ea
((Pediatric (w/sizes neonatal to adult)	1	1))
((Pocket mask or equivalent	1	1))
PATIENT ASSESSMENT AND CARE
Assessment
Sphygmomanometer
Adult, large	1	((0)) 1
Adult, regular	1	1
Pediatric	1	((0)) 1
Stethoscope, adult	1	1
Thermometer, ((hypothermia and hyperthermia)) per county protocol	1((ea))	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
Length based tool for estimating pediatric medication and equipment sizes	1	1
TRAUMA EMERGENCIES
((Trauma registry identification bands	Yes	Yes))
Triage identification for 12 patients per county protocol	Yes	Yes
Wound care
Dressing, sterile	asst	asst
Dressing, sterile, trauma	2	2
Roller gauze bandage	asst	asst
Medical tape	asst	asst
Self adhesive bandage strips	asst	asst
Cold packs	4	2
Occlusive dressings	2	2
((Burn sheets	2	2))
Scissors, bandage	1	1
Irrigation solution	2	1
Splinting
Backboard with straps	2	1
Head ((immobilizer)) immobilization equipment	1	1
Pediatric immobilization device	1	((0)) 1
Extrication collars, rigid
Adult (small, medium, large)	asst	asst
Pediatric or functionally equivalent sizes	asst	asst
Immobilizer, cervical/thoracic, adult	1	0
Splint, traction, adult w/straps	1	0
Splint, traction, pediatric, w/straps	1	0
Splint, adult (arm and leg)	2 ea	1 ea
Splint, pediatric (arm and leg)	1 ea	1 ea
General
Litter, wheeled, collapsible, with a functional restraint system per the manufacturer	1	0
Pillows, plastic covered or disposable	2	0
Pillow case, cloth or disposable	4	0
Sheets, cloth or disposable	4	((0)) 2
Blankets	2	2
Towels, cloth or disposable 12" x 23" minimum	4	((0)) 2
Emesis collection device	1	1
Urinal	1	0
Bed pan	1	0
OB kit	1	1
Epinephrine and supplies appropriate for level of certification per MPD protocols.
Adult	1	1
Pediatric	1	1
Storage and handling of pharmaceuticals in ambulances and aid vehicles must be in compliance with the manufacturers' recommendations.
Extrication plan: Agency must document how extrication will be provided when needed.
((Shovel	1	1
Hammer	1	1
Adjustable wrench, 8"	1	1
Hack saw, with blades	1	1
Crowbar, pinch point, 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: Chapters 18.71, 18.73, and 70.168 RCW. 00-08-102, § 246-976-300, 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), § 246-976-300, filed 12/23/92, effective 1/23/93.]

     (a) Is consistent with state and regional plans;

     (b) Is in good working order;

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

     (d) Allows communication with medical control.

     (2) If cellular telephones are used, there must also be another method of radio contact with dispatch and medical control for use when cellular service is unavailable.

     (3) Licensed ambulance services must provide each licensed ambulance with communication equipment which:

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

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

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

[Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW. 00-08-102, § 246-976-310, 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), § 246-976-310, filed 12/23/92, effective 1/23/93.]

     (1) Air ambulance services must:

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

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

     (c) Provide proof of compliance with Federal Acquisition Regulation (FAR), 14 CFR Part 135 of the operating requirements; commuter and on demand operations and rules governing persons on board such aircraft.

     (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 (CAMTS) 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;)) Licensed to practice in the state of Washington;

     (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) If the air medical service utilizes Washington certified EMS personnel:

     (i) The physician director must be a delegate of the MPD in the county where the air service declares its primary base of operation.

     (ii) Certified EMS personnel must follow department-approved MPD protocols when providing care;

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

     (i) Are configured so that the medical ((attendants)) personnel can access the patient. The configuration must allow medical personnel 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:

     (A) The capability to ((insure internal crew and air-to-ground exchange of information)) communicate between flight personnel ((and)), hospitals, medical control, and the ((flight operations)) services communication center((, and air traffic control facilities));

     (B) Helicopters must also have the capability to communicate with ground EMS services and public safety vehicles;

     (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))) (B) Cardiac monitor/defibrillator;

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

     (((E))) (D) 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, multiengine 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.)); and

     (vi) Helicopter aircraft must have a protective barrier sufficiently isolating the cockpit, to minimize in-flight distraction or interference.

     (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.

     (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)) are:

     (i) Air services operating aircraft for primary purposes other than civilian air medical transport((, but which)). These services 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;

     (ii) Air ambulance services that solely transport patients into Washington state from points originating outside of the state of Washington.

[Statutory Authority: RCW 18.73.140. 00-22-124, § 246-976-320, filed 11/1/00, effective 12/2/00. 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.]

     (a) Current certification levels of all personnel;

     (b) Any changes in staff affiliation with the ambulance and aid service to include new employees or employee severance; and

     (c) Make, model, and license number of all EMS response 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 WAC 246-976-430 for the trauma registry)).

     (2) ((Transporting agencies)) The certified EMS provider in charge of patient care must provide ((an initial written report of patient care to the receiving facility at the time the patient is delivered. For patients meeting the state of Washington prehospital trauma triage (destination) procedures, as described in WAC 246-976-930(3), the transporting agency must provide additional trauma data elements described in WAC 246-976-430 to the receiving facility within ten days)) the following information to the receiving facility staff:

     (a) At the time of arrival at the receiving facility, a minimum of a brief written or electronic patient report including agency name, EMS personnel, and:

     (i) Date and time of the medical emergency;

     (ii) Time of onset of symptoms;

     (iii) Patient vital signs including serial vital signs where applicable;

     (iv) Patient assessment findings;

     (v) Procedures and therapies provided by EMS personnel;

     (vi) Any changes in patient condition while in the care of the EMS personnel;

     (vii) Mechanism of injury or type of illness.

     (b) Within twenty-four hours of arrival, a complete written or electronic patient care report that includes at a minimum:

     (i) Names and certification levels of all personnel providing patient care;

     (ii) Date and time of medical emergency;

     (iii) Age of patient;

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

     (v) Patient vital signs, including serial vital signs if applicable;

     (vi) Patient assessment findings;

     (vii) Procedures performed and therapies provided to the patient; this includes the times each procedure or therapy was provided;

     (viii) Patient response to procedures and therapies while in the care of the EMS provider;

     (ix) Mechanism of injury or type of illness;

     (x) Patient destination.

     (c) For trauma patients, all other data points identified in WAC 246-976-430 for inclusion in the trauma registry must be submitted within ten days of transporting the patient to the trauma center.

     (3) Licensed services must make all patient care records available for inspection and duplication upon request of the county MPD or the department.

[Statutory Authority: RCW 70.168.060 and 70.168.090. 02-02-077, § 246-976-330, filed 12/31/01, effective 1/31/02. Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW. 00-08-102, § 246-976-330, 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), § 246-976-330, filed 12/23/92, effective 1/23/93.]

     (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.)) (1) The department verifies prehospital EMS services. Verification is a higher form of licensure that requires twenty-four-hour, seven day a week compliance with the standards outlined in chapter 70.168 RCW and this chapter. Verification will expire with the prehospital EMS service's period of licensure.

     (2) To qualify for trauma verification, an agency must be a licensed ambulance or aid service as specified in WAC 246-976-260.

     (3) The following EMS services may be verified:

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

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

     (c) Air ambulance service.

     (4) Personnel requirements:

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

     (i) Basic life support: At least one individual who is an EMR or above;

     (ii) Intermediate life support: At least one AEMT;

     (iii) Advanced life support - paramedic: At least one paramedic;

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

     (i) Basic life support: At least two certified individuals - one EMT plus one EMR;

     (ii) Intermediate life support: One AEMT, plus one EMT;

     (iii) Advanced life support - paramedic: At least two certified individuals - one paramedic and one EMT;

     (c) Verified air ambulance services must provide personnel as identified in WAC 246-976-320.

     (5) Equipment requirements:

     (a) Verified BLS vehicles must carry equipment identified in WAC 246-976-300, Table D;

     (b) Verified ILS and paramedic vehicles must provide equipment identified in Table E of this section, in addition to meeting the requirements of WAC 246-976-300;

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

TABLE E: EQUIPMENT FOR VERIFIED TRAUMA SERVICES (NOTE: "ASST" MEANS ASSORTMENTS. "X" INDICATES REQUIRED.)					AMBULANCE		AID VEHICLE
					PAR	ILS	PAR	ILS
AIRWAY MANAGEMENT
	Airway adjuncts
		Adjunctive airways, assorted per protocol			X	X	X	X
		Laryngoscope handle, spare batteries			1	1	1	1
			Adult blades, set		1	1	1	1
			Pediatric blades, straight (0, 1, 2)		1 ea	1 ea	1 ea	1 ea
			Pediatric blades, curved (2)		1 ea	1 ea	1 ea	1 ea
		McGill forceps, adult & pediatric			1	1	1	1
		ET tubes, adult and pediatric			asst	0	asst	0
	Supraglottic airways per MPD protocol				X	X	X	X
	End-tidal CO2 detector				1 ea	1 ea	1 ea	1 ea
	Oxygen saturation monitor				1 ea	1 ea	1 ea	1 ea
TRAUMA EMERGENCIES
	IV access
		Administration sets and intravenous fluids per protocol:
			Adult		4	4	2	2
			Pediatric volume control device		2	2	1	1
		Catheters, intravenous (14-24 ga)			asst	asst	asst	asst
			Needles
				Hypodermic	asst	asst	asst	asst
				Intraosseous, per protocol	2	2	1	1
		Sharps container			1	1	1	1
		Syringes			asst	asst	asst	asst
	Glucose measuring supplies				Yes	Yes	Yes	Yes
	Pressure infusion device				1	1
	Length based tool for estimating pediatric medication and equipment sizes				1	1	1	1
	Medications according to local patient care protocols

     (6) Aid service response time requirements: Verified aid services must meet the following minimum agency response times as defined by the department and identified in the regional plan:

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

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

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

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

     (7) Ground ambulance service response time requirements: Verified ground ambulance services must meet the following minimum agency response times for all EMS and trauma responses to response areas as defined by the department and identified in the regional plan:

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

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

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

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

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

     (9) Verified ambulance and aid services must comply with the approved prehospital trauma triage procedures defined in WAC 246-976-010.

     (10) The department will:

     (a) Identify minimum and maximum numbers of prehospital services, based on:

     (i) The approved regional EMS and trauma plans, including: Distribution and level of service identified for each response area; and

     (ii) The Washington state EMS and trauma plan;

     (b) With the advice of the steering committee, consider all available data in reviewing response time standards for verified prehospital trauma services at least biennially;

     (c) Administer the BLS/ILS/ALS verification application and evaluation process;

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

     (e) Obtain comments from the regional council as to whether the application(s) appears to be consistent with the approved regional plan;

     (f) Provide written notification to the applicant(s) of the final decision in the verification award;

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

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

     (11) The department may:

     (a) Conduct a preverification site visit; and

     (b) Grant a provisional verification not to exceed one hundred twenty days. The department may withdraw the provisional verification status if provisions of the service's proposal are not implemented within the one hundred twenty-day period, or as otherwise provided in chapter 70.168 RCW and this chapter.

[Statutory Authority: RCW 18.73.140. 00-22-124, § 246-976-390, filed 11/1/00, effective 12/2/00. 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.]

     (a) Provide a description of the documents an applicant must submit to demonstrate that it meets the standards as identified in chapter 70.168 RCW and WAC 246-976-390;

     (b) Conduct a preverification on-site review for:

     (i) All ALS ambulance service applications;

     (ii) All ILS ambulance service applications; and

     (iii) All BLS ambulance applications if and when there is any question of duplication of services or lack of coordination of prehospital services within the region;

     (c) Request comments from the region in which a verification application is received, to be used in the department's review;

     (d) Apply the department's evaluation criteria; and

     (e) Apply the department's decision criteria.

     (2) To apply for verification you must:

     (a) Be a licensed prehospital EMS ambulance or aid service as specified in WAC 246-976-260;

     (b) Submit a completed application:

     (i) If you are applying for verification in more than one region, you must submit a separate application for each region;

     (ii) You must apply for verification when you are:

     (A) An agency that responds to 9-1-1 emergencies as part of its role in the EMS system;

     (B) A new business or legal entity that is formed through consolidation of existing services or a newly formed EMS agency;

     (C) An EMS agency that seeks to provide prehospital emergency response in a region in which it previously has not been operating; or

     (D) A service that is changing, or has changed its type of verification or its verification status.

     (3) The department will evaluate each prehospital EMS service applicant on a point system. In the event there are two or more applicants, the department will verify the most qualified applicant. The decision to verify will be based on at least the following:

     (a) Total evaluation points received on all completed applications:

     (i) Applicants must receive a minimum of one hundred fifty points of the total two hundred points possible from the overall evaluation scoring tool to qualify for verification.

     (ii) Applicants must receive a minimum of thirty points in the evaluation of its clinical and equipment capabilities section of the evaluation scoring tool to qualify for verification;

     (b) Recommendations from the on-site review team, if applicable;