WSR 24-03-061

PROPOSED RULES

DEPARTMENT OF HEALTH

[Filed January 12, 2024, 8:03 a.m.]

Original Notice.

Preproposal statement of inquiry was filed as WSR 22-11-065.

Title of Rule and Other Identifying Information: Emergency medical services (EMS) and trauma care systems chapter updates. The department is proposing amendments to update and align requirements with national standards in WAC 246-976-010 through 246-976-182, 246-976-260 through 246-976-310, 246-976-330 through 246-976-395, 246-976-920, 246-976-960 and 246-976-970; and proposing new WAC 246-976-026, 246-976-139, and 246-976-261.

Hearing Location(s): On March 7, 2023, at 9:00 a.m, at the Washington State Department of Health, 111 Israel Road S.E., Town Center 2, Room 166, Tumwater, WA 98501; or via Zoom. Register in advance for this webinar https://us02web.zoom.us/webinar/register/WN_Okt_TvufQka8j3B5LudthA. After registering, you will receive a confirmation email containing information about joining the webinar. The department of health (department) will be offering a hybrid hearing. You may attend the hybrid hearing virtually or in person. You may also submit comments in writing.

Date of Intended Adoption: March 14, 2024.

Submit Written Comments to: Catie Holstein, EMS Director, P.O. Box 47853, Olympia, WA 98504-7853, email https://fortress.wa.gov/doh/policyreview/, fax 360-236-2830, by March 7, 2024.

Assistance for Persons with Disabilities: Contact Jill Hayes, phone 360-236-2838, fax 360-236-2830, TTY 800-833-6388 or 711, email jill.hayes@doh.wa.gov, by February 22, 2024.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The department of health (department) identified updates, revisions, and housekeeping items needed for this chapter. By doing so, the department will satisfy the requirements of RCW 43.70.041, which directs the department to establish a formal review process of existing rules every five years to reduce the regulatory burden on businesses without compromising public health and safety. The department is proposing amendments to align with current national standards, make rules more clear, concise, and organized, propose changes to address barriers to initial and renewal application processes, and respond to new legislative requirements.

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

Reasons Supporting Proposal: The current rules in WAC 246-976-010 through 246-976-182, 246-976-260 through 246-976-310, 246-976-330 through 246-976-395, 246-976-920, 246-976-960, and 246-976-970 have not been updated since 2011. Since then, substantial changes to EMS minimum standards promoted by nationally recognized EMS organizations have occurred. The EMS scope of practice has evolved significantly in the last five years as EMS has been used as a force multiplier to help address the gaps and needs of the evolving health care system. During the coronavirus disease 2019 (COVID-19) pandemic, EMS played an integral role in mitigation of the public health threat. In partnership with public health, the EMS scope of practice and environment of practice was expanded and the department is seeking to codify some of the changes to allow EMS to continue to support public health with emerging and ongoing public health threats. The department is scrutinizing some rules to identify standards that can be reduced in response to concerns from interested parties regarding barriers and delays for obtaining an EMS certification and instructor recognition, which primarily impacts the ability for rural EMS services who are dependent on volunteers with recruitment and retention of certified EMS personnel. The loss of a volunteer EMS workforce is a significant concern, and the department is working to reduce the burden of some standards on rural EMS services.

The proposed rule reflects a number of statutory amendments that were made by the Washington state legislature from 2017 through 2022, including:

In addition to proposed changes to existing rules, the department is proposing new WAC 246-976-026, 246-976-139, and 246-976-261.

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

Statute Being Implemented: RCW 18.71.205, 18.73.081, and 70.168.050.

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: Catie Holstein, 111 Israel Road S.E., Tumwater, WA 98501, 360-236-2841.

A school district fiscal impact statement is not required under RCW 28A.305.135.

A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Catie Holstein, P.O. Box 47853, Olympia, WA 98504-7853, phone 360-236-2841, fax 360-236-2830, TTY 800-833-6388 or 711, email HSQA.EMS@doh.wa.gov.

This rule proposal, or portions of the proposal, is exempt from requirements of the Regulatory Fairness Act because the proposal:

Is exempt under RCW 19.85.025(3) as the rules relate only to internal governmental operations that are not subject to violation by a nongovernment party; rules are adopting or incorporating by reference without material change federal statutes or regulations, Washington state statutes, rules of other Washington state agencies, shoreline master programs other than those programs governing shorelines of statewide significance, or, as referenced by Washington state law, national consensus codes that generally establish industry standards, if the material adopted or incorporated regulates the same subject matter and conduct as the adopting or incorporating rule; rules only correct typographical errors, make address or name changes, or clarify language of a rule without changing its effect; and rules adopt, amend, or repeal a procedure, practice, or requirement relating to agency hearings; or a filing or related process requirement for applying to an agency for a license or permit.

Is exempt under RCW 19.85.025(4).

Explanation of exemption(s): Rule sections are exempt as follows:

Scope of exemption for rule proposal:

Is partially exempt:

Explanation of partial exemptions: [See below.]

The proposed rule does impose more-than-minor costs on businesses.

Small Business Economic Impact Statement

The department is proposing amendments to EMS rules in chapter 246-976 WAC. The proposed amendments:

1. Align with current national standards.

2. Clarify scope of practice for certified EMS providers and propose minimum standards for provisional certification of EMS providers (SHB 1893 EMTs and public health, 2021-22).

3. Update education requirements for certified EMS providers (SHB 1258 Concerning EMS and persons with disabilities, 2017-18 and ESHB 1551 Modernizing control of certain communicable diseases HIV/AIDS education repeal, 2019-20, and ESSB 5229 Health equity continuing education for healthcare professionals, 2021-22).

4. Address barriers to initial and renewal application processes for prehospital services licenses and EMS provider certification.

5. Reduce barriers to obtain recognition as a senior EMS instructor.

6. Clarify staffing standards for EMS services authorized to use nonmedically trained drivers (ESSB 5751 Concerning personnel requirements for municipal ambulance services, 2017-18).

7. Clarify roles and responsibilities for medical program directors, and local and regional EMS and trauma care councils.

8. Clarify licensing standards for EMS services for reporting to the statewide EMS data registry and roles and responsibilities for medical program directors, and regional councils (SSB 5380 Concerning opioid use disorder treatment, prevention, and related services, 2019-20).

9. Propose minimum standards for emergency services supervisory organizations to use certified EMS providers (SHB 1276 EMS in diversion centers, 2021-22).

10. Make rules more clear, concise, and organized.

11. Add new sections as required.

The current rules: Establish the standards and qualifications for the issuance, suspension, and revocation of an EMS service license and trauma verification, EMS provider certification, EMS instructor recognition, EMS training program and training course approval, and minimum prerequisites required for a person to attend an initial EMS training course; establish the minimum requirements for continuing education and scope of practice and specify the provisions of specialized training for certified EMS providers; prescribe the roles and responsibilities of EMS physician medical program directors and establish qualifications for the issuance, suspension, and revocation of the medical program director certification; and prescribe the minimum roles and responsibilities for local and regional EMS and trauma care councils.

The department identified updates, revisions, and housekeeping items needed for this chapter. By doing so, the department will satisfy the requirements of RCW 43.70.041, enacted and codified in 2013, which directs the department and other state agencies to establish a formal review process of existing rules every five years to reduce the regulatory burden on businesses without compromising public health and safety.

It is anticipated that the proposed amendments to existing rules and establishing new sections will ensure regulations and standards that are clear, concise, and reflect current standards of care and best practice for the benefit and safety of the public.

The department reviewed the current rules in chapter 246-976 WAC, which have not been updated since 2011.

Since then, substantial changes to EMS minimum standards promoted by nationally recognized EMS organizations have occurred. The EMS scope of practice has evolved in the last five years, as EMS has been used as a force multiplier to help address the gaps and needs of the evolving health care system. During the 2019 COVID-19 pandemic, EMS played an integral role in mitigation of the public health threat. EMS worked in partnership with public health expanding their scope of practice and environment of practice under provisions of the declared emergency. The department is seeking to codify some of these changes to allow EMS to continue to support public health with emerging and ongoing public health threats.

The department is scrutinizing some rules to identify standards that can be reduced in response to concerns from partners and interested parties regarding barriers and delays for obtaining an EMS certification and instructor recognition which primarily impacts the ability for rural EMS services who are dependent on volunteers with recruitment and retention of certified EMS personnel. The loss of a volunteer EMS workforce is a significant concern, and the department is working to reduce the burden of some standards on rural EMS services.

The roles and responsibilities of EMS medical program directors (MPD) need to be consolidated into one area of rule, revised, and updated to be clearer about what the MPD's role is and what the MPD is authorized to do. Medical oversight of EMS has evolved with the implementation of EMS partnerships with other health care providers to respond to behavioral health, public health, and establishing community paramedic programs. The role of the MPD needs to be clarified in response to new legislation that establishes a new statewide EMS data system.

The roles and responsibilities of local and regional EMS and trauma care councils have evolved because of the rapid changes in our health care system and the COVID-19 pandemic. The department is seeking to update minimum standards and conduct general housekeeping in the rules for local and regional councils to reflect current needs and expectations for council activities.

The department has heard complaints from interested parties about the overall organization of the EMS rules, that the rules are confusing and unclear, sometimes conflict with each other, that multiple rules must be referenced to understand standards or processes for one thing, or that they cannot easily find a rule that applies to their situation. The department is seeking to address the concerns by upstaging, clarifying, and reorganizing rules to be more user friendly.

The department is responding to new legislation and proposes to make necessary updates, revisions, and additions to the EMS rules accordingly.

The probable compliance requirements that a business is likely to need include:

The proposed rules do not impose additional requirements for new kinds of professional services that a small business is likely to need to comply with the proposed rule that EMS organizations and training programs do not already have. EMS organizations have an EMS service supervisor and staff operating in an administrative capacity to manage the business aspects of their organizations. Training programs have a training program director responsible for providing oversight of the training program and managing the administrative aspects of the program.

SBEIS Table 1. Summary of businesses required to comply to the proposed rule:

Portions of the rule proposal are exempt from requirements of the Regulatory Fairness Act (chapter 19.85 RCW). Exemptions are identified above.

The department does not anticipate that compliance with the proposed rules will cause ambulance services or approved EMS training programs to lose sales or revenue due to compliance with the proposed rules.

Description: WAC 246-976-022 establishes minimum standards for EMS training programs to be approved and reapproved and includes provisions for discipline.

Proposed changes exempt from analysis under RCW 34.05.328 (5)(b)(iii) "Rules adopting … without material change … national consensus codes" and RCW 34.05.328 (5)(b)(iv) "Rules that only … clarify language of a rule without changing its effect.":

1. Description: Adds the requirement that training programs must allow students who successfully pass their course an opportunity to take the certification examination and that for basic life support (BLS), intermediate life support (ILS), and advanced life support (ALS) level courses, the training program must conduct the psychomotor examinations and competence assessments as required by the department.

Cost: The department anticipates that requiring training programs for BLS, ILS, and ALS level courses to conduct the psychomotor examinations and competence assessments will not present an additional cost to BLS or ILS programs but will present an additional cost to ALS programs that are not currently offering these until the National Registry of Emergency Medical Technicians sunsets the psychomotor examination requirement in 2024. Once the psychomotor examination requirement is sunset, training programs will be expected to provide students opportunities to demonstrate proficiency in psychomotor skills throughout the duration of the course instead of taking a summative psychomotor examination to qualify for certification.

The cost for a training program to begin administering the psychomotor exam will vary. The cost will depend on the level of the examination (emergency medical responder, emergency medical technician (EMT), advanced emergency medical technician, or paramedic level), the availability of volunteers and EMS evaluators to staff the examination, and the degree of other community support, such as donations of facilities, supplies, etc. The department provides staff that operate as proctors for the examination at no cost to training programs.

The department used the following estimates in the cost calculation:

The department estimates the cost of conducting one psychomotor examination:

The department has no way to estimate how many psychomotor examinations will take place in any given year.

2. Description: Amends the requirement for maintaining training records from four to seven years and allows for these records to be in electronic as well as paper format.

Cost: The department does not anticipate that the proposed amendment will place additional financial burden on training programs. The amendment would allow programs to use electronic instead of paper recordkeeping and would require records be kept for seven years (two recertification cycles for certified EMS providers) or for the duration of their organization's required record retention schedule, whichever is greater. The department anticipates that the proposed allowance for programs to retain records in either electronic format or paper could be a cost savings for some programs, as it could reduce filing space and staff time in managing paper documents.

3. Description: Adds the requirement that the training program provide students access to the Washington state EMS student survey and clarifies what information training programs must provide the department on their annual report.

Cost: There is no additional cost to providing students access to the Washington state EMS student survey and clarifying what must be on the annual report. The department provides a no cost option for training programs to use for the survey requirement. Annual reports submitted to the department already include the information that was clarified in the proposed rule and therefore the department does not anticipate that additional time will be needed from training programs to provide information.

4. Description: Clarifies what is required of the training program to become reapproved and amends renewal requirement for BLS and ILS training programs to every three years instead of every five years. The renewal requirement for ALS training programs remains every five years.

Cost: The department anticipates that shortening the renewal cycle interval for BLS and ILS training programs from every five years to every three years will create a negligible increased cost in staff time to prepare application materials.

Description: WAC 246-976-023 establishes minimum standards for initial EMS training course requirements and the approval process.

Proposed changes exempt from analysis under RCW 34.05.328 (5)(b)(iii) "Rules adopting … without material change … national consensus codes" and RCW 34.05.328 (5)(b)(iv) "Rules that only … clarify language of a rule without changing its effect":

Remove a requirement for training program directors and instructors to receive a recommendation from the local EMS and trauma councils to hold an initial course.

Cost: The department does not anticipate additional fiscal impact on training programs or instructors because of the proposed amendments. The department has developed and offers a no cost curriculum for the required education from new legislation that has passed.

Description: WAC 246-976-260 prescribes the requirements for ambulance and aid service licensing.

Proposed changes exempt from analysis under RCW 34.05.328 (5)(b)(iv) "Rules that only… clarify language of a rule without changing its effect." and RCW 34.05.328 (5)(c)(i) "rule that adopts, amends, or repeals … process requirements for making application to an agency for a license …" and RCW 34.05.328 (5)(b)(iii) rules adopting or incorporating by reference without material change …":

1. Make consistent to the extent possible the application process and requirements for supplemental documentation between license and verification.

2. Make consistent to the extent possible staffing and equipment standards between licensure and verification.

3. Modernize, make consistent, and reduce non-value-added application process steps and requirements for supportive documentation.

4. Allow rural EMS services to request to be approved to use nonmedically trained drivers to meet staffing standards in response to ESSB 5751 Concerning personnel requirements for municipal ambulance services, 2017-18.

5. Add the requirement for EMS services to reporting to the statewide EMS data registry in response to SSB 5380 Concerning opioid use disorder treatment, prevention, and related services, 2019-20.

Cost: The department does not anticipate additional fiscal impact of the proposed amendments to application process requirements and steps, staff and equipment standards, and EMS service requests, because the proposed amendments do not impose requirements that incur additional cost.

EMS that are already submitting data to the department and are already set up to do so will not incur additional costs. The department acknowledges that there are 131 EMS services not currently reporting to Washington EMS information system (WEMSIS). Among those, 72 are either recording services on paper records (26 services) or have an unknown record tracking system (46 services). These services will need to create a pathway for data submission. The remaining 59 services currently contract with a compliant reporting system that can add WEMSIS reporting at no cost. The department offers a no cost solution for EMS services to report data to the state EMS data registry; however, the department acknowledges that this will take administrative time to set up, estimating a one-time range of 5 - 10 hours using the median hourly wage in Washington of a medical secretary or administrative assistant of $23.07 per hour,3[3] resulting in a total probable one-time cost of $115.35 - $230.70.

Description: WAC 246-976-261 prescribes the requirements for emergency services supervisory organizations (ESSO) recognition. In 2021-2022, the department advanced legislation to codify a policy that allowed certain organizations to be recognized by the department to use certified EMS personnel.

The proposed rule establishes minimum standards for ESSOs to use certified EMS providers in response to SHB 1276 EMS in diversion centers, 2021-22.

Cost: The department does not anticipate any additional fiscal impact for currently recognized ESSOs because they already meet the minimum standards prescribed in the existing rule. Based on data from the department's licensing system, the number of certified EMS providers working with currently recognized ESSOs is 17.

However, for any new organizations who want to apply to become recognized as an ESSO, the department has provided cost estimates.

Cost of Administrative Requirements: New ESSOs are required to complete various administrative requirements (complete an application, provide an operational plan, provide a current list of certified EMS providers, and request comments and recommendations for recognition as an ESSO from the local EMS and trauma care council and the medical program director in all counties in which the organization will be conducting activities using verified EMS providers) to comply with the proposed rules. The department estimates the number of hours to complete the requirement at no more than 8 hours of an EMS chief's time, at an average salary in Washington state of $42.34 hourly4[4], resulting in an estimated cost of $338.72 annually.

Cost of Training: While the proposed rule requires ESSOs to ensure that certified emergency medical service providers can meet the training requirements to maintain their certification, the proposed rule does not require the ESSO to establish an ongoing training and education program to do so. It is important to note that most certified EMS providers who work for ESSOs are also affiliated with licensed EMS services who provide ongoing training and education programs to meet the recertification needs of certified EMS providers. ESSOs could choose to either:

1. Establish a policy that requires the certified EMS provider to maintain their own education through their affiliation with their primary licensed EMS service or obtain continuing education on their own.

Cost: This option is free to the organization as it is the EMS provider's responsibility to maintain their own EMS certification. This is the current standard amongst current recognized ESSOs.

2. Establish an ongoing education and training program (OTEP). If an ESSO chooses to do this, the most common scenario would be for the ESSO to subscribe to an existing online platform that provides continuing education.

Cost: Most online platforms that offer continuing education for certified EMS providers charge a monthly or yearly subscription fee (SBEIS Table 2). In Washington state, the most common learning management system for continuing education is Vector Solutions.

The department asked current providers to share cost estimates to understand potential one-time set-up costs and recurrent monthly or yearly costs for participants (SBEIS Table 2).

SBEIS Table 2. Costs for example training programs to comply with the proposed rule:

*Participants are required to pay the setup fee plus either per month or per year, but not both.

Cost of Equipment: The proposed rule requires ESSOs to provide medical equipment for the level of service the ESSO will provide. The department anticipates that some new organizations who want to apply to become recognized as an ESSO will have costs.

The department estimates the cost of new equipment and supplies to comply with the proposed rule as indeterminate for the following reasons: The level of medical equipment and supplies needed to comply will vary due to the scope of the breadth and depth of specialty care service an ESSO chooses to provide; start-up costs are variable because if they are an already existing service the department assumes that they will likely carry some of the required supplies and therefore will not need to purchase all of the supplies; and recurrent supply costs will be reimbursed by patient use via billing.

Methodologically, the department made a good faith effort to cost out the minimum start-up costs for equipment and supplies; however, it ran into challenges because licensed EMS services must carry medications consistent with department-approved medical program director (MPD) protocols. There are 39 counties in Washington state and 39 sets of approved MPD protocols, which include different medication lists. The department analyzed the types and numbers of medications in all the protocols statewide to help inform an estimated cost for medications that may need to be carried by licensed ESSO services.

Some equipment required for specialized patient care could be borrowed from medical facilities to be used for certain types of transports. For example, intra-aortic balloon pumps, external pacemakers, ventricular assist devices, etc.

It is of note that the department reached out to one currently licensed EMS service provider8[8] who is currently providing ground specialty care transport and they estimated the start-up cost to equip an ambulance providing a similar scope of advanced specialty care to be $120,000 for both equipment and supplies.

Description: WAC 246-976-300 prescribes the requirements for aid and ambulance service equipment. Current rules require equipment standards for licensed versus verified vehicles that are outdated and no longer relevant.

Substantial changes to EMS minimum standards promoted by nationally recognized EMS organizations have occurred. The EMS scope of practice has evolved in the last five years and EMS medical equipment and technology have evolved along with the profession.

Proposed changes exempt from analysis under RCW 34.05.328 (5)(b)(iv) "Rules that only … clarify language of a rule without changing its effect":

Under RCW 34.05.328 (5)(b)(iii) "Rules adopting or incorporating by reference without material change … national consensus codes that generally establish industry standards, if the material adopted or incorporated regulates the same subject matter and conduct as the adopting or incorporating rule":

Cost: The department does not anticipate additional costs for services who already hold a license and provide specialty care services. For new services, the cost of equipment to provide specialty care transport services is analyzed in WAC 246-976-261 Emergency services supervisory organizations.

Description: WAC 246-976-330 prescribes the record requirements for EMS services regarding personnel, vehicles, and patient care reports.

Proposed changes exempt from analysis under RCW 34.05.328 (5)(b)(iv) "Rules that only … clarify language of a rule without changing its effect":

1. Update record requirements for licensed EMS services regarding personnel and vehicles.

2. Add the requirement for licensed EMS services to periodically audit EMS provider certifications to ensure they are current and active.

3. Add the requirement for licensed EMS services to maintain a record of nonmedically trained drivers that meet requirements in RCW 18.73.150.

Cost for Audit: All EMS services currently have access to the department licensing system to see providers affiliated with their service so EMS services may periodically audit certification records to ensure their staff are current and active. Most EMS services also already maintain their own databases and certification records for their employees. Staff time for conducting a review of EMS provider certifications will vary depending on the type of staff (administrator, training officer, EMT or paramedic supervisor, fire chief, etc.) conducting the review, the number of employees, the type of recordkeeping system the EMS system uses, the amount of follow-up required for any variances found, and updating records as necessary. According to the department's licensing system, the number of providers for EMS services is 37. The department estimates it would take eight hours or less to periodically conduct this review. The most likely staff to conduct the review would be an EMT or paramedic training officer or supervisor. For estimation purposes, the department used the salary of an EMS fire chief average hourly salary in Washington state ($42.34)9[9] and made the assumption that they would conduct this review quarterly, resulting in a total annual cost per EMS service of $1,355.

Cost for Records Requirements: EMS services must comply with RCW 18.73.150 to use nonmedically trained drivers. Existing licensed EMS services have already established recordkeeping systems to meet the requirements in the statute. The estimated cost for new EMS services to meet the recordkeeping requirements in the proposed rule will vary based on the type of staff (administrator, training officer, EMT or paramedic supervisor, fire chief, etc.) collecting the information required, the number of employees, the type of recordkeeping system the EMS system uses, the amount of follow-up required for any variances found, and updating records as necessary.

According to the department's licensing system, the average number of providers for EMS services is 37. The department estimates it would take eight hours or less to periodically conduct this review. The most likely staff to conduct the review would be an EMT or paramedic training officer or supervisor.

In May 2022, the median pay for EMTs was $36,680 per year ($17.63 per hour) and for paramedics was $49,090 per year ($23.60 per hour).10[10], 11[11] The department estimates the cost for a new service to meet the proposed requirements in the new rule could be between $141 and $188. The department has no way to estimate how often these periodic reviews take place.

Description: WAC 246-976-970 establishes the responsibilities and requirements for local EMS and trauma care councils.

The roles and responsibilities of local and regional EMS and trauma care councils have evolved because of the rapid changes in our health care system and the COVID-19 pandemic. The department is seeking to update minimum standards and conduct general housekeeping in the rules for local and regional councils to reflect current needs and expectations for council activities.

Proposed rules exempt from analysis under RCW 34.05.328 (5)(b)(iv) "Rules that only … clarify language of a rule without changing its effect":

Remove the requirement for EMS councils to sign training course applications.

Cost: The department does not anticipate additional fiscal impact because of the proposed rules because local EMS and trauma care councils are already conducting activities identified in the current rule and proposed amendments.

However, the department speculates that EMS councils may experience a reduction in the cost of doing business because they will no longer be required to spend time reviewing and signing training course applications and training program directors may experience a reduction because they will not be required to obtain the signature of the EMS and trauma care council for training course applications. The most likely staff to conduct the review would be an EMT or paramedic training officer or supervisor. The reduction in cost would be minimal because the act of reviewing and signing an application would take less than a few minutes.

Summary of All Cost(s):

SBEIS Table 3. Summary of Section 3 probable cost(s):

SBEIS Table 4. Summary of probable costs for businesses to comply with proposed rules:

For ambulance services, yes, the department believes the proposed rule may have a disproportionate impact on small businesses as compared to the 10 percent of businesses that are the largest businesses required to comply with the proposed rule. The main cost driver driving disproportionate cost impact is the start-up cost for equipment based on the level of trauma care you choose to provide. Because these costs are indeterminate, the department chose to select yes, the proposed rule may have a disproportionate impact on small businesses.

For other technical and trade schools, no, the department does not believe the proposed rule may have a disproportionate impact on small businesses as compared to the 10 percent of businesses that are the largest businesses required to comply with the proposed rule. The department estimates that the psychomotor exam takes the same staffing requirements regardless of if you are a small or large business and it is not believed that more/less psychomotor exams will be needed per year depending on if you are a small or large business.

For colleges, universities, and professional schools, no, the department does not believe the proposed rule may have a disproportionate impact on small businesses as compared to the 10 percent of businesses that are the largest businesses required to comply with the proposed rule. The department estimates that the psychomotor exam takes the same staffing requirements regardless of if you are a small or large business and it is not believed that more/less psychomotor exams will be needed per year depending on if you are a small or large business.

The department worked with interested parties to propose minimum standards for equipment, medications, and specialized health care personnel, that an EMS service providing advanced life support or specialized medical care must provide.

The costs cannot be reduced because a minimum amount of medical equipment, medications, and specialized health care personnel are required to ensure safe and competent transport of patients requiring advanced life support and specialized medical care.

The proposed rule language was developed in partnership with small business interested parties who provided input and support for drafting rule language. The department accepted and proposed language promoted to reduce standards and provide flexibility for small businesses to comply with requirements.

Currently licensed EMS services are (mostly, except for time to comply with data reporting) in compliance with the proposed rules. The department does not anticipate that any jobs will be lost because of compliance with the proposed rule.

EMS is considered an essential service provider. According to licensing data housed at the department, the number of EMS services and providers have not significantly increased or declined over the past 10 years. The incidence of new applicants providing ALS or SCT levels of service is predicated on need and determined through a regionalized EMS and trauma care model. Regional EMS and trauma care councils determine a minimum and maximum number of EMS services needed to meet the emergency response and transport needs of residents in Washington through the regional planning process in accordance with chapter 70.168 RCW.

Based on this model, it is difficult for the department to determine how many jobs could be created as a result of compliance with the proposed rule, but the regional planning process does continually assess need and make recommendations on the number and distribution of EMS services based on that need.

January 12, 2024

Kristin Peterson, JD

Chief of Policy

for Umair A. Shah, MD, MPH

Secretary

OTS-4953.2