Comprehensive Review of the proposed Arkansas EMS Rules & Regulations December 12, 2012

1. Welcome! Comprehensive Review of the proposed Arkansas EMS Rules & Regulations December 12, 2012 Voice over IP – make sure your PC speakers are not muted Dial-in Access 1-480-297-0022 Access Code: 990-666-812 Audio PIN: Shown after joining the Webinar

2. Section 1 – Definitions pg. 4 • F. Air Ambulance Service – Emergency • G. Air Ambulance Service “unsure of need for two separate definitions” “does the addition of EMERGENCY open the the door making air ambulance a PRIMARYRESPONSE entity?”

3. Definitions pg. 5 • P. Emergency Medical Services“consider adding language that also addresses the care and transportation interfacility, to places of residence, to alternative care sites, etc. – not just to a medical facility.”

4. Definitions pg. 6-7 • EE. Ground Ambulance Service Area • Topic of much debate • Limited to “within a county boundary”

5. Definitions pg. 7 • FF. Intercept **suggestion** Intercept: Instances where a transporting service requests assistance from an ambulance service which provides a higher level of medical care and/or transport, and in accordance with written contracts or agreements between the ambulance service and city/county governments as may exist.

6. Definitions pg. 7 • II. Mass Casualty Incident • Better define ALS provider’s role in performing triage and being able to handoff (assign) care and transport roles to BLS and ALS resources as may respond to the MCI event

7. Definitions pg. 7 • JJ. Medical Director (ALS Services) • ArAA has received many calls and comments concerning this definition • Key: “board certified” OR“board eligible” • Clarification: define “current experience in emergency medicine”

8. Definitions pg. 8 • Of Sound Mind • This is actually the term “Of Unsound Mind” as defined in the Arkansas Code referenced(Ark. Code 20-9-601) • Syntax edit – change Sound to Unsound

9. Definitions pg. 8 • WW. Reaction Time • ArAA recommends leaving this definition unchanged

10. Definitions pg. 8 • ZZ. Service Area • Why is this defined again? • Ground and Air Ambulance Service Areas previously defined. • Add “and on file with the Department” to previous definitions

11. Definitions pg. 9 • CCC. Specialty Care Members • DDD. Specialty Mission • Simple text edits: ….by the Medical Director of an a ambulance service ….....An assignment for an ambulance service….

12. Definitions pg. 9 • Two Minute Reaction Time **suggestion** “The time from when the emergency call is received by the ambulance service and adequate information is made available which identifies the location and nature of the call, and until the ambulance is enroute.

13. Definitions pg. 9 • Probation • This term has been stricken from the definitions section but is referenced in the Violations section later in the document • Suggestion: reinstate definition

14. SECTION II: PURPOSE pg. 9 • Consider expanded definition • We do more than just prehospital EMS • Suggestion – change all references to prehospital to “out-of-hospital” (consistent with terminology in Agenda for the Future documents)

15. SECTION IIILICENSURE OF AMBULANCE SERVICES • A. 1. Patient’s choice of nearest appropriate medical facility • Insert at end…, or the destination as indicated by the Arkansas Trauma Advisory Council.

16. Section III pg. 11 • 7. Non-transferability of License • Too inflexible for business ownership • Suggest changing to Transferability • License become transferable but would still require all updated documents and credentials be on file with the Department

17. Section III pg. 12 • 10. Service Area • Insert the following: The service area of each licensed ambulance shall be clearly identified on a map provided by the Department and submitted annually to the Department. A licensed Service may cross county lines to serve a portion of an adjoining county with an agreement with the licensed Service(s) in the adjoining county, and in accordance with written contracts or agreements between the ambulance service and city/county governments as may exist. This agreement shall be submitted Department annually with the service area map. This excludes Air Ambulance Services.

18. Section III pg. 14 • 18. Transportation of non-patient care equipment • Over reaching • Would prohibit transporting items for“Toys for Tots” • Suggestion: omit Item 18

19. Section IV pg. 15 • A. 4. (first occurrence) • Advanced Response Services do not have ambulances; change all references (here and throughout the document to VEHICLE(S)*Note: item 4 is duplicated which will change all subsequent items in this section

20. Section IV pg. 15 • B. 1. • We suggest that this section reflect the ability to used tiered dispatch protocols to dictate the actual level of permitted vehicle(s) dispatched to the emergency response.

21. Section IV pg. 17 • B. 7. • Any authorized representative of the Department shall have the right to enter the premises of any service or permitted ambulance at any time in order to make whatever inspection necessary in accordance with the minimum standards and regulations prescribed herein (subject to applicable privacy laws). Each service shall maintain and make available to the Department for inspection records including, but not limited to:

22. Section IV pg. 17 • B. 7.…..herein (subject to applicable privacy laws). Each service shall maintain and make available (during normal business hours) to the Department for inspection records including, but not limited to:

23. Section IV pg. 18 • C. 4. I. • This item needs to be worded to include advanced providers handing off to BLS level of care when appropriate by triage or during MCI

24. Section IV pgs. 18-19 • C. 5. a. ….emergency evacuation services only, and does not participate in the business of providing continuous general population response for emergency medical services, and is limited to pediatrics, neonatal, high risk obstetrical, or the industrial settings.

25. Section IV pg. 19 • 7. Licensed Medical Facility Transport Service • Subsection b. 1) Strike the words “Agree to…” 1) Agree to use license…… * Also looking at language within the stretcher van rules & reg’s which requires transports only within the facility’s system

26. Section V pg. 21(vehicle permitting) • B. 6. • Edit for clarification of medical equipment “Any medical equipment carried…… • B. 10. • Change “Request” to “Notice”

27. Section V pg. 21 • B. 11. • In all subsections a., b., and c. strike references to size of lettering • Allow the service to determine size and schema of its branding • For consistency, include “may be displayed” for each item

28. Section V pg. 22 • B. 19. • Edit to read as“….with the main oxygen tank’s regulator indicating the cylinder pressure visible from within the patient compartment. the EMSP’s seat that indicates cylinder pressure.”

29. Section V pg. 23 • B. 26. • Change “sanitary” to “clean” • No way to ensure sanitary conditions

30. Section V pg. 24 • For consistency, in the Section C, change all references to “vehicle” to “ambulance”, except in C.4. • 4. Advanced Response Permitted Vehicle Ambulance

31. Sections VI – VII Air Ambulance • No specific comments or suggested changes

32. Section VIII pg. 36 • Subsection A • Clarification concerning a paramedic responding within the service area where more than one ALS provider may be licensed. • Medic initiates care thinking his/her service is responding, but another agency within the service area responds. • Would this be a violation? • “…arrival of the transporting ambulance from his service….

33. Section VIII pg. 38 • B. 1. Procedures and skills for all EMSP’s • Add clarification that these “may be performed”

34. Section IV – Education, Testing and Licensure • Request to include and recognize Professional Rescuer CPR credentials as may be issued by a qualified ECSI training center. • Emergency Care and Safety Institute (formerly National Safety Council) • Used often by industrial groups • Meets exact curriculum and criteria as AHA • Add to all subsections where AHA and Red Cross are referenced (first occurrence on pg. 42, item c.)

35. Section IX pg. 44 • C. 3. g. “Submit a signed letter of good standing from the Training Site in which your EMSP instructor certification is aligned with. • New requirement for instructors (alignment) • What happens if an instructor cannot align with a training site? • Same problem as with providers who cannot achieve backfill agreements

36. Section XI pg. 50 • EMSP Training Sites • F. Course instructor must be an Arkansas Licensed Physician or an EMS-Instructor licensed at the Paramedic level. • This would require even basic EMT courses to be taught only by a paramedic level instructor

37. Section XII pg. 52 • B. 6. a. • “…..within a medical facility with hospital concurrence.” • With the use of alternative clinical sites (ie. free standing surgery centers, clinics, etc.), we recommend striking “with hospital concurrence.”

38. Section XIV pg. 60 • C. 3. Security • “All other prescription drugs shall be stored under a single lock security.” • Clarification of whether or not the locked vehicle constitutes a single lock security system.

39. Section XIV pg. 63 • H. Storage of Pharmaceuticals ….. • Could this force inclusion of heated and/or refrigerated compartments as part of ambulance design / retrofit? • Suggest simply stating “storage to follow manufacturer’s recommendations for all pharmaceuticals carried.”

40. Section XV - TRAUMA SYSTEM pg. 63 • The ArAA recommends the inclusion of the clarifier “for ambulance services participating in the trauma system” • Suggest to include as a header to this section.Section XV. TRAUMA SYSTEMFor those ambulance services participating in the Arkansas trauma system,

41. Section XV pg. 64 • Urgent Trauma Transfers The hospital seeking the urgent trauma transfer shall contact the ATCC to provide patient condition information and to obtain concurrence with the urgent trauma transfer classification. All urgent trauma transfers shall prompt involvement of the medical director of ATCC in real time. The medical director shall verify the urgent nature of the transfer and concur there is reasonable evidence the two conditions of an urgent trauma transfer are met. If the above conditions are met and concurrence from ATCC is obtained, this transfer qualifies as an urgent trauma transfer. As soon as the sending hospital recognizes the need for an urgent trauma transfer, the hospital shall alert the local EMS provider. Once the ATCC confirms the patient meets the criteria for urgent trauma transfer, ATCC shall gains acceptance by the receiving hospital, contact the EMS provider identified by the transferring hospital to coordinate The ATCC shall confirm with the transferring hospital the time the patient will pick-up and communicate that to the EMS provider.

42. Section XVI – Violations pg. 64 • Scalability of violations has been taken away • A hit, is a hit, is a hit -- 3 hits and your done! • The ArAA requests separation of violations and punitive actions by class: • SERVICE LICENSEE TRAINING SITE • Clearly define warnings, probation, suspension, etc. • Don’t link the service to a provider’s actions in all cases

43. Section XVI pg. 65 • c. Three (3) formal citations during license term for failure to comply with Arkansas Code § 20-13-2005 and any regulations promulgated the Department in regard to ambulance services shall result in revocation of the ambulance service license. However…. • Change “shall” to “may”

44. Section XVI pgs. 65-68 • OFFENSES: • Grocery list is too long and not stratified • References are made to “probation” but probation is no longer a defined term • Earlier comments concerning splitting by class apply here as well • Also suggest adding “or under the influence of prescription drugs” everywhere “drugs” is included in the potential violations

45. MINIMUM REQUIRED EQUIPMENT LIST • Soft Supplies • Saline drops Is this eye drops? Would NS from IV bag suffice? • Transport • Pedi-Mate or Equivalent There is no certified device currently. The Section of EMS is working on this one.

46. MINIMUM REQUIRED EQUIPMENT LIST • Paramedic / ALS • New mandatories: • Adenosine • Dobutamine Drip • Glucagon $123.00 a dose (1 year shelf life at longest) • Magnesium Sulfate • begs the question, what about CaCL as antidote? • Lidocaine Drip (but no required Lidocaine bolus) • What if service opts to carry Amiodarone as the antiarrythmic?

47. MINIMUM REQUIRED EQUIPMENT LIST • Other mandatory drugs: • IV Nitroglycerine Would require IV pumps to safely administer • What is included in …ALLAdvanced Cardiac Life Support Medications*cardizem, diltiazem, isoproteronol, inderal, ACE inhibitors, fibrinolytics

48. MINIMUM REQUIRED EQUIPMENT LIST • Basic / EMT-Speciality / EMT-Volunteer • What are roof hooks? • For services giving medications (optional), what is the need to carry Sterile Saline drops? • Medications has a ** notation, but no clarifier • Glucose should be ORAL glucose

49. Next Steps • Open now for additional comments • Summarize the ArAA comments and suggestions on the Section of EMS forms • Submit to the Section by Monday, December 17, 2012

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