The purpose of this rule is to ensure the consistent quality of medical care delivered by air ambulance services in the state of Washington.
(1) An air ambulance service operating in the state of Washington must:
(a) Be licensed by the department in compliance with this section unless an exception in RCW
18.73.130 applies;
(b) Comply with all regulations and standards in this chapter pertaining to licensed and verified ambulance services and vehicles, except that WAC
246-976-290 and
246-976-300 are replaced for air ambulance services by subsections (7) and (8) of this section; and
(c) Comply with the standards in this section for all types of transports, including interfacility and prehospital transports.
(2) An air ambulance service applying for initial or renewal licensure must:
(a) Provide a completed application for licensure on forms provided by the department;
(b) Provide copies of the following current and valid documentation issued by the Federal Aviation Administration (FAA):
(i) Air Taxi Registration (OST Form 4507) showing the effective date of FAA registration and exemption under 14 C.F.R. 298;
(ii) Air carrier certificate authorizing common carriage under 14 C.F.R. 135, including Operations Specifications (FAA form 8430-18) authorizing aeromedical helicopter or fixed-wing air ambulance operations as applicable;
(iii) Certificate of Registration (AC form 8050-3) for each air ambulance operated; and
(iv) Standard Airworthiness Certificate (FAA form 8100-2) for each air ambulance operated;
(c) Provide a certificate of insurance establishing current and valid public and passenger liability insurance coverage for the air ambulance service;
(d) Provide a certificate of insurance establishing current and valid professional and general liability insurance coverage for the air ambulance service; and
(e) Provide proof of the air ambulance service's current accreditation status and a copy of the current accreditation report by a nationally recognized and department approved air ambulance accreditation entity that demonstrates that the air ambulance service meets the standards in this section. Failure to produce the accreditation report and supporting documentation to the department may be grounds for denial, suspension, or revocation of an ambulance license.
(3) An air ambulance service requesting initial licensure or renewal of licensure:
(a) That is ineligible to attain accreditation because it lacks a history of operation, must meet the standards in this section and provide proof that the air ambulance service is pursuing accreditation review with an accreditation entity approved by the department. A provisional license may be granted for no longer than two years at which time the service must provide documentation from a department approved accreditation entity that it meets the standards in this section.
(b) That has been unable to obtain accreditation may apply for a waiver of the full accreditation requirement if the air ambulance service meets all components of accreditation that are consistent with the standards in this section other than criteria related to the Federal Aviation Agency or Airline Deregulation Act regulated activities. The applicant must supply a copy of the accreditation report and supporting documentation to the department to show that it meets the standards in this section.
(4) To meet the minimum standards for medical oversight and patient care protocols an air ambulance service must:
(a) Have a physician director. The physician director must be:
(i) The department-certified medical program director (MPD) of the county where the air ambulance service declares its primary base of operation or a physician delegate of that county's MPD, as provided in WAC
246-976-920(4);
(ii) Licensed to practice in the state of Washington and in current good standing; and
(iii) Able to provide proof of educational experience consistent with the mission statement and scope of care provided by the air ambulance service;
(b) Ensure that all medical team members hold current and valid Washington state health care profession licenses;
(c) Ensure that all prehospital personnel used by the air ambulance service per subsection (5) of this section hold current and valid Washington state certifications as defined in WAC
246-976-010 and in accordance with RCW
18.71.200 and
18.71.205. Certified prehospital personnel must comply with department approved, MPD patient care protocols;
(d) Have a quality management program; and
(e) Ensure data related to patient care and transport services is collected and reviewed regularly and protected health care information is handled according to state and federal law and regulations.
(5) An air ambulance service must meet the following minimum standards for staffing of air ambulances:
(a) All medical personnel on each transport must have education, experience, qualifications, and credentials consistent with the mission statement and scope of care provided by the air ambulance service;
(b) Each critical care transport (CCT) is staffed by a medical team of at least two individuals with at least the following qualifications and licensure:
(i) One paramedic or registered nurse trained in prehospital emergency care; and
(ii) One other person who must be a registered nurse, respiratory therapist, paramedic, advanced EMT, EMT, or other appropriate specialist as appointed by the physician director;
(c) Each advanced life support (ALS) transport is staffed by a medical team of at least two individuals with at least the following qualifications and licensure:
(i) One paramedic; and
(ii) One other person, who must be a paramedic, advanced EMT, EMT, or other appropriate specialist as appointed by the physician director; and
(d) Each basic life support (BLS) transport is staffed by a medical team of at least two individuals in accordance with ambulance personnel requirements listed in RCW
18.73.150.
(6) An air ambulance service must meet the following minimum standards for training of air ambulance medical personnel:
(a) Establish and maintain a structured training program. If prehospital personnel are used by the air ambulance service, the training program must also meet requirements as defined in chapter
246-976 WAC;
(b) Create and maintain a file for each medical team member containing documentation of the personnel member's qualifications including, as applicable, licenses, certifications, and training records; and
(c) Ensure that each medical team member completes training in the following subjects before serving on a transport:
(i) Aviation terminology;
(ii) Altitude physiology and stressors of flight;
(iii) Patient loading and unloading;
(iv) Safety in and around the aircraft;
(v) In-flight communications;
(vi) Use, removal, replacement, and storage of the medical equipment installed on the aircraft;
(vii) In-flight emergency procedures;
(viii) Emergency landing and evacuation procedures; and
(ix) Policies and procedures for the air ambulance service, including policies to address altitude limitations.
(7) An air ambulance service must meet the following minimum standards for aircraft configuration and equipment to safely and effectively treat ill and injured patients on air ambulance transports and that include:
(a) A climate control system to prevent temperature extremes that would adversely affect patient care;
(b) Interior lighting that allows for patient care and monitoring without interfering with the pilot's vision;
(c) At least one outlet per patient and electric current which is capable of operating all electrically powered medical equipment unless battery power is available that exceeds the flight time for the transport;
(d) A back-up source of electric current or batteries capable of operating all electrically powered life support equipment for at least a minimum of one hour;
(e) An entry that allows for patient loading and unloading without rotating a patient and stretcher more than thirty degrees about the longitudinal (roll) axis or forty-five degrees about the lateral (pitch) axis and without compromising the operation of monitoring systems, intravenous lines, or manual or mechanical ventilation;
(f) Adequate space that allows each medical team member sufficient access to each patient to begin and maintain treatment modalities, including complete access to the patient's head and upper body for effective airway management;
(g) Adequate placement of stretcher and medical equipment that does not impede rapid egress by personnel or patient from the aircraft; and
(h) A communications system that is capable of air to ground communication with, ground fire and EMS services, public safety vehicles, hospitals, medical control, and communication centers and that allows the flight crew and medical team members to communicate with each other during the transport.
(8) An air ambulance service must meet the following minimum standards for medical equipment aboard air ambulances:
(a) Maintain and provide a minimum of the following equipment, supplies, and medications consistent with the mission statement and scope of care provided on transports. All equipment, supplies, and medications must be approved for use by the MPD and physician director.
(i) Minimum equipment available for each basic life support (BLS) transport must include:
(A) Oral/nasal pharyngeal airway;
(B) Nonrebreather oxygen mask;
(C) Bag valve mask;
(D) Pulse oximeter;
(E) Oxygen source;
(F) Automated external defibrillator;
(G) Noninvasive vital sign measurement;
(H) Glucometer;
(I) Equipment for control of bleeding to include tourniquets;
(J) Infection control;
(K) Medications consistent with scope of practice and care required for the transport type;
(L) Spinal motion restriction; and
(M) Neonatal and pediatric equipment sufficient for all aspects of prehospital and interfacility specialized care, if the air ambulance service provides transport to this population.
(ii) Minimum equipment available for each advanced life support (ALS) transport must include:
(A) All BLS equipment required in (a)(i) of this subsection; and
(B) Equipment for endotracheal intubation to include alternative airways such as supraglottic airways;
(C) Equipment for needle thoracostomy;
(D) Noninvasive carbon dioxide (CO2) monitoring with numerical and waveform capability;
(E) Equipment to establish and maintain a peripheral IV;
(F) Equipment to establish and maintain an intraosseous infusion;
(G) Ventilator;
(H) Equipment to provide continuous positive airway pressure (CPAP);
(I) Cardiac monitor capable of performing twelve lead ECG, defibrillation, cardioversion, and external pacing;
(J) Medications consistent with scope of practice and care required for the transport type; and
(K) Neonatal and pediatric equipment sufficient for all aspects of prehospital and interfacility specialized care, if the air ambulance service provides transport to this population.
(iii) Minimum equipment available for each critical care transport (CCT) must include:
(A) All BLS equipment required in (a)(i) of this subsection; and
(B) All ALS equipment required in (a)(ii) of this subsection; and
(C) Multimodality ventilators capable of invasive ventilation appropriate to all age groups transported;
(D) Invasive hemodynamic monitoring, transvenous pacemakers, central venous pressure and arterial pressure;
(E) Medications consistent with scope of practice and care required for the transport type; and
(F) Neonatal and pediatric equipment sufficient for all aspects of prehospital and interfacility specialized care, if the air ambulance service provides transport to this population.
(iv) Ensure that during a transport, the air ambulance has the equipment and supplies necessary to provide an appropriate level of medical care for the patient and to protect the health and safety of the personnel on the transport;
(v) Maintain and provide upon request equipment, supply and medication inventories that document what is included for each type of transport; and
(vi) Ensure the equipment and supplies on an air ambulance are secured, stored, and maintained in a manner that prevents hazards to personnel and patients.
