Tenn. Comp. R. & Regs. 1200-12-01-.05 - AIR AMBULANCE STANDARDS
All air ambulance service providers and crew members operating in Tennessee must comply with Chapter 140 of Title 68 of the Tennessee Code Annotated and this Rule. Failure to comply shall subject the service provider and/or its personnel to disciplinary action pursuant to T.C.A. 68-140-511.
(1) Definitions - As used
in this Rule, the following terms shall have the following meanings:
(a) "Air Medical Communications Specialist"
means any person employed by an air ambulance service coordinating
acknowledgement of medical requests, medical destination, and medical
communications during an air medical response and patient transfer.
(b) "Medical Crew Member" means any person
employed by an air ambulance service for the purpose of providing care to
patients transported by and receiving medical care from an air ambulance
service.
(c) "Special Medical
Equipment" means any device which shall be approved by the air ambulance
service medical director for the medical care of an individual patient on an
air ambulance.
(d) "Specialty Crew
Member" means any person the air ambulance service medical director assigns for
a regular medical crew member for a specialty mission.
(e) "Specialty Mission" means an air
ambulance service assignment necessitating the medical director to substitute
special medical care providers and/or equipment to meet the specified needs of
an individual patient.
(f)
"Utilization Review" means the critical evaluation of health care processes and
services delivered to patients to ensure appropriate medical outcome, safety
and cost effectiveness.
(2) Medical Equipment and Supplies. The
medical director for the emergency medical service shall ensure that the
following medical equipment and supplies are provided on each fixed-wing or
helicopter flight mission:
(a) Litter or
stretcher with at least three sets of restraining straps;
(b) An installed and a portable suction
apparatus, each of which has the capacity to deliver adequate suction,
including sterile suction catheters and a rigid suction tip for both adult and
pediatric patients;
(c)
Bag/valve/mask resuscitator(s) with clear masks and an oxygen reservoir with
connections capable of achieving 95% fraction inspired oxygen to provide
resuscitation for both adult and pediatric patients;
(d) Airway devices for adult and pediatric
patients including the following:
1.
Oropharyngeal airways;
2.
Endotracheal tubes;
3. Laryngoscope
with assorted blades and accessory items for intubation; and,
4. Alternative advanced airway devices as
approved by the service medical director;
(e) Resuscitation board suitable for cardiac
compression, unless a rigid stretcher or spine board is employed for patient
transfer;
(f) Medical oxygen
equipment on board capable of adjustable flow from 2 to 15 liters per minute
including the following:
1. Masks and supply
tubing capable of administering variable oxygen concentrations from 24% to 95%
fraction inspired oxygen for both adult and pediatric patients;
2. Medical oxygen to allow for treatment
during 150% of estimated transport time; and,
(g) Sanitary supplies including the
following:
1. Bedpan (fixed-wing flight
mission only);
2. Urinal
(fixed-wing flight mission only);
3. Towelettes (fixed-wing flight mission
only);
4. Tissues (fixed-wing
flight mission only);
5. Emesis
bags;
6. Plastic trash disposable
bags; and,
7. Non-latex
gloves;
(h) Sheets and
blankets for each patient transported;
(I) Patient assessment devices for adult and
pediatric patients, including:
1. Flashlight
and/or penlight;
2. Stethoscope and
Doppler stethoscope;
3.
Sphygmomanometer and blood pressure cuffs;
4. Electro-cardiographic monitor/recorder and
defibrillator, with transcutaneous pacemaker, having a back-up power
source;
5. Pulse
oximetry;
6. Capnography, both
continuous and portable;
7.
Transport ventilator; and
8.
Clinical thermometer or temperature strips;
(j) Trauma supplies, including:
1. Sterile dressings;
2. Roller bandages;
3. Device for chest decompression;
4. Surgical airway device as approved by
medical direction; and
5.
Semi-rigid immobilization devices;
(k) Intravenous fluids and administration
devices;
(l) Appropriate
medications including the advanced life support medications described in Rule
1200-12-01-.03; and
(m) Neonatal transport equipment that shall
conform to the standards adopted in the Tennessee Perinatal Care System
Guidelines for Transportation, Tennessee Department of Health, Women's Health
and Genetics Section, Fifth Edition, 2006 or successor publication.
1. Isolette shall be capable of being opened
from its secured position within the aircraft.
(n) In order to help ensure patient comfort
and medical care as well as the safety of patients, crew members and ground
personnel, each air ambulance the Board currently permits shall have an
environmental control system with factory-installed or FAA approved add-on air
conditioner and heater by March 31, 2014.
1.
Any air medical aircraft newly permitted by the Board after the effective date
of this rule shall have an air conditioner and heater.
2. In the event of a non-functioning air
conditioner and/or heater, the aircraft operator shall be required to follow
environmental performance criteria including, but not limited to, temperature
ranges as approved by the Board.
(3) In addition to the medical equipment and
supplies required on either a fixed wing or helicopter flight mission as
described in paragraph (2) above, the medical director for the emergency
medical service shall ensure that the following medical equipment and supplies
are provided on each helicopter flight mission:
(a) Medical oxygen equipment capable of
adjustable flow from 2 to 15 liters per minute which shall include:
1. Portable medical oxygen system with a
usable supply of at least 300 liters of oxygen; and
2. A backup source of oxygen that shall be
delivered via a non-gravity dependent delivery source which may be the required
portable tank if it is carried in the patient care area during
flight;
(b) Trauma
supplies, including:
1. Lower extremity
traction device; and
2. Semi-rigid
cervical collars.
(4) Each air ambulance service shall offer
its instruction materials to other EMS providers within its response area to
familiarize them with its requirements for control of helicopter access and
ground to air communications on the scene.
(5) Air Ambulance Personnel Qualifications
and Duties
(a) Medical Director
Qualifications and Duties
1. Each helicopter
air ambulance service shall employ a Medical Director who is responsible for
providing medical direction for the helicopter air ambulance service.
2. The Medical Director for a helicopter air
ambulance service must be a physician having the following qualifications:
(i) Currently licensed in the State of
Tennessee;
(ii) Board certified or
eligible for Board certification by a professional association or society in
General or Trauma Surgery, Family Practice, Internal Medicine, Pediatrics,
Emergency Medicine, or Aerospace Medicine;
(iii) Certification in Advanced Cardiac Life
Support (unless Board certified or eligible for Board certification in
Emergency Medicine);
(iv)
Certification in Advanced Trauma Life Support; and
(v) Certification in Pediatric Advanced Life
Support or equivalent (unless Board certified or eligible for Board
certification in Emergency Medicine), including the following:
(I) Certification in a Neonatal Resuscitation
Program; and
(II) Possess adequate
knowledge regarding altitude physiology/stressors of flight.
3. Duties of the
Medical Director for a helicopter air ambulance service shall include the
following:
(i) Active involvement in the
Quality Improvement process;
(ii)
Active involvement in the hiring, training and continuing education of all
medical personnel for the service; and
(iii) Responsibility for on-line medical
control or involved in orienting and collaborating with physicians providing
on-line medical direction according to the policies, procedures and patient
care protocols of the medical transport service.
4. The service Medical Director shall
establish mission specific and clinical procedures. He shall require each
medical crew member to complete and maintain documentation of initial and
annual training in such procedures, which shall at least include didactic and
hands-on components for the following clinical procedures:
(i) Pharmacological Assisted Intubation -
Adult and Pediatric;
(ii) Emergency
cricothyrotomy;
(iii) Alternative
airway management - Adult and Pediatric;
(iv) Chest decompression; and
(v) Intraosseous Access - Adult and
Pediatric.
(b) The medical crew shall include:
1. Each patient transported by a fixed-wing
ambulance shall be accompanied by either a physician, a registered nurse, or an
EMT-P licensed in the State of Tennessee.
2. Each transport of patients by a helicopter
air ambulance shall require staffing by a regular medical crew which as a
minimum standard shall consist of one Registered Nurse licensed in the State of
Tennessee and another licensed medical provider (i.e., EMT-P, Respiratory
Therapist, Nurse, or Physician licensed in the State of Tennessee). The
composition of the medical team may be altered for specialty missions upon
order of the medical director of the air ambulance service.
3. On a fixed-wing flight mission only, the
air ambulance service medical director may allow transport of patients in the
presence of only one medical professional; the minimum level of licensure in
such a situation would be that of EMT-P.
(c) Medical crew training and qualifications
1. The service medical director shall make a
determination that each regular medical crew member serving on an air ambulance
is physically fit for duty by ensuring the service has documentation that each
regular crew member has had a pre-employment and annual medical
examination.
2. A Registered Nurse
serving as a medical crew member on an air ambulance shall meet the following
qualifications:
(i) Have three years of
registered nursing experience in critical care nursing, or two years fulltime
flight paramedic experience and one year critical care nursing
experience;
(ii) Possess a current
Tennessee nursing license, unless exempted by T.C.A. §
63-7-102(8);
(iii) Obtain certification as an Emergency
Medical Technician within twelve (12) months of employment; and
(iv) Obtain advance nursing certification
within twelve (12) months of employment through one of the following programs:
(I) Certified Emergency Nurse; or
(II) Critical Care Registered Nurse;
or
(III) Certified Flight
Registered Nurse.
3. An EMT-Paramedic serving as a medical crew
member on an air ambulance shall meet the following qualifications:
(i) Possess a current Tennessee EMT-P license
and have three years experience as an EMT-P in an advanced life support
service;
(ii) Obtain advanced
paramedic certification within twenty-four (24) months of employment through
one of the following programs:
(I) Critical
Care Paramedic; or
(II) Certified
Flight Paramedic.
4. Each medical crew member on an air
ambulance shall have and maintain certification in Advanced Cardiac Life
Support, Pediatric Advanced Life Support or equivalent (Emergency Nursing
Pediatric Course, PEPP), and in neonatal resuscitation.
5. Each medical crew member on an air
ambulance shall attend and maintain training in one of the following:
(i) Trauma Nurse Advanced Trauma
Course;
(ii) International Trauma
Life Support;
(iii) Prehospital
Trauma Life Support; or,
(iv)
Trauma Nurse Core Course.
(d) Each fixed wing air ambulance service
shall have an air medical consultant who shall be a physician licensed within
the jurisdiction of the base of operations and shall advise on the restrictions
and medical requirements for patient transport.
(e) Each helicopter air ambulance service
shall have a Medical Control Physician who shall be available to provide on
line medical control continuously via radio or telephone who shall be board
certified or eligible for board certification by a professional association or
society in General or Trauma Surgery, Internal medicine, Pediatrics, Emergency
Medicine, Family Practice, or Aerospace Medicine.
(f) Air Medical Communications specialist
qualifications and duties:
1. Each air
medical communications specialist shall meet the following qualifications:
(i) At a minimum, be licensed as an Emergency
Medical Technician; or
(ii) Be a
higher level licensed health care professional with at least two years of
emergency medical or emergency communications experience; and
2. Have initial and recurrent
training for medical coordination and telecommunications.
3. Air medical communications specialists
shall be certified through the National Association of Air Medical
Communication Specialists (NAACS) or obtain such certification within twelve
(12) months of employment.
(i) Air medical
communication specialists shall coordinate helicopter air ambulance service
flights.
4. Air medical
communications specialists shall not be required to work more than sixteen (16)
hours in any one twenty-four (24) hour period.
(g) Duty time for medical crew members on an
air ambulance shall not exceed twenty-four (24) consecutive hours or more than
forty-eight (48) hours within a seventy-two (72) hour period. The air ambulance
service shall provide the medical flight crew adequate rest and meal time.
Personnel must have at least eight (8) hours of rest with no work-related
interruptions prior to any scheduled shift of twelve (12) hours or more in the
air transport environment.
(6) Flight Coordination
(a) Each air ambulance service operations
office director shall maintain an Operations Manual detailing policies and
procedures and shall ensure that it is available for reference in the
operations office. Personnel shall be familiar and comply with policies
contained within the manual which shall include:
1. Criteria for medical conditions including
indications or contraindications for transfer;
2. Procedures for call verification and
advisories to the requesting party;
3. Radio and telephone communications
procedures;
4. Policies and
procedures for accidents and incidents;
5. Procedures for informing the requesting
party of operations procedure, ambulance arrival, termination of mission and
delayed responses, including the following:
(i) Estimated Time of Arrival includes time
of operations acceptance to time of landing on scene; and
(ii) Any deviation from ETA greater than 5
minutes will be reported to the requesting agency;
6. Procedures shall be established for
communications failure or overdue transports;
7. Emergency protocols for alerting search
and rescue; and
8. Utilization of
the Air Medical Communication Safety Questionnaire (as approved by the
board).
(7)
Telecommunications
(a) The operations center
for an air ambulance service operating in Tennessee shall include radio and
telephone equipment to enable personnel to contact the helicopters and crew.
Telecommunications devices shall include the following:
1. EMS Communications on the established
frequencies of 155.205 MHz, 155.340 MHz, and/or upon such specific channels or
frequencies as may be designated within each region as approved and published
as a supplement to the State EMS Telecommunications Plan;
2. Direct telephone circuits accessible by
air communication; and
3. Recording
equipment for both telephone and radio messages and instant message
recall.
(8)
Helicopter Air Ambulance Response and Destination Guidelines and Procedures.
(a) Medical necessity shall govern air
ambulance service response, including medical responsibility and destination
coordination, to emergency medical situations.
(b) Medical Necessity.
1. The medical director for the helicopter
air ambulance service shall determine whether there is a medical necessity to
transport a patient by air ambulance. Medical necessity will be met if the
following conditions occur:
(i) At the time
of transport the patient has an actual or anticipated medical or surgical need
requiring transport or transfer that would place the patient at significant
risk for loss of life or impaired health without helicopter transport;
or
(ii) Patient meets the criteria
of the trauma destination guidelines; or
(iii) Available alternative methods may
impose additional risk to the life or health of the patient; or,
(iv) Speed and critical care capabilities of
the helicopter are essential; or,
(v) The patient is inaccessible to ground
ambulances; or,
(I) Patient transfer is
delayed by entrapment, traffic congestion, or other barriers; or,
(II) Necessary advanced life support is
unavailable or subject to response time in excess of twenty (20)
minutes.
(vi) Specialty
Missions with specialized medical care personnel, special medical products and
equipment, emergency supplies, and special assistance for major casualty
incidents or disasters, or mutual aid to other aero medical services are
medically necessary when their availability might lessen aggravation or
deterioration of the patient's condition.
(c) The incident commander or his designee
will coordinate the transfer of medical responsibility to the medical flight
crew by emergency services responsible for the patient at the scene of the
incident.
1. If a helicopter air ambulance
lands on a scene and it is determined through patient assessment and
coordination between ground and air medical personnel that it is not medically
necessary to transport the patient by helicopter, the appropriate ground EMS
agency will transport the patient.
2. Interfacility transfers shall not be
initiated unless an appropriate physician at the receiving facility has
accepted the patient for transfer.
(d) Patient destination shall be established
pursuant to Rule 1200-12-01-.21.
(9) Records and Reports
(a) The air ambulance service shall maintain
records including the following:
1. A record
for each patient transported including:
(i)
Name of the person transported;
(ii) Date of transport;
(iii) Origin and destination of
transport;
(iv) Presenting illness,
injury, or medical condition necessitating air ambulance service;
(v) Attending and medical
personnel;
(vi) Accessory ground
ambulance services;
(vii) Medical
facilities transferring and receiving the patient;
(viii) Documentation of treatment during
transport; and
(ix) A copy shall be
provided to the receiving facility.
2. Each air ambulance service shall report
the number of air ambulance transfers performed annually on the form provided
for such purposes to the Division of Emergency Medical Services.
(b) Each air ambulance service
shall retain patient records for at least ten years.
(10) Utilization Review (UR)
(a) The air ambulance service management
shall ensure appropriate utilization review process based on:
1. Chart review of medical benefits delivered
to a random sample of patients, including the following:
(i) Timeliness of the transport as it relates
to the patient's clinical status;
(ii) Transport to an appropriate receiving
facility;
(iii) On scene transports
(Rotor Wing) - the following types of criteria are used in the triage plan for
on-scene transports:
(I) Anatomic and
physiological identifiers;
(II)
Mechanism of injury identifiers;
(III) Situational identifiers;
(IV) Pediatric and Geriatric
Patients;
(iv)
Specialized medical transport personnel expertise available during transport
are otherwise unavailable;
2. Structured, periodic review of transports
shall be performed at least semi-annually and result in a written report;
and
3. The service shall list
criteria used to determine medical appropriateness. It will maintain records of
such reviews for two years.
(11) Quality Improvement (QI)
(a) The service shall have an established
Quality Improvement program, including, at a minimum, the medical director(s)
and management.
(b) The service
shall conduct an ongoing Quality Improvement program designed to assess and
improve the quality and appropriateness of patient care provided by the air
medical service.
(c) The service
shall have established patient care guidelines/standing orders. The QI
committee and medical director(s) shall periodically review such
guidelines/standing orders.
(d) The
Medical Director(s) is responsible for ensuring timely review of patient care,
utilizing the medical record and pre-established criteria.
(e) Operational criteria shall include at
least the following quantity indicators:
(i)
Number of completed transports;
(ii) Number of air medical missions aborted
and canceled due to weather; and
(iii) Number of air medical missions aborted
and canceled due to patient condition and use of alternative modes of
transport.
(f) For both
QI and utilization review programs, the air ambulance service shall record
procedures taken to improve problem areas and the evaluation of the
effectiveness of such action.
(g)
For both QI and utilization review programs, the air ambulance service shall
report results to its sponsoring institution(s) or agency (if applicable)
indicating that there is integration of the medical transport service's
activities with the sponsoring institution or agency (if applicable).
(12) Compliance. Compliance with
the foregoing regulations shall not relieve the air ambulance operator from
compliance with other statutes, rules, or regulations in effect for medical
personnel and emergency medical services, involving licensing and
authorizations, insurance, prescribed and proscribed acts and
penalties.
(13) Separation of
Services. Air ambulance service shall constitute a separate class of license
and authorization from the Board and Department.
Notes
Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-140-304, 68-140-307, 68-140-504, and 68-140-507.
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