CONTRA COSTA HEALTH SERVICES EMERGENCY MEDICAL ...

CONTRA COSTA HEALTH SERVICES EMERGENCY MEDICAL SERVICES AMBULANCE EQUIPMENT AND SUPPLY REQUIREMENTS 1. a. b. c.

d.

Vehicles Ambulance vehicles shall meet standards specified in Title 13, California Code of Regulations, and each shall possess a valid emergency vehicle permit issued by the California Highway Patrol. Vehicles shall be maintained, clean and in sound mechanical and body condition at all times. All ambulances shall have adequate space in the patient care compartment to accommodate at least one stretcher patient and two providers. There shall be sufficient space to allow for patient care activities during transport. Vehicles shall be equipped with appropriate mobile and/or portable radios for communications with: 1) Provider agency dispatch center 2) Contra Costa County Sheriff’s dispatch center 3) Base hospitals on the County-designated radio system

2.

Personal Protective Equipment (PPE) All ambulance providers are encouraged to adhere to the California Emergency Medical Services Authority (EMSA) guideline #216 – Minimum Personal Protective Equipment (PPE) For Ambulance Personnel in California (see attachment). Those providers that have received equipment through the PPE grant project are required to adhere to this guideline.

3.

General Emergency Care Equipment and Supplies Ambulances shall meet the State requirements for emergency care equipment and supplies. Patient care equipment and supplies should be latex-free. All equipment and supplies carried for use in providing emergency medical care shall be maintained in clean condition and good working order and shall include, but not be limited to: Minimum In-service Requirement 1 each

BLS/ALS Ambulance ITEMS Oropharyngeal airways: 00, 0, 1, 2, 3, 4, 5, 6 Nasopharyngeal airways: 18, 20, 22, 24, 26, 28, 30, 32, 34

1 each

Oxygen mask – adult/pediatric (non-rebreather)

2 each

Oxygen mask – infant/pediatric

2 each

Nasal cannula – pediatric/adult

2/adult – 2/ped

O2 tank – fixed in vehicle with regulator (M-tank or equivalent) Portable O2 tank with regulator (sufficient to provide patient with not less than 10 LPM - for 20 minutes) Self inflating resuscitation Bag-Valve device, with clear mask, capable of use with O2: Infant, Pediatric, Adult Portable Suction with regulator or Portable suction with adult/pediatric (e.g. high/low) settings – mechanical/hand powered Contra Costa EMS reviewed & revised 12/2009

Effective 1/1/2010

1 1 1 each 1

Wide bore tubing for portable suction

1

Pharyngeal tonsil tip (rigid) for suctioning

2

Suction catheters: 6F, 8FR, 10FR, 18FR

1 each

Band-Aids

12

4” Sterile bandage compresses or equivalent

12

3x3” or 4x4” sterile gauze pads

4

2” or 3” rolled bandages

6

40” triangular bandages

4

10x30” or larger universal dressing

2

1”, 2” or 3” adhesive tape

2 rolls

Bandage shears

1

Vaseline gauze Arm splints – with soft or cushioned surface or equivalent padded board, wrap around, wire ladder, inflatable or cardboard (able to accommodate adult/pediatric/infants) Leg splints – with soft or cushioned surface or equivalent padded board, wrap around, wire ladder, inflatable or cardboard (able to accommodate adult/pediatric/infants) Traction splints – with lower extremity limb support slings, padded ankle hitch traction strap and heel rest or equivalent (reel, sager or equivalent): Adult/Pediatric Spineboard – long with 4 straps (or equivalent) Spineboard : (pediatric capable) – short with 2 straps or equivalent (Kendrick Extrication Device) Head immobilizer – disposable or impervious to bodily fluids

2 2

2

1 each 1 1 2

Cervical collars – Hard: sizes to fit all patients over one (1) year of age Optional: adjustable cervical collar (hard only): sizes to fit all patients over one (1) year of age Scoop stretcher with straps (or equivalent) Blood pressure cuffs with sphygmomanometers (portable): Adult, Large arm (obese), Pediatric, Infant Stethoscope: Adult/Pediatric (or combination) Burn sheets (sterile) – may be disposable or linen (with date of sterilization and expiration indicated) Irrigation tubing

1 each

Saline for irrigation, sterile:

2000cc

Cold packs Obstetrical Kit (sterile, to include minimum of umbilical cord tape or clamps (2), 1 scissors or scalpel, 1 aspirating bulb syringe, 1 pair gloves, 2 drapes, dressings & towels, clean plastic bag) Contra Costa EMS reviewed & revised 12/2009

Effective 1/1/2010

2 each 2 1

1 1 set 1

2 1

Newborn Stocking Cap

1

Emergency thermal blanket (reflective foil) or equivalent Ambulance gurney – capability for elevating the head and be adjustable, straps for securing patient to gurney, wheels, non-permeable covering material, means of securing gurney in vehicle. Automated External Defibrillator (AED) - required as of January 1, 2010

2

Triage tags

20

Current map (within 2 years) of entire county or ambulance zone maps

1

Current Contra Costa EMS Field Treatment Guidelines and policies

1

Faces Pain Scale (for adult & pediatric use)

1

1 1

Ankle and wrist restraints (4 per set)

1 set

Child safe restraints (infant/pediatric)

1 set each

Battery operated flashlight

1

Emesis basin or disposable emesis bags and covered waste container

1

Linen – towels, sheets, pillow cases, blankets, pillows

2 each

Glucose Paste

1 tube

Contra Costa EMS reviewed & revised 12/2009

Effective 1/1/2010

ALS Ambulance Emergency Care Equipment and Supplies: In addition to the BLS ambulance supply/equipment requirements, advanced life support units shall include, but not be limited to, the following: Minimum In-service Requirement

ALS Ambulance ITEMS Cellular telephone

1

Monitor/defibrillator (portable) – must have strip chart recorder, 12-lead and synchronized cardioversion & ETCO2 monitoring capabilities. Defibrillator capable of discharging below 25 joules for pediatric use.

1

Extra charged batteries for monitor/defibrillator

1

Defibrillator paddles/pads: Adult, Pediatric

1 set each

12-lead patches

2 sets

Laryngoscope handle

1

Portable cardio-respiratory monitor with pulse oximetry capability

1

Pulse oximeter adult & pediatric probes

1 set each

Laryngoscope blades: #0, 1, 2, 3, 4 Miller

1 each

Laryngoscope blades: #2, 3, 4 Macintosh

1 each

Endotracheal tubes: 6.0, 7.0, 8.0, 9.0 cuffed

2 each

Endotracheal tube introducer (e.g. Bougie)

1

Water soluble lubricant – individual packets

3

Magill forceps: Adult, Pediatric

1 each

Batteries (extra) for laryngoscope

1 set

Bulbs (extra) for laryngoscope

1

ETT securing device: Adult

2

Stylet: Adult,

1 each

Pen light

1

End-Tidal CO2 (ETCO2) detector

2

ETT placement assessment device (bulb)

1

ETT Nebulizer Adapter King Airway Kit Tube – size 3, 4 and 5 Syringe Lubricant Hand-held nebulizer for inhalation

2 1 2

Nebulizer mask – adult and pediatric Contra Costa EMS reviewed & revised 12/2009

2 each Effective 1/1/2010

Pleural Decompression/Needle Thoracostomy kit: (or equivalent) Angiocatheter – 12 - 14ga Syringe – 30cc One-way valve Rubber connecting tube Betadine swabs (4) Alcohol swabs (4) Vaseline gauze (2) Sterile gauze pads (2) Tape

2 sets

Continuous Positive Airway Pressure (CPAP) device

1

IO insertion device e.g. EZIO

1

Intraosseous needle – adult and pediatric

2 each

Pressure bag for adult IO

1

Syringes: 1cc, 30cc

2

Syringes: 3cc, 5cc, 10cc or 12cc

2 each

Needles: 18ga 1”, 20ga 1”, 22ga 1”, 25 or 24 ga ”

2 each

Medication-added labels

2

IV catheters: 16ga, 18ga, 20ga, 22ga, 24ga

4 each

Alcohol swabs

5

Tourniquet

2

Razor

1

Armboard(s) (adaptable for infant, child, adult)

1 each

Normal Saline solution – 500cc or 1000cc bag for adult patients

4 liters

Universal vial adapter/dispensing pin

2

Normal Saline solution – 100ml, 250ml for pediatric patients

2 each

Saline lock with extension tubing

2

IV tubing: mini drip (60gtt), macro drip (10/15gtt) or equivalent (8)

4 each

IV extension tubing

4

Glucometer (with lancets and test strips)

1

Secured drug box

1

Pediatric length-based weight determination tape e.g. Broselow or equivalent

1

Mucosal Atomizer Device

2

Adenosine (6mg)

5


Effective 1/1/2010

Albuterol (2.5mg/3ml unit dose ampule)

4

Amiodarone (150mg/3ml ampule)

6

Atropine (1mg preload)

4

Aspirin (81mg tablets)

1 bottle

Diphenhydramine (Benadryl) (50mg/1cc)

2

Calcium Chloride (1 gm)

1

Dextrose 10% (250 ml)

2

Dextrose 50% (25gm/50cc)

2

Dopamine (400mg/250cc premixed bag) (or equivalent)

1

Epinephrine 1:10,000 (1mg/10cc)

4

Epinephrine 1:1,000 (1mg/1cc)

2

Glucagon (1mg/1cc)

1

Lidocaine 2% for IO pain control

100 mg

Midazolam (Versed) (5mg/ml ampule/vial)

10 mg

Morphine Sulfate (10mg/1cc ampule/vial)

20 mg

Naloxone (Narcan)

4 mg

Nitroglycerin (0.4 mg/tab or multidose spray)

1 bottle

Sodium Bicarbonate (50mEq/50cc)


1

Effective 1/1/2010

MINIMUM PERSONAL PROTECTIVE EQUIPMENT (PPE) FOR AMBULANCE PERSONNEL IN CALIFORNIA GUIDELINES

June 2005 EMSA # 216

MINIMUM PERSONAL PROTECTIVE EQUIPMENT (PPE) FOR AMBULANCE PERSONNEL IN CALIFORNIA GUIDELINES June 2005

Prepared by:

Richard E. Watson EMSA Interim Director Daniel Smiley EMSA Deputy Director Jeff Rubin Chief, Disaster Medical Services Norma Schroeder Disaster Medical Specialist

1

EMS Safety & WMD Training Committee Representatives: California Ambulance Association California Council of Emergency Medical Service Educators California Department of Forestry and Fire Protection Office of the State Fire Marshal California Environmental Protection Agency California Fire Chief’s Association Emergency Medical Services Section California Health Executives Association of California California Highway Patrol California Occupational Safety & Health Administration California Paramedic Program Directors California Peace Officers Association California Police Chief’s Association California Professional Firefighter Association California Professional Firefighter Joint Apprentice Committee California Sheriffs Association California State Firefighters Association California National Guard Citygate Associates, Llc Commission on Peace Officers Standards & Training County Health Executives Association of California Department of Health Services Division of Drinking Water & Environmental Management Emergency Preparedness Office Radiological Health Branch Department of Mental Health Emergency Medical Directors Association of California, Inc. Emergency Medical Services Authority Disaster Interest Group, Hospital & Health Systems Disaster Medical Services Division Medical Consultants Emergency Medical Services Administrators Association of California Los Angeles City Fire Department Los Angeles County Department of Health Services Emergency Medical Services Agency Metropolitan Medical Response System Anaheim Fremont Los Angeles San Diego San Francisco Office of Emergency Services Fire & Rescue Branch Law Enforcement Branch California Specialized Training Institute Service Employees International Union

2

MINIMUM PERSONAL PROTECTIVE EQUIPMENT (PPE) FOR AMBULANCE PERSONNEL IN CALIFORNIA TABLE of CONTENTS

I.

EMS Safety & WMD Training Committee................................................................................................................ 1 A. Prepared by .................................................................................................................................................. 1 B. EMS Safety & WMD Training Committee Representatives ....................................................................... 2

II.

Table of Contents ....................................................................................................................................................... 3

III.

Issue: Personal Protective Equipment for Ambulance Personnel............................................................................... 4 A. Introduction.................................................................................................................................................. 4 B. Background .................................................................................................................................................. 4 C. Discussion .................................................................................................................................................... 5 D. Committee Goals & Recommendations....................................................................................................... 6

IV.

Guidelines .................................................................................................................................................................. 7

V.

Appendix A: Identifying Required Personal Protection (PPE Level A through D) ................................................. 11

3

MINIMUM PERSONAL PROTECTIVE EQUIPMENT (PPE) FOR AMBULANCE PERSONNEL IN CALIFORNIA

Introduction At the suggestion of the Emergency Medical Services (EMS) Commission, the EMS Authority (EMSA) formed a committee to develop guidelines to enhance the safety and training of EMS responders. Membership consists of public and private constituent groups and experts. The first meeting convened in April 2004. The first priority of the group was to develop Guidelines for standardizing personal protective equipment (PPE) for EMS personnel. These Guidelines can be implemented by local EMS agencies, with cooperation from EMS service providers. Funding for most of the items within the Guidelines is available through the Department of Homeland Security.

Background The working environment for all first responders changed following the terrorist events of “September 11th”. At the World Trade Center, 450 emergency responders perished. This was one-sixth of the total number of victims. These basic potential differences between terrorist incidents and natural disasters include the scale, duration, and complexity regarding the potential range of hazards that could be present. Additionally, incidents at the World Trade Center and Pentagon demonstrated shortfalls in first responder preparedness: • • • •

Unavailability of PPE, particularly at the beginning of an incident, Lack of interoperability, i.e., many types or brands of equipment, and many vendors, Inadequate prescription, fit, use, and maintenance of various PPE, and Lack of participation in training and exercises for multi-casualty events.

First responders, including medical personnel need a greater level of protection including proper equipment and training to enable an “all-hazard” response with an emphasis on chemical, biological, radiological, nuclear, and explosive (CBRNE) events. EMSA considered the adequacy of personal protective equipment (PPE) and related training for EMS and ambulance personnel and found it lacking. A subsequent EMSA survey of EMS Directors from other states failed to produce any statewide recommendations for PPE for EMS personnel.

4

Discussion Since September 11, 2001, increasing demands to prepare for and respond to disasters have been placed upon the ambulance workforce. The U.S. Department of Homeland Security has made funding available to enhance response to terrorist attacks. Public and private EMS personnel form the backbone of the emergency medical response to disasters within the first eight hours following an event. Using data from the U.S. Centers for Disease Control, the transport and treatment of patients are largely within a short time period (see Figure 1). While predicting emergency department casualties, this identifies the critical need to have local and regional medical resources available within the first few hours as a base capability. As a result, an emphasis has been placed upon enhancing the prehospital “surge capacity” as well as the hospital “surge” capacity. The EMSA identified a problem with widely varying levels of PPE and individual preparedness for EMS and ambulance personnel in California. Personal protective equipment is clothing and gear designed to protect workers from safety and health hazards, as well as to prevent injury resulting from incorrect use or malfunction of equipment. In general, the greater risk, the greater the level of PPE required.

5

Committee Goals & Recommendations The EMSA convened a Committee to examine this issue, comprised of leaders from the California Fire Chief’s Association, California Ambulance Association, EMS Administrator’s Association, various union and professional organizational representatives, and others. The Committee agreed that it is in the best interest of the State and its EMS personnel to have minimal, proper PPE available routinely to EMS responders. They identified the following goals as important considerations in the development of these Guidelines: • Increase safety for EMS personnel • Develop uniform, statewide guidance on PPE for EMS personnel, to include both the public and private sectors • Meet or exceed State and federal standards • Reduce purchasing and training costs • Promote funding opportunities • Increase mutual aid interoperability Through consensus, the Committee developed the list of recommended minimum PPE. The recommendations are in addition to applicable OSHA and Cal-OSHA standards, and are derived largely from the following published standards: 1) NFPA 1999 EMS Standards (2003 ED) 2) OSHA: OSHA's General Description & Discussion of the Levels of Protection and Protective Gear – 29 CFR 1926.65 App. B, Part IV, Level D The minimum PPE for respiratory protection is Level D, with an escape hood immediately available. In some work environments, based upon the specific job duties, all EMS personnel have a full complement of Level C protection available to protect them from specific hazards that they may encounter. This will be determined by the employing agency. Respiratory protection equipment requires employers to have a respiratory program. (See Appendix A for graphics and brief descriptions of the Level A through Level D.) The Guidelines are for both public and private EMS providers, as well as for “nonemergency” providers of ambulance services. Ambulance services in California may have both emergency and non-emergency roles on a daily basis. In some jurisdictions, ambulance services may be primarily utilized in a “non-emergency” capacity. EMSA believes that these “non-emergency” providers may represent an immediate source of prehospital “surge” capacity within a system. These EMS providers should be fully integrated into any response plan, and have the same PPE immediately available as other providers. These Guidelines also promote the need for California’s EMS personnel to have suitable, standardized PPE on a day-to-day basis, as well as for potential extended operations or terrorist incidents. EMS providers should ensure that personnel receive proper training in all available equipment.

6

GUIDELINES MINIMUM PERSONAL PROTECTIVE EQUIPMENT (PPE) FOR AMBULANCE PERSONNEL IN CALIFORNIA •

• • •

Every person working on an ambulance in California (public or private, emergency or non-emergency) should have available the following minimum equipment, supplies, and personal protective equipment (PPE) – per responder – to ensure safety, readiness, and the ability to meet surge capacity. Use of respiratory equipment must be covered by fitting, fit-testing, training, proficiency, and core competencies, for each responder prior to provision, and periodically thereafter. Ambulance personnel should not respond to an incident requiring PPE beyond their level of provision and training, without adhering to published standards. Funding for the majority of these items – for both public and private entities – is available through the Office of Homeland Security (OHS) Grant Program.

ITEM

Worn

Unit

• • •

HQ

•

SPECIFICATIONS NFPA 1999 EMS Standards (2003 ED) i OSHA 29 CFR 1926.65 App. B, Part IV, Level D ii Cal OSHA where federal OSHA 29, and other standards as applicable, are exceeded Firescope California Standardized Hazardous Materials Equipment List iii

Head Hard Hat - Work Helmet • Blue Eye Protection

Hearing Protection Body Garment – EMS (Uniform) • Blue preferred Garment – single use

1

1 pair

Multiple use NFPA 1999 EMS Standards Full-body - shirt & pants, or jumpsuit/coveralls Barrier protection NFPA 1999 e.g., barrier garment, such as “white Tyvek” Decontamination equipment and material used to clean, remediate, remove, or mitigate chemical, biological, or radiological contamination. OSHA: disposable chemical resistant overalls, or 2piece chemical-splash suit NFPA 1999 EMS Standards, if full body coverage top is not worn underneath.

1 set

1 set

Hooded, chemicalresistant clothing

Jacket, full length – EMS, with reflective stripes

NFPA 1951 ANSI Z89.1-1986 (Class and B), OSHA: 29 CFR 1910.135 & 29 CFR 1926.100(b), CSA Z94.1-M1992 (Class G), or equivalent NFPA 1999 ANSI Z87.1 e.g., glasses, face shield, or work goggles, or mask with side protection and splash resistance for infection control. Fit over glasses and sunglasses - preferred Ear plugs or other

1

1 set

1

7

ITEM

Worn

Unit

• • •

HQ

•


Hands Gloves – Chemicalprotective, nitrile

Single use. Body substance isolation. Nitrile-type or equivalent. Latex may be used for exams. 21 CFR 880, Class 2 EN 455-2 sizing

1 box

Gloves – Work

1 pair

Multiple use NFPA 1999: • Physical protection (cut resistance: leather or other) • Barrier protection

Feet Footwear

1 pair

Footwear covers

Multi-use, Safety NFPA 1999 EMS Standards: • Height: min. 4” • Cut, puncture, & abrasion resistant • Toe safety • Barrier protection • ANSI Z41-1991 - American National Standard for Personal - Protective Footwear, if determined by entry job description, or incident response zone OSHA: • Safety toe & shank • Chemical resistant Single-use NFPA 1999 OSHA: chemical resistant

1 pair

Respiratory iv • •

N-100 Mask, or N-95 Mask

Escape Hood v

Including applicable: • Written Respirator Program policies • Health questionnaire • Fit-testing • Training: selection, use, storage Specifications: • NIOSH Respirator Selection Logic 2004, http://www.cdc.gov/niosh/docs/2005-100/default.html • OSHA 42 CFR 84 - Breathing Apparatus Standards a • 8CCR 5144 - Respiratory protection regulation governing the use of all respirators, including that for TB • Firescope California Standardized Hazardous Materials Equipment List, 2004 Ed, pg. 7-10 As previous, above Note: Follow NIOSH standards, when finalized

5

1

Routine Equipment

8

ITEM

Worn

Unit

• • •

HQ

• Flashlight, small Knife - Folding Glass punch Scissors/Shear

1 1 1 1

Stethoscope Personal communication device • Field Operations Guides (FOGs) Prophylactic Medications: • Mark I AutoInjector Kit Extended Operations Equipment

1 1

Daypack—“Go Pack”, containing:

• • •

Water Water purification Rain Gear

Or headlamp Capable of cutting seatbelts Capable of breaking windshields Bandage/Utility Note: Small equipment items/tools can be combined in a “multi-tool” Radio, on appropriate frequency

Yes

Per local entity policy • •

1 •

1 qt. 1

Tablets or device • Head protection • Top protection • Bottom – optional Emergency medical garment, as above

1 set

Extra set of emergency medical garments

1 set

•

MRE

•

Ear protection

For 72 hrs. 1 set

As determined by local hazard assessments Written policies & procedures re: administration and rotation. Located on designated units/rigs

Mission-ready backpack or duffel bag for response operations during a potential extended, or weapon(s) of mass destruction, event. • Equipped for individual’s self-sustainment for 72 hours • Containing supplies, equipment, and references needed to sustain operations and provide general response operations support

1

•

Prophylactic medications: • Mark I Antidote


Meals Ready-to-Eat, or equivalent

Extra set

1

9

ITEM

Worn

Unit

HQ

• • •

• •

Kit Field Operations Guides (FOGs)

Yes


Per local entity policy

Funding: Office of Homeland Security (OHS) Grant Program. For 2005, see “Responder Knowledge Base, FY2005 Authorized Equipment List (for grant funding) http://www2.rkb.mipt.org/ael_fy2005.cfm

NFPA 1999 EMS Standards (2003 ED). Reference: NFPA 1999 EMS Standards (2003 ED) – downloadable, $28.75. http://webstore.ansi.org/ansidocstore/product.asp?sku=199903PDF i

OSHA's General Description & Discussion of the Levels of Protection and Protective Gear – 29 CFR 1926.65 App. B, Part IV, Level D. http://www.osha-safety-training.net/PUB/pubs.html ii

iii Firescope California Standardized Hazardous Materials Equipment List, Ed. 2004, Personal Protective Equipment (PPE). http://www.firescope.org/ics-hazmat/pos-manuals/haz-equiplist.pdf iv

Respiratory Notes: • Escape hoods, and Masks (N-95, N-100, and P-100) are not safe for engineered-aerosol dispersion or weaponized substances. • All N-95, N-100, P-100 rated equipment – whether disposable masks, APR, or PAPR respirators – are valid for use against particulate contaminants only, not vapors or gases. • N-100 & P-100, strictly speaking, filter to 99.97% efficiency for particles 0.3 microns in diameter. • The nine classes of particulate respirators (N, P, R, 95, 99, and 100) are available as filtering face piece (disposable) respirators, but are also available with elastomeric face pieces and disposable filters and/or cartridges. • In a potential bio-terrorism event, a paper mask will not be sufficient, since an agent could potentially enter through the eyes. Although NIOSH currently gives half-face piece, elastomeric respirators the same protection factor as disposable ones by NIOSH, it is a controversial determination. • A full face-piece, elastomeric respirator not only protects the eyes; it is given a higher assigned protection factor than half-face respirators. • Where Cal/OSHA has jurisdiction, Section 5192 (HAZWOPER) applies to employees going to the site of a release. In such an event, minimum respirator requirements in for those in the assigned section would apply, namely, self-contained breathing apparatus (SCBA) until reduced by the Incident Commander. • Firescope California Standardized Hazardous Materials Equipment List, Ed. 2004, Personal Protective Equipment (PPE), pg. 7-12, et seq.

OSHA Safety & Health Information Bulletin: “CBRN Escape Respirators”, provides guidance on use, selection, and training. OSHA’s Current Policy and Interim Guidance for Respirator Program Managers: http://www.osha.gov/dts/shib/shib082903a.html

v

Appendix A

10

11