A Truckload of Tools

The first thing to know, in an article about what equipment ambulances carry and why, is that we're not generalizing. There are 50 states that each do their own thing on this, and countless smaller jurisdictions that can add additional requirements above and beyond what their states mandate. There's a lot of overlap from system to system, of course, but don't go looking for exact matches or broad brushstrokes. It is, as one state EMS director put it, "quite a mosaic" of whats, whys and hows out there.

     But it might be useful, we figured, to look briefly at a few individual cases and find out a bit more about the whole process: how those lists are developed, who informs them, how changes occur and how it all affects you in the field. The following Q&As do that. We've provided a pair of views from on high (i.e., state bosses) and one from the ground (a top exec with a large ambulance service that operates in three states).

     If there are unusual requirements or other unique aspects to your mandated equipment and gear that are worth sharing with your peers or discussing further, let us know.

DAN WILLIAMS
Section Chief, EMS Systems Section Wisconsin Dept. of Health and Family Services

     In Wisconsin, EMS is under the Department of Health and Family Services. But minimum ambulance equipment standards are set by the state Department of Transportation in a regulation known as Trans 309, which covers equipment and vehicle standards as part of ambulance inspections. That's made things a bit tricky, but officials have worked to ensure EMS input into the DOT's work.

EMS is under Health and Family Services in your state, but the ambulance regulations come from DOT. How does that work?

Williams: Virtually all EMS activity in Wisconsin comes out of the Department of Health and Family Services. However, when we put the ambulance inspection program in place, nobody in that department felt comfortable inspecting the vehicles. So we had the opportunity to weigh in on all of the equipment and medications and those types of things, and they agreed to inspect for those things while they inspected the vehicles for safety. It works; it's just a little awkward at times. There are plans to open that rule up again later this year (2006) or next year, to review and revise the medical equipment list and medications and those types of things. They do that periodically just to make sure everything is current.

It seems like such an arrangement could make things slow or difficult to change as science evolves or new products emerge. How do you compensate for that?

     Each time the rule has been revised, we've tried to use more open-ended language. When something changes, we can usually make changes allowed under the rule without having to open the rule up to a new legislative process. Because when you do that, it takes about a year and a half for the process to be completed.

How politicized is the process? Are there people like vendors or advocacy groups who seek to influence it?

     I don't think they have much influence, but I'll qualify that. Any influence comes in their specific areas of care. A group like EMSC, for instance, might get all charged up about a piece of equipment or procedure or something they believe should be in the Trans 309 rule. But there's usually equal representation from other areas of EMS on the revision committee, so anything new really does get a fair amount of scrutiny and has to pass muster for everybody to be added or removed.

To what extent can local services exceed these minimums?

     They can add additional equipment, but they can't do things that would exceed their scope of practice. Each service is required to submit an operational plan to our office every other year or anytime something changes, and that's our opportunity to make sure they're not exceeding their scope of practice.

DIA GAINOR
EMS Bureau Chief Idaho Dept. of Health and Welfare

     Unlike the Badger State, Idaho's ambulance must-haves are maintained within the EMS house. The state's EMS Bureau is under its Department of Health and Welfare, and its minimum equipment list is maintained by that bureau, in that department. What's similar is the latitude the state gives to the locals in deciding what's best for their communities.

How are your state's equipment standards developed? How much comes from the legislature, and how much from your office?

Gainor: Our standards are promulgated using a mechanism called incorporation by reference. The existence of the standard is in our administrative code, which has to be approved by the Board of Health and Welfare, as well as the legislature. But the details of the document are subject to our own methods of development and consensus and endorsement by our state EMS advisory committee. There's not a list of equipment found in law, but there's the requirement to have that list set in law, and deference to the Board of Health and Welfare as the ultimate approving entity.

How does change occur?

     When the EMS Bureau determines the need to update the list, we use a collaborative process-a multidisciplinary, multiagency convention of EMS system participants and stakeholders-to decide what revisions would be appropriate. And then since that causes a new version of the list to exist, we then go to the Board of Health and Welfare to update the incorporation by reference and get the most recent version promulgated into rule.

Is there anything unique or unusual about your list compared to those of other states?

     We have a unique portion of our administrative code whereby the Bureau has the authority to make exceptions to the minimum equipment requirements, upon inspection, when the circumstances and available alternatives assure that appropriate patient care will be provided for all foreseeable incidents. I think that may be one of the more unique aspects of our regulatory oversight of equipment. Is it reasonable to require that an air-medical service carry a Jaws of Life? No, because we can reasonably expect that equipment to be brought to the scene by a more appropriate vehicle. Or we may have services that do strictly neonatal interfacility transfers. We can't take an adult-oriented list of equipment and demand they carry that, if all they're carrying is neonates. So on a case-by-case basis, we can make exceptions based on the idiosyncrasies of the local EMS agencies. I think our model has some inherent respect for the judgment and expertise of the local chief administrative official and medical director in those matters.

JEFF SARGENT
COO, Southwest Ambulance

     Mesa, AZ-based Southwest Ambulance has more than 1,200 employees and almost 300 ambulances. It also operates in three states-Arizona, New Mexico and Utah-which means three different sets of regulatory hoops to jump through. This has necessitated an operating model that's somewhat decentralized.

What are the challenges of operating in three states, and how does Southwest cope with three different regulatory environments?

Sargent: We have what's basically an on-ground manager in each area, and that person is responsible for interacting with the governing body of EMS. Obviously, that's different in each state, and in some states there's more than one we have to interact with. We have different medical directors in each location as well; that way we make sure we have the local flavor in the service we provide to that community. So we're not trying to manage it all globally; we're watching it globally and providing support, but as everyone says, EMS is essentially local, and that's the philosophy we've used in managing the individual systems.

How much are you able to work with the state offices and have input into developing equipment lists?

     We've taken an active role. In Arizona, we have a director of EMS whose basic job is dealing with the Department of Health. We have people on EMS committees. In New Mexico, we're starting the process of becoming more engaged. We're afforded that luxury because of our size, where a smaller provider may not have that.

How much local variation do you see within states? Do things differ from community to community?

     It goes down to individual jurisdictions. An IV catheter is an IV catheter in the grand scheme of things, but we may see specific styles requested to integrate locally. For example, Roswell (NM) has one hospital. When we went in there, the hospital requested that we use the same needleless system they did. So supplies are totally local, especially in smaller communities. A patient getting charged for two sets of IV tubing, because one system uses one needleless system and the other uses a different one, is just not acceptable. Where we can be similar, we are.

What's involved in going into a new state?

     We use a partnership model, and get a lot of input on how we operate. Our biggest challenge is, once awarded a contract or the granting of a license, learning the intricacies of that community in the short time frame before startup. Without a large amount of staff on the ground, we utilize some of our resources in other locations to stock ambulances to meet minimum standards. But we always find with startups that once we're doing the ambulance inspections, inevitably something that's a local requirement isn't there, and then you're working in the last few hours to make sure everything's up to par.