6 CCR 1015-3
DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Prevention Services Division (1015, 1016) – Rules promulgated by the Colorado Board of Health EMERGENCY MEDICAL SERVICES 6 CCR 1015-3 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] Chapter One Section 1 – Purpose and Authority for Rules 1.1 These rules address the recognition process for emergency medical services (EMS) education programs; the certification process for all levels of emergency medical technician; the procedures for denial, revocation, suspension, limitation, or modification of an emergency medical technician certificate; the collection of essential data related to the performance and needs of the emergency medical care system in Colorado; and the licensure of ground and air ambulance services.
1.2 The authority for the promulgation of these rules is set forth in Section 25-3.5-101 et seq., C.R.S. Section 2 – Definitions 2.1 All definitions that appear in Section 25-3.5-103, C.R.S., shall apply to these rules.
2.2 "Advanced Cardiac Life Support (ACLS)” – A course of instruction designed to prepare students in the practice of advanced emergency cardiac care.
2.3 "Board of Medical Examiners (BME) Rules" – Rules adopted by the Board of Medical Examiners that establish the responsibilities of medical directors and all authorized acts of emergency medical technicians, located at 3 CCR 713-6, Rule 500.
2.4 "Continuing Education" – Education required for the renewal of a state or national emergency medical technician certificate.
2.5 "Council" – State Emergency Medical and Trauma Services Advisory Council.
2.6 "Department" – Colorado Department of Public Health and Environment.
2.7 "Emergency Medical Technician-Basic (EMT-Basic)" – An individual who has a current and valid EMT-Basic certificate issued by the Department and who is authorized to provide basic emergency medical care in accordance with BME rules.
2.8 “Emergency Medical Technician-Basic with IV Authorization” – An individual who has a current and valid EMT-Basic certificate issued by the Department and who has met the conditions defined in Section 4 of the BME rules relating to IV authorization.
2.9 "Emergency Medical Technician-Intermediate (EMT-Intermediate)" – An individual who has a current and valid EMT-Intermediate certificate issued by the Department and who is authorized to provide limited acts of advanced emergency medical care in accordance with BME rules.
2.10 "Emergency Medical Technician-Paramedic (EMT-Paramedic)" – An individual who has a current and valid EMT-Paramedic certificate issued by the Department and who is authorized to provide limited acts of advanced emergency medical care in accordance with BME rules.
2.11 “EMS Education Center" – A state-recognized provider of initial courses that qualify graduates for state or national emergency medical technician certification or for expanded scope of practice.
2.12 "EMS Education Group" – A state-recognized provider of EMS continuing education topics and/or refresher courses that qualify individuals for renewal of a state or national emergency medical technician certification.
2.13 "EMS Education Program" – A state-recognized provider of EMS education including a recognized education group, center or hospital.
2.14 "EMS Education Program Standards" – Department approved minimum standards for EMS education that shall be met by state-recognized EMS education programs.
2.15 "Emergency Medical Technician Refresher Course" – A course of study based on the Department approved curriculum that meets the education requirements for renewal of a state or national emergency medical technician certificate.
2.16 "Graduate EMT-Intermediate" – An individual who has successfully completed a Department recognized EMT-Intermediate education course but has not yet successfully completed the certification requirements set forth in these rules.
2.17 "Graduate EMT-Paramedic" – An individual who has successfully completed a Department recognized EMT-Paramedic education course but has not yet successfully completed the certification requirements set forth in these rules.
2.18 “Initial Course" – A course of study based on a Department approved curriculum that prepares a person for first-time state or national EMT certification, or for expanded scope of practice as defined by BME rules.
2.19 “Initial EMT Certification” – First time application for and issuance by the Department of a certificate at any EMT level. This shall include applications received from persons holding any level of certification issued by the Department who are applying for either a higher or lower level certificate.
2.20 “Letter of Admonition” – A form of disciplinary sanction that is placed in a certificate holder’s file and represents an adverse action against the certificate holder.
2.21 "Medical Director" – A physician holding an active Colorado medical license who authorizes and directs, through established protocols and standing orders, the performance of students-in- training enrolled in state-recognized EMS education programs, graduate EMT-Intermediates or EMT-Paramedics, or state-certified EMTs who perform medical acts, and who is specifically identified as being responsible to assure the performance competency of those authorized individuals as described in the physician's medical continuous quality improvement program.
2.22 "National Registry of Emergency Medical Technicians (NREMT)" – A national EMT certification organization.
2.23 "Practical Skills Examination" – A skills test conducted at the end of an initial course and prior to application for national or state EMT certification.
2.24 “Provisional Certification” – A certification, valid for not more than 90 days, that may be issued by the Department to an applicant seeking certification as an EMT. Section 3 – State Recognition of Emergency Medical Services (EMS) Education Programs
3.1 Specialized Education Curricula
3.1.1 The specialized education curricula established by the Department include but are not limited to the following:
A) EMT-Basic initial and refresher courses B) EMT-Basic intravenous therapy (IV) course C) EMT-Intermediate initial and refresher courses D) EMT-Paramedic initial and refresher courses E) EMS instructor courses
3.2 Application for State Recognition as an EMS Education Program
3.2.1 The Department may grant recognition for any of the following types of EMS education programs:
A) EMT-Basic education center B) EMT-Basic education group C) EMT-Basic IV education group D) EMT-Intermediate education center E) EMT-Intermediate education group F) EMT-Paramedic education center G) EMT-Paramedic education group 3.2.2 Any education provider seeking to conduct EMS education to prepare graduates for national or state EMT certification shall apply for state recognition as described below.
3.2.3 Initial EMS education program recognition shall be valid for a period of three (3) years from the date of the Department's written notice of recognition.
3.2.4 EMS education programs shall utilize personnel who meet the qualification requirements in state EMS education program standards.
3.2.5 State-recognized EMS education programs are required to present current Colorado emergency medical technician scope of practice content, as established in BME rules, within every emergency medical technician initial and refresher course.
3.2.6 EMS education centers that provide initial education at the EMT-Paramedic level shall obtain accreditation from the Commission on Accreditation of Allied Health Education Programs (CAAHEP). The EMS education center shall provide the Department with verification that an application for accreditation has been submitted to CAAHEP prior to the EMS education center initiating a second course.
3.2.7 EMS education centers that provide initial education at the EMT-Paramedic level shall maintain accreditation from CAAHEP. Loss of CAAHEP accreditation by an EMS education center shall result in proceedings for the revocation, suspension, limitation or modification of state recognition as an EMS education program.
3.2.8 Applicants for state EMS education program recognition shall submit the following documentation to the Department:
A) a completed application form provided by the Department;
B) a personnel roster, to include a current resume for the program director and medical director;
C) a description of the facilities to be used for course didactic, lab, and clinical instruction and a listing of all education aids and medical equipment available to the program;
D) program policies and procedures, which at a minimum shall address:
3.2.9 After receipt of the application and other documentation required by these rules, the Department shall notify the applicant of recognition or denial as an EMS education program, or shall specify a site review or modification of the materials submitted by the applicant.
3.2.10 If the Department requires a site visit, the applicant shall introduce staff, faculty, and medical director, and show all documentation, equipment, supplies and facilities.
3.2.11 Applications determined to be incomplete shall be returned to the applicant.
3.2.12 The Department shall provide written notice of EMS education program recognition or denial of recognition to the applicant. The Department's determination shall include, but not be limited to, consideration of the following factors:
A) fulfillment of all application requirements;
B) demonstration of ability to conduct EMS education in compliance with the Department's EMS education program standards;
C) demonstration of necessary professional staff, equipment and supplies to provide the education.
3.2.13 Denial of recognition shall be in accordance with Section 4 of these rules.
3.3 EMS Education Program Recognition Renewal
3.3.1 Renewal of recognition shall be valid for a period of five (5) years from the date of the Department's notice of recognition renewal and shall be based upon satisfactory past performance and submission of an updated application form.
3.3.2 Additional information as specified in Section 3.2.8 may be required by the Department. The Department may require a site review in conjunction with the renewal application. Section 4 – Disciplinary Sanctions and Appeal Procedures for EMS Education Program Recognition 4.1 The Department, in accordance with the State Administrative Procedure Act, Section 24-4-101, et seq., C.R.S., may initiate proceedings to deny, revoke, suspend, limit or modify EMS education program recognition for, but not limited to, the following reasons:
4.1.1 the applicant fails to meet the application requirements specified in Section 3 of these rules.
4.1.2 the applicant does not possess the necessary qualifications to conduct an EMS education program in compliance with EMS education program standards.
4.1.3 the applicant fails to demonstrate access to adequate clinical or internship services as required in EMS education program standards.
4.1.4 fraud, misrepresentation, or deception in applying for or securing EMS education program recognition.
4.1.5 failure to conduct the EMS education program in compliance with EMS education program standards.
4.1.6 failure to notify the Department of changes in the program director or medical director.
4.1.7 providing false information to the Department with regard to successful completion of education or practical skill examination.
4.1.8 failure to comply with the provisions in Section 3 of these rules.
4.2 If the Department initiates proceedings to deny, revoke, suspend, limit or modify an EMS education program recognition, the Department shall provide notice of the action to the EMS education program (or program applicant) and shall inform the program (or program applicant) of its right to appeal and the procedure for appealing. Appeals of Departmental actions shall be conducted in accordance with the State Administrative Procedure Act, Section 24-4-101, et seq., C.R.S. Section 5 – Emergency Medical Technician Certification
5.1 General Requirements
5.1.1 The Department may issue the following EMT certifications:
A) EMT-Basic B) EMT-Intermediate C) EMT-Paramedic D) Provisional 90-day EMT certification at the Basic, Intermediate or Paramedic level.
5.1.2 No person shall hold himself or herself out as an EMT or offer, whether or not for compensation, any services included in these rules or authorized acts permitted by the Board of Medical Examiners rules (BME rules), unless that person is currently state- certified as an EMT under these regulations, or is working under the provisions of the BME rules pertaining to Graduate EMT-Intermediate or Graduate EMT-Paramedic, or otherwise authorized by law.
5.1.3 Certificates shall be effective for a period of three (3) years after the date of issuance. The date of issuance shall be determined by the date the Department approves the application.
5.1.4 Upon the expiration date of a Department-issued EMT certificate, the person named in the certificate is no longer a currently certified EMT and is not authorized to act as a state- certified EMT, except under the circumstances specified below in Section 5.1.5.
5.1.5 Pursuant to Section 24-4-104(7), C.R.S., of the State Administrative Procedure Act, if an EMT has made timely and sufficient application for certification renewal and the Department fails to take action on the application prior to the certificate’s expiration date, the EMT’s existing certification shall not expire until the Department acts upon the application. The Department, in its sole discretion, shall determine whether the application was timely and sufficient.
5.1.6 Multiple certifications within the levels of EMT shall not be permitted. Certification at a higher level indicates that the holder of the certificate may also provide medical care allowed under a lower level of certification, provided the lower level certification has not been revoked, modified, suspended, or expired.
5.1.7 If a currently certified EMT seeks a higher or lower level of certification, he or she shall satisfy the requirements for initial certification at the new EMT level, except as described below.
A) If the higher level EMT certification is valid and in good standing, the applicant for a lower level certificate shall not be required to submit current and valid certification from the NREMT at the lower EMT level.
5.2 Initial EMT Certification
5.2.1 Applicants for initial EMT certification shall:
A) be no less than 18 years of age at the time of application;
B) submit to the Department a completed application form provided by the Department, and C) submit to the Department with a completed application form all of the following:
5.3 Renewal of EMT Certification
5.3.1 General Requirements
A) Any person who holds an expired EMT certificate is not a state-certified EMT and shall not hold himself or herself out as such or provide medical care in the capacity of a state-certified EMT.
B) Persons who have permitted their certification to expire for a period not to exceed six
C) Persons who have permitted their certification to expire for a period of greater than six
D) All certificates renewed by the Department shall be valid for three (3) years from the date of issuance.
E) Date of issuance is the date of application approval by the Department, except, for applicants successfully completing the renewal of certification requirements during the last six (6) months prior to their certificate expiration date, the date of issuance shall be the expiration date of the current valid certificate being renewed.
F) Pursuant to Section 24-4-104(7), C.R.S., of the State Administrative Procedure Act, if an EMT has made timely and sufficient application for certification renewal and the Department fails to take action on the application prior to the certificate’s expiration date, the EMT’s existing certification shall not expire until the Department acts upon the application. The Department, in its sole discretion, shall determine whether the application was timely and sufficient.
5.3.2 Application for Renewal of EMT Certification
An applicant for renewal of an EMT certification shall:
A) submit to the Department a completed application form provided by the Department;
B) submit to the Department with a completed application form all of the following:
C) complete one of the following:
5.3.3 Education Requirements to Renew an EMT Certificate Without the Use of a Current and Valid NREMT Certification A) For renewal of a Department-issued EMT certificate without the use of a current and valid NREMT certification, the following education is required:
5.4 Provisional EMT Certification
5.4.1 General Requirements
A) The Department may issue a provisional EMT certification to an applicant whose fingerprint-based criminal history record check has not been received by the Department at the time of application for certification.
B) To be eligible for a provisional certification, the applicant shall, at the time of application, have satisfied all requirements in these rules for initial or renewal certification.
C) A provisional certification shall be valid for not more than ninety days.
D) The Department may renew a provisional certification.
E) The Department may impose disciplinary sanctions pursuant to these rules if the Department finds that an EMT who has received a provisional certification has violated any of the certification requirements or any of these rules.
F) Once a provisional certification becomes invalid, an applicant may not practice or act as an EMT unless an initial or renewal certification has been issued by the Department to the applicant.
5.4.2 Application for Provisional Certification
An applicant for a provisional certification shall:
A) submit to the Department a completed application form provided by the Department.
B) submit to a fingerprint-based criminal history record check as provided in sections
C) submit to the Department with a completed application form all of the following:
Section 6 – Disciplinary Sanctions and Appeal Procedures for EMT Certification 6.1 For good cause, the Department may deny, revoke, suspend, limit, modify, or refuse to renew an EMT certificate, may impose probation on a certificate holder, or may issue a letter of admonition in accordance with the State Administrative Procedure Act, Section 24-4-101, et seq., C.R.S.
6.2 Good cause for disciplinary sanctions listed above shall include, but not be limited to:
6.2.1 failure to meet the requirements of these rules pertaining to issuance and renewal of EMT certification.
6.2.2 fraud, misrepresentation, or deception in applying for or securing EMT certification.
6.2.3 aiding and abetting in the procurement of EMT certification for any person not eligible for certification.
6.2.4 utilizing NREMT certification that has been illegally obtained, suspended or revoked, to obtain a state EMT certification.
6.2.5 unlawful use, possessing, dispensing, administering, or distributing controlled substances.
6.2.6 driving an emergency vehicle in a reckless manner, or while under the influence of alcohol or other performance altering substances.
6.2.7 responding to or providing patient care while under the influence of alcohol or other performance altering substances.
6.2.8 demonstrating a pattern of alcohol or other substance abuse.
6.2.9 materially altering any Department EMT certificate, or using and/or possessing any such altered EMT certificate.
6.2.10 having an EMT certificate or license suspended or revoked in another state or country.
6.2.11 unlawfully discriminating in the provision of services.
6.2.12 representing qualifications at any level other than the person's current EMT certification level.
6.2.13 representing oneself to others as an EMT or providing medical care without possessing a current and valid EMT certificate issued by the Department.
6.2.14 failing to follow accepted standards of care in the management of a patient, or in response to a medical emergency.
6.2.15 failing to administer medications or treatment in a responsible manner in accordance with the medical director's orders or protocols.
6.2.16 failing to maintain confidentiality of patient information.
6.2.17 failing to provide the Department with the current place of residence or failing to promptly notify the Department of a change in current place of residence or change of name.
6.2.18 a pattern of behavior that demonstrates routine response to medical emergencies without being under the policies and procedures of a designated emergency medical response agency and/or providing patient care without medical direction when required.
6.2.19 performing medical acts not authorized by the BME rules and in the absence of any other lawful authorization to perform such medical acts.
6.2.20 failing to provide care or discontinuing care when a duty to provide care has been established.
6.2.21 appropriating or possessing without authorization medications, supplies, equipment, or personal items of a patient or employer.
6.2.22 falsifying entries or failing to make essential entries in a patient care report, EMS education document, or medical record.
6.2.23 falsifying or failing to comply with any collection or reporting required by the state.
6.2.24 failing to comply with the terms of any agreement or stipulation regarding EMT certification entered into with the Department.
6.2.25 violating any state or federal statute or regulation, the violation of which would jeopardize the health or safety of a patient or the public.
6.2.26 unprofessional conduct at the scene of an emergency that hinders, delays, eliminates, or deters the provision of medical care to the patient or endangers the safety of the public.
6.2.27 failure by a certificate holder to report to the Department any violation by another EMT of the good cause provisions of this section when the certificate holder knows or reasonably believes a violation has occurred.
6.2.28 committing or permitting, aiding or abetting the commission of an unlawful act that substantially relates to performance of an EMT’s duties and responsibilities as determined by the Department.
6.3 Good cause for disciplinary sanctions also includes conviction of, or a plea of guilty, or of no contest, to a felony or misdemeanor that relates to the duties and responsibilities of an EMT, including patient care and public safety. For purposes of this paragraph, “conviction” includes the imposition of a deferred sentence.
6.3.1 The following crimes set forth in the Colorado Criminal Code (Title 18, C.R.S.) are considered to relate to the duties and responsibilities of an EMT:
A) offenses under Article 3 – offenses against a person.
B) offenses under Article 4 – offenses against property.
C) offenses under Article 5 – offenses involving fraud.
D) offenses under Article 6 – offenses involving the family relations.
E) offenses under Article 6.5 – wrongs to at-risk adults.
F) offenses under Article 7 – offenses related to morals.
G) offenses under Article 8 – offenses – governmental operations.
H) offenses under Article 9 – offenses against public peace, order and decency.
I) offenses under Article 17 – Colorado Organized Crime Control Act.
J) offenses under Article 18 – Uniform Controlled Substances Act of 1992.
6.3.2 The offenses listed above are not exclusive. The Department may consider other pleas or criminal convictions, including those from other state, federal, foreign or military jurisdictions.
6.3.3 In determining whether to impose disciplinary sanctions based on a plea or on a felony or misdemeanor conviction, the Department may consider, but is not limited to, the following information:
A) the nature and seriousness of the crime including but not limited to whether the crime involved violence to or abuse of another person and whether the crime involved a minor or a person of diminished capacity;
B) the relationship of the crime to the purposes of requiring a certificate;
C) the relationship of the crime to the ability, capacity or fitness required to perform the duties and discharge the responsibilities of an EMT; and D) the time frame in which the crime was committed.
6.4 Appeals
6.4.1 If the Department denies EMT certification, the Department shall provide the applicant with notice of the grounds for denial and shall inform the applicant of the applicant’s right to request a hearing.
A) A request for a hearing shall be submitted to the Department in writing within sixty
B) If a hearing is requested, the applicant shall file an answer within sixty (60) calendar days from the date of the notice.
C) If a request for a hearing is made, the hearing shall be conducted in accordance with the State Administrative Procedure Act, Section 24-4-101 et seq., C.R.S.
D) If the applicant does not request a hearing in writing within sixty (60) calendar days from the date of the notice, the applicant is deemed to have waived the opportunity for a hearing.
6.4.2 If the Department proposes disciplinary sanctions as provided in this section, the Department shall notify the certificate holder by first class mail to the last address furnished to the Department by the certificate holder. The notice shall state the alleged facts and/or conduct warranting the proposed action and state that the certificate holder may request a hearing.
A) The certificate holder shall file a written answer within thirty (30) calendar days of the date of mailing of the notice.
B) A request for a hearing shall be submitted to the Department in writing within thirty
C) If a request for a hearing is made, the hearing shall be conducted in accordance with the State Administrative Procedure Act, Section 24-4-101 et seq., C.R.S.
D) If the certificate holder does not request a hearing in writing within thirty (30) calendar days of the date of mailing of the notice, the certificate holder is deemed to have waived the opportunity for a hearing.
6.4.3 If the Department summarily suspends a certificate, the Department shall provide the certificate holder notice of such in writing, which shall be sent by first class mail to the last address furnished to the Department by the certificate holder. The notice shall state that the certificate holder is entitled to a prompt hearing on the matter. The hearing shall be conducted in accordance with the State Administrative Procedure Act, Section 24-4-101, et seq., C.R.S.
Section 7 – Placeholder Section 8 – Placeholder Section 9 – Placeholder Section 10 – Placeholder Section 11 - Data and Information Collection and Record Keeping
11.1 Authority
The authority and requirement for data collection is provided in C.R.S. § 25-3.5-501(1), which states, “Each ambulance service shall prepare and transmit copies of uniform and standardized records, as specified by regulation adopted by the department, concerning the transportation and treatment of patients in order to evaluate the performance of the emergency medical services system and to plan systematically for improvements in said system at all levels.” Additional authority for data collection and analysis is provided in C.R.S. § 25-3.5-307, requiring data collection and reporting by air ambulance agencies, and C.R.S. § 25-3.5-704(2)(h), requiring the establishment of a continuous quality improvement system to evaluate the statewide emergency medical and trauma services system.
11.2 Purpose and Scope
This section consists of rules for the collection and reporting of essential data related to the performance, needs and quality assessment of the statewide emergency medical and trauma services system. These rules focus primarily on the data that ambulance agencies are required to collect and provide to the Department. Rules regarding the collection of data by designated trauma facilities can be found in 6 CCR 1015-4, Chapter 1.
11.3 Definitions
1. Agency or agencies as used in this section 11 means (ground) ambulance services and air ambulance services.
2. Air Ambulance means a fixed-wing or rotor-wing aircraft that is equipped to provide air transportation and is specifically designed to accommodate the medical needs of individuals who are ill, injured, or otherwise mentally or physically incapacitated and who require in-flight medical supervision.
3. Air Ambulance Service means any governmental or private organization licensed by the department to transport in any aircraft patient(s) who require in-flight medical supervision to a medical facility.
4. Ambulance means any privately or publicly owned ground vehicle that meets the requirements of C.R.S. § 25-3.5-103(1.5).
5. Ambulance service means the furnishing, operating, conducting, maintaining, advertising, or otherwise engaging in or professing to be engaged in the transportation of patients by ambulance. Taken in context, it also means the person so engaged or professing to be so engaged. The person so engaged and the vehicles used for the emergency transportation of persons injured at a mine are excluded from this definition when the personnel utilized in the operation of said vehicles are subject to the mandatory safety standards of the federal mine safety and health administration, or its successor agency.
6. Patient means any individual who is sick, injured, or otherwise incapacitated or helpless.
11.4 Reporting Requirements
1. All ambulance service agencies and air ambulance service agencies licensed in Colorado shall provide the Department with the required data and information as specified in sections 2 and 3 below in a format determined by the Department or in an alternate media acceptable to the Department.
2. The required data and information for the agency profile shall be based on the Colorado Emergency Medical Services Information System (CEMSIS).
a. Agency profile data shall include but not be limited to information about licensing, service types and level, agency contact information, agency director and medical director contact information, demographics of the service area, number and types of responding personnel, number of calls by response type, data collection methods, counties served, organizational type, and number and type of vehicles.
b. Agencies shall provide agency profile data to the Department using the CEMSIS portal website.
c. Agencies shall update agency profile data whenever changes occur and at least annually.
3. The required data and information on patient care shall be based on the National Emergency Medical Services Information System (NEMSIS).
a. These rules incorporate by reference the National Highway Traffic Safety Administration (NHTSA) Uniform Pre-Hospital Emergency Medical Services Dataset, Version 2.2.1, National Elements Subset, published in 2006. Such incorporation does not include later amendments to or editions of the referenced material. The Health Facilities and Emergency Medical Services Division of the Department maintains copies of the complete text of required data elements for public inspection during regular business hours, and shall provide certified copies of any non-copyrighted material to the public at cost upon request. Information regarding how the incorporated materials may be obtained or examined is available from the Division by contacting:
b. All agencies licensed in Colorado shall report the required data elements on all responses that resulted in patient contact. Although not required, agencies may also report the required data elements on responses that did not result in patient contact or transport (all calls).
c. Agencies shall obtain approval from the Department prior to using third party media to submit the required data.
d. Agencies shall provide the data to the Department at least quarterly based on a calendar year or on a schedule submitted to and approved by the Department. The quarterly download must be submitted to the Department within 60 days of the end of the quarter (i.e., data for EMS responses occurring in January through March must be submitted by June 1; for responses in April through June by September 1; for responses in July through September by December 1; for responses in October through December by March 1). The data may be submitted more frequently than quarterly.
4. In order to be eligible to apply for funding through the EMTS grants program, agencies shall provide agency profile information as described in section 2 and regularly submit patient care information as described in section 3.
5. If an agency fails to comply with these rules, the Department may report this lack of compliance to the county(ies) in which the agency is licensed and/or to the agency’s medical director.
11.5 Confidentiality of Data and Information on Patient Care
1. The data and information provided to the Department in accordance with 11.4 section 3 of these rules shall be used to conduct continuing quality improvement of the Emergency Medical and Trauma System, pursuant to C.R.S. § 25-3.5-704 (2)(h)(I). Any data provided to the department that identifies an individual patient’s, provider’s or facility’s care outcomes or is part of the patient’s medical record shall be strictly confidential, whether such data are recorded on paper or electronically. The confidentiality protections provided in C.R.S. § 25-3.5-704 (2)(h)(II) apply to this data.
2. Any patient care data in the EMS data system that could potentially identify individual patients or providers shall not be released in any form to any agency, institution, or individual, except as provided in section 11.5,3.
3. An agency may retrieve the patient care data that the agency has submitted via the Department’s web-based data entry utility and that are stored on the Department’s servers.
4. Results from any analysis of the data by the Department shall only be presented in aggregate according to established Department policies.
5. The Department may establish procedures to allow access by outside agencies, institutions or individuals to information in the EMS data system that does not identify patients, providers or agencies. These procedures are outlined in the Colorado EMS Data System Data Release Policy and other applicable Department data release policies. Section 12 - Licensure Of Ambulance Services
12.1 Purpose And Scope
12.1.1 These rules are promulgated pursuant to § 25-3.5-308, CRS (2004). They are consistent with § 25-3.5-301, 302, and 304 -306, CRS (2004). Each county may adopt rules that exceed these rules adopted herein.
12.2 Definitions
12 .2.1 Based: an ambulance service headquartered, having a substation, office ambulance post or other permanent location in a county.
12.2.2 County: county or city and county government within Colorado.
12.2.3 Department: the Colorado Department of Public Health and Environment.
12.2.4 Ambulance: any public or privately owned land vehicle especially constructed or modified and equipped, intended to be used and maintained or operated by, ambulance services for the transportation, upon the roads, streets and highways of this state, of individuals who are sick, injured, or otherwise incapacitated or helpless.
12.2.5 Ambulance-advanced life support: a type of permit issued by a county to a vehicle equipped in accordance with Section 9 of these rules and operated by an ambulance service authorizing the vehicle to be used to provide ambulance service limited to the scope of practice of the emergency medical technician-intermediate or emergency medical technician-paramedic as defined in the Colorado Board of Medical Examiners rules, 3 CCR 713-6, Rule 500, Sections 5 and 6.
12.2.6 Ambulance-basic life support: a type of permit issued by a county to a vehicle equipped in accordance with Section 9 of these rules and authorized to be used to provide ambulance service limited to the scope of practice of the emergency medical technician- basic as defined in the Colorado Board of Medical Examiners rules, 3 CCR 713-6, rule 500, section 4.
12.2.7 Ambulance service license: a legal document issued to an ambulance service by a county as evidence that the applicant meets the requirements for licensure to operate an ambulance service as defined by county resolution or regulations.
12.2.8 Ambulance service: the furnishing, operating, conducting, maintaining, advertising, or otherwise engaging in or professing to be engaged in the transportation of patients by ambulance. Taken in context, the person so engaged or professing to be so engaged and the vehicles used for the emergency transportation of persons injured at a mine are excluded from this definition when the personnel utilized in the operation of said vehicles are subject to the mandatory safety standards of the federal mine safety and health administration, or its successor agency.
12.2.9 Medical Director: a Colorado licensed physician who establishes protocols and standing orders for medical acts performed by department-certified EMTs of a prehospital EMS service agency and who is specifically identified as being responsible to assure the competency of the performance of those acts by such department-certified EMTs as described in the physician’s medical continuous quality improvement program. Any reference to a “physician advisor” in the state EMS rules or in the Board of Medical Examiners previously adopted rules shall apply to a “medical director” as defined in these rules.
12.2.10 Patient Care Report: a medical record of an encounter between any patient and a provider of medical care.
12.2.11 Permit: the authorization issued by the governing body of a local government with respect to an ambulance used or to be used to provide ambulance service in this state.
12.2.12 Medical quality improvement program: a process consistent with Colorado Board of Medical Examiners rules, 3 CCR 713-6, Rule 500, Section 3.2 (b), used to objectively, systematically and continuously monitor, assess and improve the quality and appropriateness of care provided by the medical care providers operating on an ambulance service.
12.2.13 Rescue Unit: any organized group chartered by this state as a corporation not for profit or otherwise existing as a nonprofit organization whose purpose is the search for and the rescue of lost or injured persons and includes, but is not limited to, such groups as search and rescue, mountain rescue, ski patrols, (either volunteer or professional), law enforcement posses, civil defense units, or other organizations of governmental designation responsible for search and rescue.
12.2.14 Quick Response Teams: provides initial care to a patient prior to the arrival of an ambulance.
12.3 County Issuance Of Licenses And Permit
12.3.1 License Required
A) Within one year following adoption of these rules, no person or agency, private or public, shall transport a patient from any point within Colorado in an ambulance, to any point within or outside Colorado unless that person or agency holds a valid license and permits issued by the county where the service is based and by the county where the patient originates, except as provided in subsection 3.2 of these rules.
B) Ambulance services that are based outside Colorado, but respond within Colorado and transport patients originating in Colorado are required to be licensed in Colorado by the county in which they provide service.
C) Counties may enter into reciprocal licensing and permitting agreements with other counties and neighboring states.
12.3.2 County Exemptions From Licensure or Permit Requirements
A) Vehicles used for the transportation of persons injured at a mine when the personnel used on the vehicles are subject to the mandatory safety standards of the federal mine safety and health administration, or its successor agency.
B) Vehicles used by other agencies including quick response teams and rescue units that do not routinely transport patients or vehicles used to transport patients for extrication from areas inaccessible to a permitted ambulance. Vehicles used in this capacity may only transport patients to the closest practical point for access to a permitted ambulance or hospital.
C) Vehicles, including ambulances from another state, used during major catastrophe or mass casualty incident rendering services when permitted ambulances are insufficient.
D) An ambulance service that does not transport patients from points originating in Colorado, or transporting a patient originating outside the borders of Colorado.
E) Vehicles used or designed for the scheduled transportation of convalescent patients, individuals with disabilities, or persons who would not be expected to require skilled treatment or care while in the vehicle.
F) Vehicles used solely for the transportation of intoxicated persons or persons incapacitated by alcohol as defined in § 25-1-302, CRS (2004) but who are not otherwise disabled or seriously injured and who would not be expected to require skilled treatment or care while in the vehicle.
G) Ambulances operated by a department or an agency of the federal government, originating from a federal reservation for the purpose of responding to, or transporting patients under federal responsibility.
12.3.3 General Requirements For County Licensure Of Ambulance Services
A) Counties shall adopt by resolution or regulations a process for licensure of ambulance services. The process shall include, but not be limited to:
B) These rules incorporate by reference (Section 12.3.3 (a) (9)) materials originally published elsewhere. These rules do not include later amendments to or editions of the incorporated materials. The Department of Public Health and Environment maintains copies of the complete text of the incorporated materials for public inspection during regular business hours, and shall provide certified copies of any non-copyrighted material to the public at cost upon request. The incorporated material may be examined at any state publications depository library. Information regarding how the incorporated materials may be obtained or examined is available from:
12.3.4 Licensure Process
A) Ambulance Service License
B) Permits Of Vehicles
12.3.5 Licensure Period
A) The licensure period for all ambulance services shall be for twelve months.
12.3.6 License Renewal
A) Counties shall create an annual license renewal process. The license renewal process shall require the ambulance service to submit a completed renewal application form and the required licensure fee, as defined in county resolution or regulations. The licensure renewal process shall require the receipt of applications for renewal no less than 30 days before the date of license expiration.
12.4 Complaints
12.4.1 Each county must have a written complaint and investigation policy and procedure to address:
A) complaints against any ambulance service licensed in the county.
B) allegations of unlicensed ambulance services or vehicles without a valid permit operating within the county.
12.4.2 The policy shall include, but not be limited to, the procedures associated with complaint intake; complaint validation; criteria for initiating an investigation; a method for notification to the complainant about the resolution of the investigation; and a method for the notification of other local entities with jurisdiction over ambulance services, the department and/or the Board of Medical Examiners for complaints regarding certified emergency medical technicians, other medical personnel associated with the service or the medical director.
12.4.3 The county shall notify the primary medical director of the ambulance service, in writing, of any violation of the ambulance licensing regulations by the ambulance service or alleged complaints or violations by individual medical providers operating on an ambulance service.
12.5 Denial, Revocation, Or Suspension Of Licensure And Vehicle Permits
12.5.1 Each county shall develop policies and procedures for the denial, suspension or revocation of an ambulance service license or ambulance permit consistent with § 25- 3.5-304, CRS (2004).
12.6 Minimum Data Collection And Reporting Requirements
12.6.1 The county shall require that licensed ambulance services complete a patient care report for each patient that is assessed. The patient care report shall include the minimum pre- hospital care data set as set forth in the Emergency Medical Services Rules, 6 CCR 1015-3.
12.6.2 The county shall require that the ambulance service provide patient care information to the department pursuant to Emergency Medical Services Rules, 6 CCR 1015-3.
12.6.3 The county shall require that each licensed ambulance service complete and submit to the department an agency profile as defined by State Emergency Medical and Trauma Services Advisory Council and approved by the department to provide information on resources available for planning and coordination of statewide emergency medical and trauma services on an annual basis.
12.7 Minimum Staffing Requirements
12.7.1 The county shall establish by resolution or regulations ambulance staffing requirements to include, but not be limited to:
A) The minimum requirement for the person responsible for providing direct emergency medical care to patients transported in an ambulance shall be certified as an emergency medical technician-basic as defined in Emergency Medical Services Rules, 6 CCR 1015-3.
B) The minimum requirement for the ambulance driver shall be a valid driver’s license.
12.7.2 Consistent with § 25-3.5-202, CRS (2004) in the case of an emergency in any ambulance service area where no person possessing the qualifications required by this section is present or available to respond to a call for the emergency treatment and transportation of patients by ambulance, any person may operate such ambulance to transport any sick, injured, or otherwise incapacitated or helpless person in order to stabilize the medical condition of such person pending the availability of personnel meeting these minimum qualifications.
12.8 Medical Oversight And Quality Improvement
12.8.1 The county shall require each ambulance service operating within their jurisdiction to have a primary medical director meeting the requirements established by the Colorado Board of Medical Examiners as defined in the Colorado Board of Medical Examiners 3 CCR 713-6, Rule 500 to supervise the medical acts performed by all personnel on the ambulance service. The county shall require a licensee to inform the county within 15 calendar days, in writing, of changes in medical oversight of the ambulance service and/or the medical director of record.
12.8.2 The county ambulance service licensure application shall include an attestation by the medical director of willingness to provide medical oversight and a medical continuous quality improvement program for the ambulance service.
12.8.3 The county shall require each licensed ambulance service operating within their jurisdiction to have an ongoing medical continuous quality improvement program consistent with the requirements as defined in the Colorado Board of Medical Examiners rules 3 CCR 713-6, Rule 500, 3.2, b.
12.9 Minimum Equipment Requirements
12.9.1 Counties shall ensure that permitted ambulances are in compliance with the minimum equipment list for the type of service defined by their permit as defined in 9.3 and 9.4 of these rules.
12.9.2 Minimum Equipment For Basic Life Support Ambulances
A) Ventilation And Airway Equipment
B) Patient Assessment Equipment
C) Splinting Equipment
D) Dressing Materials
E) Obstetrical Supplies
F) Miscellaneous Equipment
G) Ambulance Service Medical Treatment Protocols.
H) Communications Equipment
I) Extrication Equipment
J) Body Substance Isolation (BSI) Equipment Properly Sized To Fit All Personnel
K) Safety Equipment
12.9.3 Minimum Equipment Requirement for Advanced Life Support Ambulances
A) All Equipment Listed In 9.2 B) Ventilation Equipment
C) Patient Assessment Equipment
D) Intravenous Equipment
E) Pharmacological Agents
Section 13 - Air Ambulance Licensing
13.1 Purpose and Scope
These rules are promulgated pursuant to Section 25-3.5-307, C.R.S. (2007).
13.2 Definitions
1. Air Ambulance: A fixed-wing or rotor-wing aircraft that is equipped to provide air transportation and is specifically designed to accommodate the medical needs of individuals who are ill, injured, or otherwise mentally or physically incapacitated and who require in-flight medical supervision.
2. Air Ambulance License: A legal document issued by the department as evidence that an air ambulance service meets the requirements for licensing as defined in these rules.
3. Air Ambulance Service: Any governmental or private organization licensed by the department to transport in an aircraft patient(s) who require in-flight medical supervision to a medical facility.
4. Aircraft: A rotor or fixed wing vehicle.
5. Commission on Accreditation of Medical Transport Systems (CAMTS): A national not for profit organization that provides accreditation services for air medical and inter-facility transport services.
6. Department: The Colorado Department of Public Health and Environment.
7. Federal Aviation Regulations (FAR): Regulations promulgated by the Federal Aviation Administration of the U.S. Department of Transportation, governing the operation of all aircraft in the United States.
8. Medical Protocol: Written standards for patient medical assessment and management.
9. Patient Care Report (PCR): A medical record of an encounter between any patient and a provider of medical care.
10. Rescue Unit: Any organized group chartered by this state as a corporation not for profit or otherwise existing as a nonprofit organization whose purpose is the search for and the rescue of lost or injured persons and includes, but is not limited to, such groups as search and rescue, mountain rescue, ski patrols, (either volunteer or professional), law enforcement posses, civil defense units, or other organizations of governmental designation responsible for search and rescue.
13.3 Licensing
1. Licensing Required Upon the effective date of these rules, no person, agency, or entity, private or public, shall transport a sick or injured person by aircraft from any point within Colorado, to any point within or outside Colorado unless that person, agency, or entity holds a valid air ambulance service license to do so that has been issued by the department, except as provided in subsection 13.3,2 and 3 of these rules.
2. Exception from Licensing-Exigent Circumstances Upon request, the department may authorize an air ambulance service to provide a particular transport upon a showing of exigent circumstances. Exigent circumstances include but are not limited to:
A. A humanitarian transport as determined by the department. In determining whether to authorize a humanitarian transport, the department shall consider the following factors:
B. A disaster or mass casualty event in Colorado that limits the availability of licensed services;
C. A need for specialized equipment not otherwise readily available through Colorado licensed air ambulance services.
3. Licensing Not Required A. An air ambulance service agency that solely transports patients from points originating outside Colorado is not required to be licensed in Colorado.
B. Rescue unit aircraft that are not specifically designed to accommodate the medical needs of individuals who are ill, injured, or otherwise mentally or physically incapacitated and who require in-flight medical supervision.
13.4 Out of State Air Ambulance Services Licensing Requirements
Air ambulance services that are based outside the state, but pick up patients in Colorado, are required to be licensed in Colorado by the department, except as provided in section 13.3,2 of these rules.
13.5 Application for Licensing
1. At the time of application, applicants must be in compliance with all Federal Aviation Regulations such as proof of insurance, aircraft inspection certificates, Federal Aviation Administration part 135 certificate and Federal Communications Commission part 90.
2. Accreditation by CAMTS. Except as provided in 13.5,3 below, applicants that are currently accredited by CAMTS may receive a license to operate an air ambulance service upon completion of the documentation and fees that are required by the department and proof of such accreditation.
3. The department may issue a conditional license to an applicant that has not yet received CAMTS accreditation upon proof that the applicant is actively working toward CAMTS accreditation. The department may require that such proof be verified by CAMTS. Any applicant that receives a conditional license shall complete its CAMTS accreditation within two years after issuance of the initial conditional license.
4. If the holder of a conditional license fails to complete CAMTS accreditation within two years after the issuance of the initial conditional license, its conditional license shall be revoked and no license of any type shall be issued until it demonstrates successful completion of CAMTS accreditation.
5. At such time as any air ambulance service licensed under section 13.3,1 of these rules receives a "notification of potential withdrawal of accreditation" from CAMTS, or is no longer CAMTS accredited, the service shall immediately notify the department.
13.6 Fees
All applicants seeking licensure by the department under these air ambulance service rules shall submit the following non-refundable fees with each initial or renewal licensure application:
1. $860 for each air ambulance service, plus $100 for each aircraft used by the air ambulance service.
2. For applicants who are not CAMTS accredited, the applicant shall pay a fee of $525 to the department in addition to the fee set forth in 13.6,1 above.
13.7 Licensing Process
1. To become licensed and maintain licensed status as an air ambulance service, the service shall:
A. Achieve and maintain CAMTS accreditation.
B. Demonstrate compliance with applicable federal, state, and local laws and regulations to operate a business in Colorado.
C. Submit to the department a completed application form and the required application fee.
D. Demonstrate compliance with these rules.
E. Upon request, submit to the department copies of the service's written policy and procedure manual, operation/medical protocols, and other documentation the department may deem necessary.
2. The department may conduct an inspection of the service and its aircraft to assure compliance with these rules.
3. When change of ownership of an air ambulance service occurs, the new owner or operator must file for and obtain an air ambulance service license from the department prior to beginning operations.
13.8 Licensing Period
Any air ambulance service license issued by the department shall be valid for a period not to exceed one year.
13.9 Licensing Renewal
1. To renew an existing air ambulance service license, the licensee shall submit a renewal application and fees, as set by the department, no later than three (3) months prior to the date of license expiration.
2. A renewal inspection may be required by the department to assure service compliance with these rules.
13.10 Types of Service
In order to identify the types of services to be provided, air ambulance licenses shall be issued for each of the following types of service.
1. Rotor wing advanced life support (RW-ALS)
2. Rotor wing critical care (RW-CC)
3. Rotor wing specialty care (RW-SC)
4. Fixed wing basic life support (FW-BLS)
5. Fixed wing advanced life support (FW-ALS)
6. Fixed wing critical care (FW-CC)
7. Fixed wing specialty care (FW-SC)
13.11 General Operational Requirements
1. Each air ambulance service shall work in coordination with all other air ambulance services to assure optimal minimal response times.
2. Policies for responding to requests for services shall include:
A. Consultation with the requesting party regarding how and to whom those flights will be referred, based on the air ambulance service's scope of service, geographical proximity, transport capability and type of call.
B. The closest appropriate service shall be dispatched unless a specific air ambulance service is requested by the requesting party.
C. All air ambulance services must have a communications system in place capable of providing appropriate, timely referrals.
D. Factors affecting the estimated time of arrival (ETA) of air ambulance service shall be communicated to the calling party as soon as possible, within five (5) minutes for inter-facility transports and three (3) minutes for scene requests.
E. Scene requests shall be referred within three (3) minutes to the next closest, available, appropriate resource if the initial requested air ambulance service does not have an aircraft and crew immediately available.
F. Inter-facility transport requests shall be referred within five (5) minutes to the next closest, available, appropriate resource if the initial requested air ambulance service does not have an aircraft and crew immediately available.
G. Air ambulance service response policies and times shall be available to the public, upon request.
H. In accordance with Section 11 of these rules, Colorado licensed air ambulance services shall complete a patient care report (PCR) to include the minimum pre- hospital care data set for each patient that is transported. The minimum data elements identified by the department shall be compiled and submitted to the department in a format and frequency specified by the department.
I. Each licensed air ambulance service shall complete and submit to the department an agency profile to provide information on resources available for planning and coordination of statewide emergency medical and trauma services.
13.12 Complaints
Complaints in writing relating to the quality and conduct of any air ambulance service may be made by any person or may be initiated by the department. The department may make inquiry as to the validity of such complaint prior to initiating an investigation. If the department determines that the complaint warrants a more extensive review, an investigation may be initiated. If the complaint does not warrant further review or the inquiry determines that the complaint is not within regulatory jurisdiction of the department, the department will notify the complainant of the results of the inquiry. The department shall refer complaints that are related to the requirements of CAMTS or a successor organization to CAMTS or such successor organization for investigation. The department may forward complaints to other regulatory agencies.
13.13 Denial, Revocation, Suspension, Summary Suspension, or Limitations of Air Ambulance Licenses 1. If the department proposes for good cause to deny, revoke, suspend, summarily suspend or limit the license of an air ambulance service, the department shall notify the air ambulance service of its right to appeal the denial, revocation, suspension, summary suspension, or limitation, and the procedure for appealing. Appeals of departmental denials, revocations, suspensions, summary suspensions, or limitations shall be conducted in accordance with the State Administrative Procedure Act, Section 24-4-101, et seq., C.R.S.
2. In accordance with Section 24-4-104(4) C.R.S., the department may summarily suspend an air ambulance service license when the department has objective and reasonable grounds to believe and finds, upon a full investigation, that the holder of the license has been guilty of deliberate and willful violation or that the public health, safety or welfare imperatively requires emergency action by the department. If the department summarily suspends a license, the department shall provide the air ambulance service with notice of such suspension in writing. The notice shall state that the air ambulance service is entitled to a prompt hearing on the matter.
3. Good cause for sanctions include but are not limited to:
A. An applicant or licensee who fails to meet the requirements for licensing as set forth in these rules.
B. An applicant or licensee who has committed fraud, misrepresentation, or deception in applying for a license.
C. Falsifying reporting information provided to the department.
D. Violating any state or federal statute, rule or regulation that would jeopardize the health or safety of a patient or the public.
E. Unprofessional conduct, which hinders, delays, eliminates, or deters the provision of medical care to the patient or endangers the safety of the public.
F. Failure to achieve or maintain CAMTS accreditation.
13.14 General Requirements
1. These rules incorporate by reference the following materials:
A. For services whose most recent application for CAMTS accreditation was submitted prior to January 1, 2007: the Accreditation Standards of the Commission on Accreditation of Medical Transport Systems (CAMTS), Sixth Edition, published October 2004.
B. For services whose most recent application for CAMTS accreditation is submitted on or after January 1, 2007: the Accreditation Standards of the Commission on Accreditation of Medical Transport Systems (CAMTS), Seventh Edition, published September 2006.
C. Such incorporation does not include later amendments to or editions of the referenced material. The Health Facilities and Emergency Medical Services Division of the Colorado Department of Public Health and Environment maintains copies of the complete text of the incorporated materials for public inspection during regular business hours, and shall provide certified copies of any non-copyrighted material to the public at cost upon request. Information regarding how the incorporated materials may be obtained or examined is available from the division by contacting:
2. These materials have been submitted to the state publications depository and distribution center and are available for interlibrary loans. The incorporated material may be examined at any state publications depository library.
CHAPTER TWO – EMS PRACTICE AND MEDICAL DIRECTOR OVERSIGHT RULES Rules Defining the Qualifications and Duties of Emergency Medical Services Medical Directors and the Authorized Medical Acts of Emergency Medical Technicians SECTION 1 - Purpose and Authority for Establishing Rules 1.1 The purpose of these rules is to define the qualifications and duties of medical directors to Emergency Medical Services (EMS) agencies and to define the authorized medical acts of emergency medical technicians (EMTs).
1.2 The general authority for the promulgation of these rules by the executive director or chief medical officer of the department is set forth in Sections 25-3.5-203 and 206, C.R.S.
1.3 These rules apply to and are controlling for any physician functioning as a medical director to an EMS organization and who authorizes and directs the performance of medical acts by EMTs at all levels of certification in the State of Colorado. These rules also define the scope of practice for EMTs.
1.4 These rules shall take effect on January 1, 2011.
SECTION 2 - Definitions - All definitions that appear in Section 25-3.5-103, C.R.S., and 6 CCR 1015- 3, CHAPTER ONE shall apply to these rules.
2.1 “Certified EMT” – an individual who has been certified by the department to act as an EMT-Basic, EMT-Intermediate or EMT-Paramedic pursuant to EMS Rules.
2.2 “Colorado Medical Board” – the Colorado Medical Board established in Title 12, Article 36, C.R.S., formerly known as the state Board of Medical Examiners.
2.3 “Department” - The Colorado Department of Public Health and Environment.
2.4 “Emergency Medical Practice Advisory Council (EMPAC)” – the council established pursuant to Section 25-3.5-206, C.R.S., that is responsible for advising the department regarding the appropriate scope of practice for EMTs and for the criteria for physicians to serve as EMS medical directors.
2.5 “Emergency Medical Services Rules (EMS Rules)” – Rules Pertaining to Emergency Medical Services, 6 CCR 1015-3, CHAPTER ONE, promulgated by the state Board of Health.
2.6 “Emergency Medical Technician-Basic (EMT-Basic)” - an individual who has a current and valid EMT-Basic certificate issued by the department and who is authorized to provide basic emergency medical care in accordance with these rules.
2.7 “Emergency Medical Technician-Basic with IV Authorization” - an individual who has a current and valid EMT-Basic certificate issued by the department and who has met the conditions defined in Section 5.5 of these rules.
2.8 “Emergency Medical Technician-Intermediate (EMT-Intermediate)” - an individual who has a current and valid EMT-Intermediate certificate issued by the department and who is authorized to provide limited acts of advanced emergency medical care in accordance with these rules.
2.9 “Emergency Medical Technician-Paramedic (EMT-Paramedic)” - an individual who has a current and valid EMT-Paramedic certificate issued by the department and who is authorized to provide advanced emergency medical care in accordance with these rules.
2.10 “EMS Service Agency” - any organized agency including but not limited to a “rescue unit” as defined in Section 25-3.5-103(11) C.R.S., using certified EMTs to render initial emergency medical care to a patient prior to or during transport. This definition does not include criminal law enforcement agencies, unless the criminal law enforcement personnel are EMTs who function with a “rescue unit” as defined in Section 25-3.5-103(11), C.R.S. or are performing any medical act described in these rules.
2.11 “Graduate EMT-Intermediate” - an individual who has a current and valid Colorado EMT-Basic certification issued by the department and who has successfully completed a department- recognized EMT-Intermediate initial course but has not yet successfully completed the certification requirements set forth in the EMS Rules.
2.12 “Graduate EMT-Paramedic” - an individual who has a current and valid Colorado EMT-Basic certificate or a current and valid Colorado EMT-Intermediate certification issued by the department and who has successfully completed a department-recognized EMT-Paramedic initial course but has not yet successfully completed the certification requirements set forth in the EMS Rules.
2.13 “Licensed in Good Standing” – as used in these rules, means that a physician functioning as an EMS medical director holds a current and valid license to practice medicine in Colorado that is not subject to any restrictions.
2.14 “Medical Base Station” - the source of direct medical communications with certified EMTs.
2.15 “Medical Director” – for purposes of these rules means a physician licensed in good standing who authorizes and directs, through protocols and standing orders, the performance of students-in- training enrolled in department-recognized EMS education programs, graduate EMT- Intermediates or EMT-Paramedics, or certified EMTs of a prehospital EMS service agency and who is specifically identified as being responsible to assure the competency of the performance of those acts by such certified EMTs as described in the physician’s medical continuous quality improvement program.
2.16 “Protocol” - written standards for patient medical assessment and management approved by an EMS medical director.
2.17 “State Emergency Medical and Trauma Services Advisory Council (SEMTAC)” – a council created in the department pursuant to Section 25-3.5-104, C.R.S., that advises the department on all matters relating to emergency medical and trauma services.
2.18 “Standing Order” - written authorization by a medical director for the performance of specific medical acts by certified EMTs independent of making medical base station contact.
2.19 “Supervision” - Oversee, direct or manage. Supervision may be through direct observation or by indirect oversight as defined in the medical director’s continuous quality improvement program.
2.20 “Waiver” – a department-approved exception to these rules granted to a medical director. SECTION 3 – Emergency Medical Practice Advisory Council 3.1 The Emergency Medical Practice Advisory Council (EMPAC), under the direction of the executive director of the department, shall advise the department in the areas set forth below in Section 3.8.
3.2 The EMPAC shall consist of the following eleven members:
3.2.1 Eight voting members appointed by the governor as follows:
A) Two physicians licensed in good standing in Colorado who are actively serving as EMS medical directors and are practicing in rural or frontier counties;
B) Two physicians licensed in good standing in Colorado who are actively serving as EMS medical directors and are practicing in urban counties;
C) One physician licensed in good standing in Colorado who is actively serving as an EMS medical director in any area of the state;
D) One EMT certified at an advanced life support level who is actively involved in the provision of emergency medical services;
E) One EMT certified at a basic life support level who is actively involved in the provision of emergency medical services; and F) One EMT certified at any level who is actively involved in the provision of emergency medical services;
3.2.2 One voting member who is a member of the SEMTAC, appointed by the executive director of the department; and 3.2.3 Two nonvoting ex officio members appointed by the executive director of the department.
3.3 EMPAC members shall serve four-year terms; except that, of the members initially appointed to the EMPAC by the governor, four members shall serve three-year terms.
3.4 A vacancy on the EMPAC shall be filled by appointment by the appointing authority for that vacant position for the remainder of the unexpired term.
3.5 EMPAC members serve at the pleasure of the appointing authority and continue in office until the member’s successor is appointed.
3.6 The EMPAC shall meet at least quarterly and more frequently as necessary to fulfill its obligations.
3.7 The EMPAC shall elect a chair and vice-chair from its members.
3.8 The duties of the EMPAC include:
3.8.1 Provide general technical expertise on matters related to the provision of patient care by EMTs;
3.8.2 Advise or make recommendations to the department on:
A) The acts and medications that certified EMTs are authorized to perform or administer under the direction of a medical director.
B) Requests by medical directors for waivers to the scope of practice of EMTs as established in these rules.
C) Modifications to EMT certification levels and capabilities.
D) Criteria for physicians to serve as EMS medical directors. SECTION 4 - Medical Director Qualifications and Duties
4.1 A medical director shall possess the following minimum qualifications:
4.1.1 Be a physician currently licensed to practice medicine in the State of Colorado.
4.1.2 Be trained in Advanced Cardiac Life Support.
4.1.3 Physicians acting as medical directors for department-recognized EMS education programs must possess authority under their licensure to perform any and all medical acts to which they extend their authority to EMTs, including any and all curricula presented by EMS education programs.
4.2 The duties of a medical director shall include:
4.2.1 Be actively involved in the provision of emergency medical services in the community served by the EMS service agency being supervised. Involvement does not require that a physician have such experience prior to becoming a medical director, but does require such involvement during the time that he or she acts as a medical director. Active involvement in the community could include, by way of example and not limitation, those inherent, reasonable and appropriate responsibilities of a medical director to interact with patients, the public served by the EMS service agency, the hospital community, the public safety agencies, and the medical community, and should include other aspects of liaison oversight and communication normally expected in the supervision of certified EMTs.
4.2.2 Be actively involved on a regular basis with the EMS service agency being supervised. Involvement does not require that a physician have such experience prior to becoming a medical director, but does require such involvement during the time that he or she acts as a medical director. Involvement could include, by way of example and not limitation, involvement in continuing education, audits, and protocol development. Passive or negligible involvement with the EMS service agency and supervised EMTs does not meet this requirement.
4.2.3 Notify the department on an annual basis of the EMS service agencies for which medical control functions are being provided in a manner and form as determined by the department.
4.2.4 Establish a medical continuous quality improvement (CQI) program for each EMS service agency being supervised. The medical continuous quality improvement program shall assure the continuing competency of the performance of that agency’s certified EMTs. This medical continuous quality improvement program shall include, but not be limited to, appropriate protocols and standing orders and provision for medical care audits, observation, critiques, continuing medical education and direct supervisory communications.
4.2.5 Submit to the department an affidavit that attests to the development and use of a medical continuous quality improvement program for all EMS service agencies supervised by the medical director. As set forth below in section 4.3, the department may review the records of a medical director to determine compliance with the CQI requirements in these rules.
4.2.6 Provide monitoring and supervision of the medical field performance of each supervised EMS service agency’s certified EMTs. This responsibility may be delegated to other physicians or other qualified health care professionals designated by the medical director. However, the medical director shall retain ultimate authority and responsibility for the monitoring and supervision, for establishing protocols and standing orders and for the competency of the performance of authorized medical acts.
4.2.7 Ensure that all protocols issued by the medical director are (1) appropriate for the certification and skill level of each individual to whom the performance of medical acts is delegated and authorized, and (2) compliant with accepted standards of medical practice. The medical director shall be familiar with the training, knowledge and competence of each of the individuals to whom the performance of such procedures is delegated.
4.2.8 Ensure that any data and/or documentation required by these rules are submitted to the department.
4.2.9 Notify the department within fourteen business days excluding state holidays prior to his or her cessation of duties as medical director.
4.2.10 Notify the department within fourteen business days excluding state holidays of his or her termination of the supervision of a certified EMT for reasons that may constitute good cause for disciplinary sanctions pursuant to the EMS Rules. Such notification shall be in writing and shall include a statement of the actions or omissions resulting in termination of supervision and copies of all pertinent records.
4.2.11 Physicians acting as medical directors for EMS education programs recognized by the department that require clinical and field internship performance by students shall be permitted to delegate authority to a student-in-training during their performance of program-required medical acts and only while under the control of the education program.
4.3 Departmental Review of Medical Directors
4.3.1 The department may review the records of a medical director to determine compliance with the requirements and standards in these rules and with accepted standards of medical oversight and practice.
4.3.2 Complaints in writing against medical directors for violations of these rules may be initiated by any person, the Colorado Medical Board or the department.
4.3.3 Complaints in writing against medical directors may be referred to the Colorado Medical Board for review as appropriate.
SECTION 5 - Medical Acts Allowed for the EMT-Basic 5.1 An EMT-Basic may, under the supervision and authorization of a medical director, perform emergency medical acts consistent with and not to exceed those listed in Appendices A and C of these rules for an EMT-Basic.
5.2 An EMT-Basic may, under the supervision and authorization of a medical director, administer and monitor medications and classes of medications consistent with and not to exceed those listed in Appendices B and D of these rules for an EMT-Basic.
5.3 Any EMT-Basic who is a member or employee of an EMS service agency and who performs said emergency medical acts must have authorization and be supervised by a medical director to perform said emergency medical acts.
5.4 EMT-Basics may carry out a physician order for a mental health hold as set forth in Section 27-10- 105(1), C.R.S. Such physician order may be a direct verbal order or by electronic communications.
5.5 An EMT-Basic who has successfully completed a department-recognized intravenous education course may be referred to as an “Emergency Medical Technician - Basic with IV Authorization.” Any provisions of these rules that are applicable to an EMT-Basic shall also be applicable to an EMT-Basic with IV Authorization. In addition to the acts an EMT-Basic is allowed to perform, an EMT-Basic with IV Authorization may, under supervision and authorization of a medical director, perform medical acts consistent with and not to exceed those listed in Appendices A and C of these rules for an EMT-Basic with IV Authorization. In addition to the medications and classes of medications an EMT-Basic is allowed to administer and monitor pursuant to these rules, an EMT- Basic with IV Authorization may, under supervision and authorization of a medical director, administer and monitor medications and classes of medications consistent with and not to exceed those listed in Appendices B and D of these rules for an EMT-Basic with IV Authorization.
5.6 An EMT-Basic with IV authorization may, under the supervision and authorization of a medical director, administer and monitor medications and classes of medications which exceed those listed in Appendices B and D of these rules for an EMT-Basic with IV authorization under the direct visual supervision of an EMT-Intermediate or Paramedic when the following conditions have been established:
5.6.1 The patient must be in cardiac arrest or in extremis.
5.6.2 Drugs administered must be limited to those authorized by these rules for EMT- Intermediate or Paramedic as stated in Appendices B and D.
5.6.3 The medical director(s) shall amend the appropriate protocols and medical continuous quality improvement program used to supervise the EMS personnel to reflect this change in patient care. The medical director(s) and the protocol(s) of the EMT-Basic and the EMT-Intermediate or Paramedic, shall all be in agreement. SECTION 6 - Medical Acts Allowed for the EMT-Intermediate 6.1 In addition to the acts an EMT-Basic and an EMT-Basic with IV Authorization are allowed to perform pursuant to these rules, an EMT-Intermediate may, under the supervision and authorization of a medical director perform advanced emergency medical care acts consistent with and not to exceed those listed in Appendices A and C of these rules for an EMT-Intermediate.
6.2 In addition to the medications and classes of medications an EMT-Basic and an EMT-Basic with IV Authorization are allowed to administer and monitor pursuant to these rules, an EMT-Intermediate may, under the supervision and authorization of a medical director, administer and monitor medications and classes of medications defined in Appendices B and D of these rules for an EMT-Intermediate.
6.3 EMT-Intermediates may carry out a physician order for a mental health hold as set forth in Section 27-10-105(1), C.R.S. Such physician order may be a direct verbal order or by electronic communications.
6.4 An EMT-Intermediate may, under the supervision and authorization of a medical director, administer and monitor medications and classes of medications which exceed those listed in Appendices B and D of these rules for an EMT-Intermediate under the direct visual supervision of an EMT- Paramedic, when the following conditions have been established:
6.4.1 Drugs administered must be limited to those authorized by these rules for EMT-Paramedics as stated in Appendices B and D.
6.4.2 The medical director(s) shall amend the appropriate protocols and medical continuous quality improvement program used to supervise the EMS personnel to reflect this change in patient care. The medical director(s) and protocol(s) of the EMT-Intermediate and Paramedic shall all be in agreement.
6.5 In the event of disaster or emergency, the Chief Medical Officer for the Department of Public Health and Environment or the State EMTS Medical Director may temporarily authorize the administration of other immunizations, vaccines, biologicals or tests not listed in these rules. SECTION 7 - Medical Acts Allowed for the EMT-Paramedic 7.1 In addition to the acts an EMT-Intermediate is allowed to perform pursuant to these rules, an EMT- Paramedic may, under the supervision and authorization of a medical director, perform advanced emergency medical care acts consistent with and not to exceed those listed in Appendices A and C of these rules for an EMT-Paramedic.
7.2 In addition to the medications and classes of medications an EMT-Intermediate is allowed to administer and monitor pursuant to these rules, an EMT-Paramedic may, under the supervision and authorization of a medical director, administer and monitor medications and classes of medications defined in Appendices B and D for an EMT-Paramedic, under standing order or direct verbal order of a physician, including by electronic communications.
7.3 EMT-Paramedics may carry out a physician order for a mental health hold as set forth in Section 27- 10-105(1), C.R.S. Such physician order may be a direct verbal order or by electronic communications.
SECTION 8 - Graduate EMT-Intermediates and Graduate EMT-Paramedics.
8.1 Medical directors may supervise graduate EMT-Intermediates as defined in these rules acting as EMT-Intermediates for a period of no more than six months following successful completion of an appropriate department-recognized initial course. Medical directors may supervise graduate EMT- Paramedics as defined in these rules acting as EMT-Paramedics for a period of no more than six months following successful completion of an appropriate department- recognized initial course. Such graduate EMT-Intermediates and graduate EMT-Paramedics must successfully complete certification requirements, as specified in the EMS Rules, within six months of the successful completion of a department-recognized initial course to continue to function under the provisions of these rules.
SECTION 9 - General Acts Allowed 9.1 Certified EMTs may function in acute care settings. Functioning in this environment must be in compliance with the Colorado Medical Board’s statutes and rules, under the auspices of a medical director and within parameters of the acts allowed or waiver as described in these rules.
9.2 EMTs may not practice in camps in a nursing capacity including the dispensing of medications.
9.3 Any EMT working for an EMS service agency must be supervised by a medical director who complies with the requirements in these rules.
9.4 A medical director may limit the scope of practice of any EMT.
SECTION 10 – Waivers to Scope of Practice 10.1 Any medical director may apply to the department for a waiver to the scope of practice set forth in these rules for EMTs under his/her supervision in specific circumstances, based on established need, provided that on-going quality assurance of each EMT’s competency is maintained by the medical director.
10.2 A waiver is not necessary for the skills and medications listed in Appendices A, B, C or D of this rule.
10.3 All levels of EMT may, under the supervision and authorization of a medical director, perform specific skills or administer specific medications not listed in Appendices A, B, C, or D of this rule, only if the medical director has been granted a waiver from the department for that specific skill or medication. Waivered skills or medication administration may be authorized by the medical director under standing orders or direct verbal orders of a physician, including by electronic communications. No EMT shall function beyond the scope of practice identified in these rules for their level until their medical director has received official written confirmation of the waiver being granted by the department.
10.4 Medical directors seeking a waiver shall submit a completed application to the department in a form and manner determined by the department.
10.4.1 The application shall include, but not be limited to, a description of the act or medication to be waived, information regarding the justification for the waiver, the proposed education, training and quality assurance process, literature review, and copies of the applicable protocols. The forms and affidavit required by Section 4 of these rules shall also be included.
10.4.2 The department may require the applicant to provide additional information if the initial application is determined to be insufficient.
10.4.3 An application shall not be considered complete until the required information is submitted.
10.4.4 The completed waiver application shall be submitted to the department in a timely fashion as specified by the department.
10.5 The EMPAC shall review waiver requests and make recommendations to the department. The EMPAC may make recommendations to deny, approve, table, request more information from the applicant or impose special conditions on the waiver.
10.6 After receiving recommendations from the EMPAC, the department shall make a decision on the waiver request and send notice of that decision to the applicant within thirty (30) calendar days of the recommendation. If granted, the notice shall include the effective date and expiration date of the waiver.
10.6.1 If the waiver is granted, the department may:
A) Specify the terms and conditions of the waiver.
B) Specify the duration of the waiver.
C) Specify any reporting requirements.
10.6.2 The department may require the submission of progress reports regarding the waiver.
10.6.3 The department may deny, revoke or suspend a waiver if it determines:
A) That its approval or continuation jeopardizes the health, safety and/or welfare of patients;
B) The applicant has provided false or misleading information in the waiver application;
C) The applicant has failed to comply with conditions or reporting on an approved waiver;
D) That a change in federal or state law prohibits continuation of the waiver.
10.7 If the department denies a waiver application or revokes or suspends a waiver, it shall provide the medical director with a notice explaining the basis for the action. The notice shall also inform the medical director of his or her right to appeal and the procedure for appealing the action.
10.8 Appeals of departmental actions shall be conducted in accordance with the state Administrative Procedure Act, Section 24-4-101, et seq., C.R.S.
10.9 If the rule pertaining to a waived skill or medication administration is amended or repealed obviating the need for the waiver, the waiver shall expire on the effective date of the rule change.
10.10 Waivers granted by the Colorado Medical Board which have not expired prior to the effective date of these rules shall continue in effect until the waiver expires as set forth below. The waiver holder shall not be required to apply to the department for continuation of the existing waiver.
10.11 Waivers granted by the Colorado Medical Board on or after November 21, 2009, shall be in effect for a period not to exceed 2 years unless otherwise specified by the Colorado Medical Board. For waivers authorized by the Colorado Medical Board prior to November 21, 2009, the expiration date shall be as follows:
10.11.1 If the waiver identified a date of expiration, the waiver shall expire on that date.
10.11.2 For waivers that do not include a date of expiration or otherwise identify any length of duration, such waivers shall expire in accordance with the schedule outlined below:
A) Waivers filed by a medical director whose last name begins with A through H shall expire on February 1, 2010.
B) Waivers filed by a medical director whose last name begins with I through P shall expire on February 1, 2011.
C) Waivers filed by a medical director whose last name begins with Q through Z shall expire on February 1, 2012.
10.11.3 This provision does not prohibit a medical director from requesting that the department renew a waiver previously submitted provided that the information is appropriately updated and otherwise in compliance with this rule.
APPENDICES These Appendices define the maximum skills, acts or medications that may be delegated to an EMT- Basic, EMT-Basic with IV Authorization, EMT-Intermediate, EMT-Paramedic under appropriate supervision by a medical director.
Y = YES May be performed or administered by emergency medical technicians with physician supervision as described in these rules.
Y* = Medications with an asterisk (*) shall be administered only under direct verbal order by a physician. There are a few special circumstances when the EMT-Intermediate is unable, despite adequate attempts, to make contact with a physician to obtain a direct verbal order. In those cases the EMT-Intermediate is allowed to administer the following medications under standing order:
1) Cardiac arrest medications (amioderone, atropine, epinephrine, lidocaine, vasopressin) may be administered under standing order in the case of cardiac arrest.
2) Behavioral management medications (haloperidol, diazepam, and midazolam) may be administered under standing order when the safety of the patient or the EMT is at risk.
3) In such special circumstances when, a direct verbal order has not been obtained, the medical director should be notified.
N = NO May not be performed or administered by emergency medical technicians except with an approved waiver as described in Section 10 of these rules. B = Medical acts, skills or medications that may be performed or administered by an EMT-Basic with appropriate medical director supervision and training recognized by the department. B-IV = Medical acts, skills or medications that may be performed or administered by an EMT-Basic with IV Authorization with appropriate medical director supervision and training recognized by the department. I = Medical acts, skills or medications that may be performed or administered by an EMT-Intermediate with appropriate medical director supervision and training recognized by the department. P = Medical acts, skills or medications that may be performed or administered by an EMT-Paramedic with appropriate medical director supervision and training recognized by the department. APPENDIX A PREHOSPITAL MEDICAL SKILLS AND ACTS ALLOWED Additions to these medical skills and acts allowed cannot be delegated unless a waiver has been granted as described in Section 10 of these rules.
AIRWAY/VENTILATION/OXYGEN ADMINISTRATION Skill B B-IV I Airway - Esophageal- N N N Single Lumen Airway - Laryngeal Mask Y Y Y Airway - Y Y Y Esophageal/Tracheal - Multi Lumen Airway – Nasal Y Y Y Airway – Oral Y Y Y Bag - Valve - Mask Y Y Y (BVM)
Carbon Monoxide Y Y Y Monitoring Chest Decompression – N N Y Needle Chest Tube Insertion N N N CPAP/BiPAP/PEEP N N Y Cricoid Pressure - Y Y Y Sellick’s Maneuver Cricothyroidotomy – N N N Needle Cricothyroidotomy – N N N Surgical Demand Valve - Oxygen Y Y Y Powered End Tidal CO2 Y Y Y Monitoring/Capnometry/ Capnography Flow Restrictive Oxygen Y Y Y Powered Ventilatory Device Gastric Decompression - N N N NG/OG Tube Insertion Inspiratory Impedence Y Y Y Threshold Device Intubation – Digital N N N Intubation - Bougie Style N N Y Introducer Intubation - Lighted N N Y Stylet Intubation - Medication N N N Assisted (non-paralytic)
Intubation - Medication N N N Assisted (paralytics)
(RSI)
Intubation - Maintenance N N N with paralytics Intubation – Nasotracheal N N N Intubation – Orotracheal N N Y Intubation – Retrograde N N N Extubation N N Y Obstruction - Direct N N Y Laryngoscopy Oxygen Therapy – Y Y Y Humidifiers Oxygen Therapy - Nasal Y Y Y Cannula Oxygen Therapy - Non- Y Y Y rebreather Mask Oxygen Therapy - Simple Y Y Y Face Mask Oxygen Therapy - Venturi N N Y Mask Peak Expiratory Flow N N Y Testing Pulse Oximetry Y Y Y Suctioning – N N Y Tracheobronchial Suctioning - Upper Y Y Y Airway Tracheostomy Y Y Y Maintenance - Airway management only Tracheostomy N N Y Maintenance - Includes replacement Ventilators - Automated N N N Transport (ATV)
CARDIOVASCULAR/CIRCULATORY SUPPORT Skill B B-IV I Cardiac Monitoring - Y Y Y Application of electrodes and data transmission Cardiac Monitoring - N N Y Rhythm and diagnostic EKG interpretation Cardiopulmonary Y Y Y Resuscitation (CPR)
Cardioversion – Electrical N N N Carotid Massage N N N Defibrillation - Y Y Y Automated/Semi- Automated (AED)
Defibrillation – Manual N N Y External Pelvic Y Y Y Compression Hemorrhage Control - Y Y Y Direct Pressure Hemorrhage Control - Y Y Y Pressure Point Hemorrhage Control – Y Y Y Tourniquet MAST/Pneumatic Anti- Y Y Y Shock Garment Mechanical CPR Device Y Y Y Transcutaneous Pacing N N Y Transvenous Pacing – N N N Maintenance Implantable N N N Cardioverter/Defibrillator Magnet Use Therapeutic Induced N N Y* Hypothermia (TIH)
Arterial Blood Pressure . . .
Indwelling Catheter - Maintenance N N N N Invasive Intracardiac N N N Catheters - Maintenance Central Venous Catheter N N N Insertion Central Venous Catheter N N Y Maintenance/Patency/Use Percutaneous N N N Pericardiocentesis IMMOBILIZATION Skill B B-IV I Spinal Immobilization - Y Y Y Cervical Collar Spinal Immobilization - Y Y Y Long Board Spinal Immobilization - Y Y Y Manual Stabilization Spinal Immobilization - Y Y Y Seated Patient, etc.
Splinting – Manual Y Y Y Splinting – Rigid Y Y Y Splinting – Soft Y Y Y Splinting – Traction Y Y Y Splinting – Vacuum Y Y Y INTRAVENOUS CANNULATION/FLUID ADMINISTRATION/FLUID MAINTENANCE Skill B B-IV I Blood/Blood By-Products N N N Initiation (out of facility initiation)
Colloids - (Albumin, N N N Dextran) – Initiation Crystalloids (D5W, LR, N Y Y NS) - Initiation/Maintenance Intraosseous – Initiation N N Y Medicated IV Fluids N N Y Maintenance - As Authorized in Appendix B Peripheral - Excluding N Y Y External Jugular - Initiation Peripheral - Including N N Y External Jugular - Initiation Use of PeripheraI N Y Y Indwelling Catheter for IV medications (Does not include PICC)
MEDICATION ADMINISTRATION - ROUTES Skill B B-IV I Aerosolized/Nebulized/At Y Y Y omized Buccal Y Y Y Endotracheal Tube (ET) N N Y Extra-abdominal N N Y umbilical vein Intradermal N N Y Intramuscular (IM) Y Y Y Intranasal (IN) N Y Y Intraosseous N N Y Intravenous (IV) N N Y Piggyback Intravenous (IV) Push N Y Y Nasogastric N N N Ophthalmic N N Y Oral Y Y Y Rectal N N Y Subcutaneous Y Y Y Sublingual Y Y Y Topical N N Y Use of Mechanical N N Y Infusion Pumps MISCELLANEOUS Skill B B-IV I Aortic Balloon Pump N N N Monitoring Assisted Delivery Y Y Y Blood Glucose Y Y Y Monitoring Dressing/Bandaging Y Y Y Esophageal Temperature N N Y* Probe for TIH Eye Irrigation Y Y Y Noninvasive Eye Irrigation Morgan N N Y Lens Maintenance of N N N Intracranial Monitoring Lines Physical examination Y Y Y Restraints – Verbal Y Y Y Restraints – Physical Y Y Y Restraints – Chemical N N Y Urinary Catheterization - N N N Initiation Urinary Catheterization - Y Y Y Maintenance Venous Blood Sampling - N Y Y Obtaining 1 Therapeutic Induced Hypothermia (TIH) - 1. Approved methods of cooling include:
a. Surface cooling methods including ice packs, evaporative cooling and surface cooling blankets or surface heat-exchange devices.
b. Internal cooling with the intravenous administration of cold crystalloids (4°C / 39°F) 2. Esophageal temperature probe allowed for monitoring core temperatures in patients undergoing TIH.
3. The medical director should work with the hospital systems to which their agencies transport in setting up a “systems” approach to the institution of TIH. Medical directors should not institute TIH without having receiving facilities that also have TIH programs to which to transport these patients.
APPENDIX B PREHOSPITAL FORMULARY OF MEDICATIONS ALLOWED TO BE ADMINISTERED Additions to this medication formulary cannot be delegated unless a waiver has been granted as described in Section 10 of these rules.
GENERAL Medications B B-IV I Over-the-counter- Y Y Y medications Oxygen Y Y Y ANTIDOTES Medications B B-IV I Atropine N N Y* Calcium salt - Calcium N N N chloride Calcium salt - Calcium N N N gluconate Cyanide antidote N N Y Glucagon N N Y* Naloxone N Y Y Nerve agent antidote Y Y Y Pralidoxime N N N Sodium bicarbonate N N N BEHAVIORAL MANAGEMENT Medications B B-IV I Anti-Psychoic – N N N Droperidol Anti-Psychotic – N N Y* Haloperidol Anti-Psychotic – N N N Olanzapine Anti-Psychotic – N N N Zisprasidone Benzodiazepine – N N Y* Diazepam Benzodiazepine – N N N Lorazepam Benzodiazepine – N N Y* Midazolam Diphenhydramine N N Y* CARDIOVASCULAR Medications B B-IV I Adenosine N N Y* Amiodarone - bolus N N Y* infusion only Aspirin Y Y Y Atropine N N Y* Calcium salt - Calcium N N N chloride Calcium salt - Calcium N N N gluconate Diltiazem - bolus infusion N N N only Dopamine N N N Epinephrine N N Y* Lidocaine - bolus and N N Y* continuous infusion Magnesium sulfate - N N N bolus infusion only Morphine sulfate N N Y* Nitroglycerin - sublingual Y* Y* Y (patient assisted)
Nitroglycerin - sublingual N N Y (tablet or spray)
Nitroglycerin - topical N N Y* paste Sodium bicarbonate N N Y* Vasopressin N N Y* Verapamil - bolus N N N infusion only DIURETICS Medications B B-IV I Butanemide N N N Furosemide N N Y* Mannitol (trauma use N N N only)
ENDOCRINE AND METABOLISM Medications B B-IV I IV Dextrose N Y Y Glucagon N N Y Oral glucose Y Y Y Thiamine N N N GASTROINTESTINAL MEDICATIONS Medications B B-IV I Anti-nausea – Droperidol N N N Anti-nausea – N N Y* Metoclopramide Anti-nausea – N N Y* Ondansetron Anti-nausea – N N N Prochlorperazine Anti-nausea – N N Y* Promethazine Decontaminant - Y Y Y Activated charcoal Decontaminant – Sorbitol Y Y Y PAIN MANAGEMENT Medications B B-IV I Anesthetic - Lidocaine N N Y (for intraosseous needle insertion)
Benzodiazepine – N N Y* Diazepam Benzodiazepine – N N Y* Lorazepam Benzodiazepine – N N N Midazolam General - Nitrous oxide N N Y* Narcotic Analgesic – N N Y* Fentanyl Narcotic Analgesic - N N N Hydromorphone Narcotic Analgesic - N N Y* Morphine sulfate Ophthalmic anesthetic - N N Y Opthaine Ophthalmic anesthetic N N Y -Tetracaine Topical Anesthetic - N N N Benzocaine spray Topical Anesthetic - N N N Lidocaine jelly RESPIRATORY AND ALLERGIC REACTION MEDICATIONS Medications B B-IV I Antihistamine - N N Y* Diphenhydramine Bronchodilator - N N Y* Anticholinergic - Atropine (aerosol/nebulized)
Bronchodilator - N N Y* Anticholinergic - Ipratropium Bronchodilator - Beta Y* Y* Y* agonist - Albuterol Bronchodilator - Beta N N Y* agonist - L-Albuterol Bronchodilator - Beta N N Y* agonist - Metaproterenol Corticosteroid - N N N Dexamethasone Corticosteroid - N N Y* Methylprednisolone Corticosteroid – N N N Prednisone Epinephrine N N Y* Epinephrine Auto- Y Y Y Injector Magnesium Sulfate - N N N bolus infusion only Racemic Epinephrine N N Y* Short Acting Y* Y* Y* Bronchodilator meter dose inhalers (MDI)
(Patient assisted)
Short Acting N N Y* Bronchodilator meter dose inhalers (MDI)
Terbutaline N N N SEIZURE MANAGEMENT Medications B B-IV I Benzodiazepine – N N Y* Diazepam Benzodiazepine – N N Y* Lorazepam Benzodiazepine – N N Y* Midazolam OB -associated - N N N Magnesium sulfate - bolus infusion only VACCINES Medications B B-IV I Post-exposure, N N N employment, or pre- employment related - Hepatitis B Post-exposure, N N N employment, or pre- employment related - Tetanus Post-exposure, N N N employment, or pre- employment related - Influenza Post-exposure, N N N employment, or pre- employment related - PPD placement Public Health Related - N N Y Vaccine administration in conjunction with County Public Health Departments and local EMS medical direction, after demonstration of proper training, will be authorized for public health vaccination efforts and pandemic planning exercises.
MISCELLANEOUS Medications B B-IV I Analgesic Sedative – N N N Etomidate Benzodiazepine - N N Y* Midazolam for TIH Lidocaine - bolus for N N Y* intubation of head-injured patients Narcotic Analgesic - N N Y* Fentanyl for TIH Hemostatic agents - Y Y Y topical Technology- and Pharmacology- Dependent Patients The transport of patients with continuous intravenously administered medications and nutritional support, previously prescribed by licensed health care workers and typically managed day-to-day at their residence by either the patient or caretakers, shall be allowed. This will simplify transport options for patients that currently may require specialized critical care transport teams under existing rules. The EMS provider is not authorized to manage, alter, or interfere with these patient medication/nutrition systems except after direct contact with medical control, and where cessation and/or continuation of medication pose a threat to the safety and well-being of the patient. Procedural Sedation Procedural sedation, as defined by the combination of intravenous agents such as benzodiazepines and/or narcotics for the planned purpose of facilitating the performance of a procedure is not an authorized EMS practice in Colorado. INTERFACILITY TRANSPORT The EMS Medical Director, in collaboration with the transferring facility’s medical director, should have protocols in place to ensure the appropriate level of care is available during interfacility transport and the transporting EMT may decline to transport any patient he/she believes requires a level of care beyond his/her capabilities.
Inter-facility transport typically involves three types of patients:
1. Those patients whose safe transport can be accomplished by ambulance, under the care of an EMT- Basic, EMT-Intermediate, or EMT-Paramedic, within the “acts allowed” under these rules.
2. Those patients whose safe transport can be accomplished by ambulance, under the care of an EMT- Paramedic, but may require skills to be performed or medications to be administered that are outside the “acts allowed” under these rules, but have been approved through waiver granted by the department.
3. Those patients whose safe transport requires the skills and expertise of a critical care transport team under the care of an experienced critical care practitioner. The hemodynamically unstable patient (typically from an Intensive Care setting) who requires special monitoring (i.e. CVP, ICP), multiple cardioactive/vasoactive medications, or specialized critical care equipment (i.e. intra-aortic balloon pump) should remain under the care of an experienced critical care practitioner and every attempt should be made to transport that patient while maintaining the appropriate level of care. The capabilities of the institution, the capabilities of the transporting agency and most importantly, the well-being of the patient, should be considered when making transport decisions. Unless otherwise noted, these indicate hospital/facility initiated interventions and/or medications. APPENDIX C INTERFACILITY TRANSPORT - ONLY MEDICAL SKILLS AND ACTS ALLOWED Additions to these medical skills and acts allowed cannot be delegated unless a waiver has been granted as described in Section 10 of these rules.
The following medical skills and acts are approved for interfacility transport of patients, with the requirements that the medical skill or intervention must have been initiated in a medical facility under the direct order and supervision of licensed medical providers, and are NOT authorized for field initiation. EMS continuation and monitoring of these interventions is to be allowed with any alterations in the therapy requiring direct online medical control. The EMS provider should continue the same medical standards of care with regards to patient monitoring that was initiated in the medical care setting. It is understood that these skills or interventions may not be addressed in the National Standard EMT- Basic, EMT-Intermediate or EMT-Paramedic Curricula and may not be addressed in any future national education standards that may replace the current National Standard Curriculum. As such, it is the joint responsibility of the medical director and individuals performing these skills, to obtain appropriate additional training needed to safely and effectively utilize and monitor these interventions in the interfacility transport environment.
CARDIOVASCULAR/CIRCULATORY SUPPORT Skill B B-IV I Aortic Balloon Pump N N N Monitoring Chest Tube Monitoring N N N Central Venous Pressure N N N Monitor Interpretation APPENDIX D INTERFACILITY TRANSPORT - ONLY FORMULARY OF MEDICATIONS ALLOWED TO BE ADMINISTERED Additions to this medical formulary cannot be delegated unless a waiver has been granted as described in Section 10 of these rules.
The following formulary of medications are approved for interfacility transport of patients, with the requirements that the intervention must have been initiated in a medical facility under the direct order and supervision of licensed medical providers, and are NOT authorized for field initiation. EMS continuation and monitoring of these interventions is to be allowed with any alterations in the therapy requiring direct online medical control. The EMS providers should continue the same medical standards of care with regards to patient monitoring that was initiated in the medical care setting. It is understood that these skills or interventions may not be addressed in the National Standard EMT- Basic, EMT-Intermediate or EMT-Paramedic Curricula and may not be addressed in any future national education standards that may replace the current National Standard Curriculum. As such, it is the joint responsibility of the medical director and individuals administering these medications, to obtain appropriate additional training needed to safely and effectively utilize and monitor these interventions in the interfacility transport environment.
CARDIOVASCULAR Medications B B-IV I Anti-arrhythmic - N N Y Amiodarone - continuous infusion Anti-arrhythmic - N N Y Lidocaine - continuous infusion Anticoagulant - N N N Glycoprotein inhibitors Anticoagulant - Heparin N N N (unfractionated)
Anticoagulant - Low N N N Molecular Weight Heparin (LMWH)
Diltiazem N N N Dobutamine N N N Nitroglycerin, N N N intravenous HIGH RISK OBSTETRICAL PATIENTS Medications B B-IV I Magnesium sulfate N N N Oxytocin - infusion N N N INTRAVENOUS SOLUTIONS Medications B B-IV I Monitoring and N Y Y maintenance of hospital/medical facility initiated crystalloids Monitoring and N N Y maintenance of hospital/medical facility initiated colloids (non- blood component)
infusions Monitoring and N N N maintenance of hospital/medical facility initiated blood component infusion Initiate hospital/medical N N N facility supplied blood component infusions Total parenteral nutrition N N Y (TPN) and/or vitamins MISCELLANEOUS Medications B B-IV I Antibiotic infusions N N Y Antidote infusion - N N N Sodium bicarbonate infusion Electrolyte infusion - N N N Magnesium sulfate Electrolyte infusion - N N N Potassium chloride Insulin N N N Mannitol N N N Methylprednisolone - N N N infusion _____________________________________________________ Editor’s Notes History Entire Rule eff. 03/01/2008.
Section 11 eff 05/30/2008.
Sections 1-6 eff. 12/30/2009.
Chapter One, Chapter Two eff. 12/15/2010.