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WVOEMS Licensing of EMS AgenciesApplication Packet 350 Capitol Street, Room 425 Charleston, WV 25301-3714 (304) 558-3956 Table of Contents HYPERLINK \l "EMSAgencyLicenseApplication" EMS Agency License Application (New, Renewal, and Modification) …………………………….…. 3Initial Agency Personnel Roster …………………………………………………………….……………..7Agency Station Register ……………………………………………………………………………………8Agency Rate Structure …………………………………….………………………………………………..9Class A Rapid Response Non Transport Vehicles Supplies. (EMR, BLS, and ALS)……...……….…10Ground Ambulance Equipment and Supply List Class B-C……………………………………………..13CCT EMS Vehicle Equipment and Supply List Class D-E……………………………………………….19Instructions: These forms can be either printed and filled out or you may complete them by filling in the fillable spaces. After completing the packet, email to EMSLicensure@. West Virginia Department of Health and Human Resources Bureau for Public Health Office of Emergency Medical Services -152400top350 Capitol Street, Room 425 Charleston, WV 25301-3716EMS Agency License Application Date: ? Application ? Renewal ? Modification (highlight area for modification Agency: FEIN: DBA: County: Physical Address: Squad Code: City: State: Click or tap here to enter text.Zip Code: Mailing Address (if different than above) Website: City: State:Zip Code: Phone: Fax: Email Address: Official Representative: Title: Mailing Address: WV OEMS No: City: State: Zip Code: Daytime Phone: Home Phone: Fax: Cell: Email Address: ? Agency Training Coordinator: ? Agency Training Officer: Title: Mailing Address: WV OEMS No: City: State: Click or tap here to enter text.Zip Code: Daytime Phone: Home Phone: Fax: Cell: Email Address: Assistant Agency Training Officer: Title: Mailing Address: WV OEMS No: City: State: Zip Code: Daytime Phone: Home Phone: Fax: Cell: Email Address: Medical Director: WV License No: Mailing Address: WV OEMS No: City: State: Zip Code: Daytime Phone: Home Phone: Fax: Cell: Email Address: Attach additional page(s) if Agency has more than one Asst. Medical Director-476250top00Bureau for Public Health Office of Emergency Medical Services Licensure Level (check all that applies)Non-Transporting ? Fire Department Rapid Response – Basic Life Support (Non-Transporting) **? Fire Department Rapid Response - Advance Life Support (Non-Transporting) **? Rapid Response - Basic Life Support (Non-Transporting)? Rapid Response – Advanced Life Support (Non-Transporting)Transporting ? Basic Life Support Ground Ambulance? Advance Life Support Ground Ambulance? Critical Care Transport Ground Ambulance? Specialized Multipatient Medical Transport (EMS Agencies Only)? Fix Wing Transport? Rotary Wing Transport** Only fire departments recognized by the State Fire Marshall's Office are eligible to apply for a license, under these requirements and standards found in WV Office Emergency Medical Legislative Rule §64CSR48.Provider DescriptionCorporate Structure:? Government/Public? Private Non-Profit? Private-for-ProfitOrganization Type:? Ambulance? Fire Department? Hospital Based? Industrial ? Other: Describe the area(s) in which you provide service. Attach additional pages if necessary and map if available.Insurance Information(attach copy of current policy)Medical Liability Insurance Provider: Policy No.: Address: Expiration Date: City: State: Zip: Agent’s Name: Phone: Fax: -515620topBureau for Public Health Office of Emergency Medical Services Staffing Information?Staff LevelFull-timePart-timePaid per CallVolunteerTotalEMVO EMR EMT ACT PARAMEDIC MCCN/MCCP Totals VehiclesNumber of Non-Transporting Class A: Number of Ground Ambulance Basic Life Support units (BLS) Class B: Number of Ground Ambulance Advanced Life Support units (ALS) Class C: ?Number of Ground Ambulance CCT units Class D: ?Number of Rotary/Fixed wings units Class E: ? ?Number of SMPMT units?Class F: Radio Frequencies:?Transmit Frequency Receive Frequency ?Transmit Frequency PL Receive Frequency ?12 Lead Transmission Method: ______________ ___________________Rapid Response Agency ChartRapid Response AgencyLevel of Service Attach additional pages if necessary?APPLICATION AKNOWLEDGEMENT I verify that all information contained within this document is true and accurate. Any subsequent transactions which alter this information will be promptly reported to the West Virginia Office of Emergency Medical Services Licensure Coordinator.?Print Agency Official Representative Name:Title:?Date:? ? Signature Agency's Official RepresentativeDate: Print Agency Medical Director Name:?Date:? ? Signature of Agency Medical DirectorDate -400050topWest Virginia Department of Health and Human Resources Bureau for Public Health Office of Emergency Medical Services 350 Capitol Street, Room 425 Charleston, WV 25301-3716 EMS Agency Personnel RosterAgency Name: Note: If you have an up to date Continuum account, you can attach the Continuum roster to the application packet with the Agency Medical Director’s signature in place of completing this document.Name:WV Number:CertificationJob Title:Expiration Date: (mm/dd/yyyy)Phone: 826135127000West Virginia Department of Health and Human Resources Bureau for Public Health Office of Emergency Medical Services 350 Capitol Street, Room 425 Charleston, WV 25301-3716EMS Agency Station RegistryAgency Name: Current EMS Agencies, are these stations current within Continuum? ? YES ? NOStation Number:Number of Vehicles:Address or Location of StationPrecise directions to locationGPS: Longitude/Latitude -7048509525West Virginia Department of Health and Human Resources Bureau for Public Health Office of Emergency Medical Services 350 Capitol Street, Room 425 Charleston, WV 25301-3716 EMS Agency Rate StructureRate Structure?EMS Agency:Squad Code:? ? Official Representative:? Address:? City:State:Zip:? County:Region:Phone:? ? Reimbursement Information Type of ReimbursementAmountBasic Life Support (BLS) Advanced Life Support (ALS) Critical Care Transport (CCT) Fixed Wing Air Ambulanced Rotary Wing Air Ambulance ??Mileage Loading Total Calls for Previous Year Billing Company: ? ?Agency Official Representative (Print)Signature:Date:West Virginia Department of Health and Human ResourcesOffice of Emergency Medical ServicesClass A Rapid Response Non-Transporting Minimum Equipment and Supplies. (EMR, BLS, and ALS)This is the minimum equipment and supplies required on dedicated Class A EMS Rapid Response Vehicles operated by Licensed EMS Agencies and Fire Department Rapid Response Licensed Agencies. All supplies must be clean and organized. When applicable, items must be sealed and within current expiration period. Vehicles must have required equipment on-board during EMS response and patient treatment. Effective December 22, 2020Response TypeEMRBLSALSQtyQtyQtyAirway and VentilationPortable suction unit, assembled and ready for use – commercially available manual unit is acceptable1 ?1 ?1 ?Large bore rigid oral suction catheters – must have internal diameter greater than or equal to 0.25 inches1 ?1 ?1 ?Portable oxygen system with non-gravity dependent oxygen flow regulator (bourdon gauge flowmeter/15 lpm)1 ?1 ?1 ?Adult nasal cannula1 ?1 ?1 ?Pediatric nasal cannula1 ?1 ?1 ?Adult non-rebreather (NRB) mask1 ?1 ?1 ?Pediatric non-rebreather (NRB) mask1 ?1 ?1 ?Oxygen connection tubing – may be with BVM or nebulizers1 ?1 ?1 ?Oropharyngeal airways – sizes 0 through 51 ?1 ?1 ?King LT/LT-D airway kits – sizes 3, 4, and 5.NA1 ?1 ?Adult end-tidal CO2 detectors – colorimetric or qualitativeNA1 ?1 ?Pediatric end-tidal CO2 detectors – colorimetric or qualitativeNA1 ?1 ?Adult, child and infant bag valves, self-filling with oxygen reservoir1 ?1 ?1 ?Clear masks for bag valves, sizes: adult, child, infant and neonatal1 ?1 ?1 ?Chest decompression large bore needle:Adult: minimum of 3.25” length 14 – 16 gauge Child: 1.5" 16 gauge for pediatrics NANA1 ?Monitoring and AssessmentBlood pressure cuffs – XL, Adult and Child sizes1 ?1 ?1 ?Stethoscope, suitable for adult and pediatric use1 ?1 ?1 ?AED with adult defibrillator pads – if NOT pediatric capable, must have pediatric pads1 ?1 ?NAGlucometer with single-use fully disposable lancets and glucose strips1 ?1 ?1 ?Pulse oximeter for adult and pediatric use with all necessary equipment (portable or attached to cardiac monitor)1 ?1 ?1 ?Patient monitoring system capable of cardiac rhythm monitoring, 12-lead acquisition, data transmission, transcutaneous pacing, defibrillation and cardioversionNANA1 ?Spare battery for patient monitoring systemNANA1 ?Adult and pediatric defibrillation and transcutaneous pacing cables/pads and electrodes for patient monitoring systemNANA1 ?Cables, probes and supplies for ECG monitoring NANA1 ?Immobilization EquipmentRigid cervical collar:Large, medium, small and child -OR- Adjustable cervical collar – adult and pediatric1 ?1 ?1 ?Padded extremity splints (cardboard, wire, air, or SAMS)2 ?2 ?2 ?Wound ManagementSterile burn sheets1 ?1 ?1 ?Sterile 10” x 30” multi-trauma dressings2 ?2 ?2 ?Sterile 4”x4” gauze 12 ?12 ?12 ?Sterile occlusive dressings, 3” x 8” or larger1 ?1 ?1 ?Adhesive tape, assorted sizes and types. One roll must be hypoallergenic/latex-free2 rolls ?2 rolls ?2 rolls ?Self-adhering gauze bandages – Kling or equivalent4 rolls ?4 rolls ?4 rolls ?Triangular bandages2 ?2 ?2 ?Commercial Arterial Tourniquet – CAT?, MAT?, etc.1 ?1 ?1 ?Heavy-duty bandage scissors or shears1 ?1 ?1 ? Infection Control Protective eyewear – full peripheral glasses, goggles or face shieldMin 2 ?Min 2 ?Min 2 ?NIOSH N-95 or N-100 face masksMin 2 ?Min 2 ?Min 2 ?Protective gowns or coverallsMin 2 ?Min 2 ?Min 2 ?Protective shoe coversMin 2 ?Min 2 ?Min 2 ?Disposable exam gloves meeting NFPA 1999 requirements – assorted and appropriate sizes. Must include hypoallergenic/latex-free types (XL, L, M, and S)1 ?1 ?1 ?Disinfectant waterless hand cleaner1 ?1 ?1 ?Biohazard trash bags1 ?1 ?1 ?Portable sharps containers1 ?1 ?1 ? MedicationsAlbuterol, 2.5 mg/3 ml unit dose ampuleNA2 ?2 ?Ipratropium Bromide (Atrovent?) 500 microgram unit dose ampules (If not carrying Combivent? -OR- Duoneb?NA2 ?2 ?Combivent? -OR- Duoneb? - 2.5mg Albuterol mixed with 0.5mg Ipratropium Bromide. (Optional: Squads may also choose to carry Albuterol and Ipratropium Bromide individually.)NA2 ?2 ?Aspirin, 81 mg tablets, chewableNA1 BTL ?1 BTL ?Nitroglycerin, 0.4 mg (1/150) tablet or sprayNA1 BTL ?1 BTL ?Atropine, 1 mg, pre-loaded syringeNANA3 ?D50W, 25 gm pre-loaded syringeNANA1 ?Oral glucose, 15 gmNA2 ?2 ?Epinephrine, 1:10,000, 1 mg pre-loaded syringeNANA6 ?Epinephrine, 1:1,000, 1 mg (BLS MUST carry Epi 1:1000 -OR- 2 each Epi Pen and 2 each Epi Pen Jr.)NA2 ?2 ?Epi Pen and Epi Pen Jr. Option (First Responders shall only utilize auto-injectors)2 ?NANANaloxone, 2 mg/2ml total1 ?1 ?1 ?Normal saline, 0.9%, 1000 mlNANA2 ?OB EquipmentSterile OB kits with bulb syringe1 ?1 ?1 ?Thermal absorbent blanket and head cover made of a heat-reflective material1 ?1 ?1 ?Safety - Quantities for crew configurationProtective helmet meeting ANSI Z89.1 Type II, NFPA 1908-2007 or NFPA 1951-2007 standardsMin Crew ?Min Crew ?Min Crew ?Protective eyewear meeting ANSI Z87.1-2003 standardsMin Crew ?Min Crew ?Min Crew ?High visibility clothing compliant with 23 CFR Part 643 (Federal Highway Worker Visibility Act) ANSI/ISEA 107-2004-Class 3 or 207.Min Crew ?Min Crew ?Min Crew ?Protective gloves, extrication-type or heavy-duty leatherMin Crew ?Min Crew ?Min Crew ?Current DOT Emergency Response Guidebook (paper or electronic version)1 ?1 ??MiscellaneousBlankets1 ?1 ?1 ?Flashlight1 ?1 ?1 ?Cold packs2 ?2 ?2 ?Hot packs2 ?2 ?2 ?Protocol manuals appropriate for level of staffing (paper or electronic version)???WV Triage Tags25 ?25 ?25 ?WV triage tape rolls – red, yellow, green and black1 ea ?1 ea ?1 ea ? IV and Medication Administration60gtts/ml Mini-drip IV administration set. May utilize Select-3? sets or equivalentNANA2 ?10 to 15gtts/ml Macro-drip IV administration set. May utilize Select-3? sets or equivalentNANA2 ?Extension sets. May utilize Select-3? sets or equivalentNANA2 ?Saline locks and flushesNANA2 ?Adequate site preparation materials – alcohol or povidoneNANA2 ?Venous tourniquetsNANA2 ?IV catheters, sizes 14g, 16g, 18g, 20g, 22g and 24gNANA2 ea ?Nebulizer kitsNA1 ?1 ?Drug atomizersNA1 ?1 ?Syringes in appropriate quantities and sizes – 1ml, 3ml, 5ml, 10ml, 30ml, 60ml NA2 ?2 ?Needles in appropriate quantities, sizes and lengths. Some greater than 1.5” in length for IM mediation administrationNA2 ?2 ?Length/weight based pediatric drug and equipment reference – Broselow tape or Pedi Wheel or equivalentNANA1 ? Effective December 22, 2020West Virginia Department of Health and Human ResourcesOffice of Emergency Medical ServicesClass B and C Ground Ambulance Minimum Equipment and Supply List (BLS and ALS)This is the minimum equipment and supplies required on dedicated Class A EMS Rapid Response Vehicles operated by Licensed EMS Agencies and Fire Department Rapid Response Licensed Agencies. All supplies must be clean and organized. When applicable, items must be sealed and within current expiration period. Vehicles must have required equipment on-board during EMS response and patient treatment. Effective December 22, 2020Response TypeBLSALSQtyQtyAirway and VentilationFixed suction system, electric powered with disposable collection container and large bore tubing, assembled and ready for use1 ?1 ?Portable suction unit, assembled and ready for use – commercially available manual suction unit is acceptable1 ?1 ?Yankauer suction tube. Large bore rigid oral suction catheters – must have internal diameter greater than or equal to 0.25 inches2 ?2 ?Flexible suction catheters – 6F, 10F and 14F2 ea. ?2 ea. ?Salem sump NG tubes – 8F, 12F and 18F with irrigation syringeN/A1 ea. ?Meconium aspirator ET-tube adaptorN/A1 ?On-board oxygen system (“M”-size cylinder or equivalent) with 2 wall outlets 1 ?1 ?Adjustable oxygen flow regulators (Float Ball/15 lpm)2 ?2 ?Portable oxygen system with bourdon gauge flowmeter, non-gravity dependent oxygen flow regulator (15 lpm)1 ?1 ?Full spare portable oxygen cylinder (“D”-size or larger)1 ?1 ?Adult nasal cannula4 ?4 ?Pediatric nasal cannula4 ?4 ?Adult non-rebreather (NRB) mask4 ?4 ?Pediatric non-rebreather (NRB) mask4 ?4 ?Oxygen connection tubing – may be with BVM or nebulizers2 ?2 ?Nasopharyngeal airways – assorted sizes, 16F – 34F. No less than 5 different sizes1 ?1 ?Oropharyngeal airways – sizes 0 through 51 ?1 ?King LT/LT-D airway kits – sizes 3, 4, and 5.1 ea. ?1 ea. ?Adult end-tidal CO2 detectors – colorimetric or qualitative2 ea. ?2 ea.?Pediatric end-tidal CO2 detectors – colorimetric or qualitative. 2 ea. ?2 ea.?Laryngoscope handle with extra batteriesN/A1 ea. ?Laryngoscope blades – 0 & 1 (Miller) straight 2, 3, 4 (Miller) straight or (Macintosh) curvedspare bulbs if applicableN/A1 ea. ?Et tubes, sizes --2.5 uncuffedN/A2 ea.?3.0 or 3.5 uncuffedN/A2 ea.?4.0 or 4.5 cuffed or uncuffedN/A2 ea.?5.0 or 5.5 cuffed or uncuffedN/A2 ea.?6.0 or 6.5 cuffed N/A2 ea.?7.0 or 7.5 cuffedN/A2 ea.?8.0 or 8.5 cuffedN/A2 ea.?ET-tube stylets, adult and pediatric (if not already prepackage with ETT)N/A1 ea. ?Magill forceps, adult and pediatricN/A1 ea. ?Chest decompression large bore needle, Adult 14 - 16 gauge minimum of 3.25” length Child 16 gauge minimum 1.25" lengthN/A1 ea. ?Adult, child and infant bag valves, self-filling with oxygen reservoir (Ambu)1 ?1 ?Clear masks for bag valves, sizes: adult, child, infant and neonatal (if not prepackage with ambu bags)1 ?1 ?CPAP device with 2 masks and tubing circuits1 ?1 ?Monitoring and AssessmentBlood pressure cuffs – XL, adult and child sizes1 ea. ?1 ea. ?Stethoscope, suitable for adult and pediatric use1 ?1 ?AED with adult and pediatric defibrillator pads1 ?OptionalGlucometer with single-use fully disposable lancets and glucose strips1 ?1 ?Pulse oximeter for adult and pediatric use (portable or cardiac monitor)1 ?1 ?Thermometer, capable of measuring a range of 86°-105° F1 ?1 ?Patient monitoring system capable of cardiac rhythm monitoring, 12-lead acquisition, data transmission, transcutaneous pacing, defibrillation and cardioversionOptional1 ?Spare battery for patient monitoring systemOptional1 ?Adult and pediatric defibrillation and transcutaneous pacing pads and 12-lead Electrode pads.N/A2 ea. ?Cables, probes and supplies for ECG monitoring and pulse oximetry monitoringOptional1 ea. ?Immobilization EquipmentCervical Collar –Rigid cervical collar – large, medium, small and child -OR- Adjustable cervical collar – adult and pediatric2 ea. ?2 ea. ?Head/cervical immobilization devices – towel/blanket rolls are acceptable2 sets ?2 sets ?Short spinal immobilization device – KED, XP-1 or equivalent1 ?1 ?Radiolucent, fluid impervious full-length backboards2 ?2 ?Four 9-foot immobilization straps ( 2 shoulder, 1 waist, 1 leg) or equivalent (spider straps)2 sets ?2 sets ?Traction splint(s)Adult and child OR Single splint adjustable for both1 ea. ?1 ea. ?Padded extremity splints (cardboard, air, wire, or SAMS)2 ea. ?2 ea. ?Wound ManagementSterile burn sheets2 ?2 ?Sterile 10” x 30” multi-trauma dressings2 ?2 ?Sterile ABD pads, 5” x 9” or larger2 ?2 ?Sterile 4”x4”s (1 bx of 24)24 ?24 ?Sterile occlusive dressings, 3” x 8” or larger2 ?2 ?Adhesive tape, assorted sizes and types. One roll must be hypoallergenic/latex-free4 rolls ?4 rolls ?Self-adhering gauze bandages – Kling or equivalent8 rolls ?8 rolls ?Triangular bandages4 ?4 ?Commercial Arterial Tourniquet – CAT?, MAT?, etc.2 ?2 ?Heavy-duty bandage scissors or shears1 ?1 ?Sterile saline irrigation, 1000ml total (can be from liter bag or 100 Pre-loaded 10 cc syringes of Sterile Saline)1000 ml ?1000 ml ?Infection Control – Quantities for Crew.Protective eyewear – full peripheral glasses, goggles or face shield2 ?2 ?NIOSH N-95 or N-100 face masks2 ?2 ?Protective gowns or coveralls2 ?2 ?Protective shoe covers2 ?2 ?Disposable exam gloves meeting NFPA 1999 requirements – assorted and appropriate sizes. Must include hypoallergenic/latex-free types1 bx ea. ?1 bx ea. ?Disinfectant waterless hand cleaner1 ?1 ?Disinfectant for cleaning vehicle interior and equipment1 ?1 ?Biohazard trash bags2 ?2 ?Fixed and portable sharps containers1 ?1 ?MedicationsAcetaminophen (Tylenol?), 160mg/5mL oral suspension1 BTL ?1 BTL ?Albuterol, 2.5mg/3mL or 2.5mg/0.5mL unit dose ampule4 ?4 ?Albuterol/Ipratropium (Duo-Neb?), 2.5mg/0.5mg in 3mL unit dose ampule4 ?4 ?Combivent? -OR- Duoneb? - 2.5mg Albuterol mixed with 0.5mg Ipratropium Bromide. (Squads may also choose to carry Albuterol and Ipratropium Bromide individually and mix them per the Optional Medication List M.)2 ?2 ?Amiodarone, (150 mg/3 ml) (50 mg/ 1ml) (May be substituted with Lidocaine) 450mg totalN/ATotal 450 mg ?Lidocaine (Xylocaine?), 100mg pre-loaded syringe (May be substituted with Amiodarone.)N/A3 ?Amiodarone, 150mg/100 ml pre-mixed solution (Red Bag) (May be substituted with Lidocaine)N/A1 ?Lidocaine (Xylocaine?), 1gm/250 ml pre-mixed solution (Blue Bag) (May be substituted with Amiodarone.)N/A1 ?Aspirin, 81mg chewable tablets1 BTL ?1 BTL ?Nitroglycerin, 0.4mg (1/150) tablets or spray1 BTL ?1 BTL ?Adenosine (Adenocard?), (6 mg/2 ml) 18mg totalN/ATotal 18mg ?Atropine, 1mg pre-loaded syringeN/A3 ?D50W, 25g pre-loaded syringeN/A2 ?Oral Glucose, 15g tubes2 ?2 ?Glucagon, 1mg N/A1 ?Dexamethasone 10mg N/ATotal 10 mg ?Diltiazem (Cardizem?), 100mg total – Can use ADD-Vantage? system or any combination to total 100 mg (50 mg/10 ml or 25 mg/5 ml)N/ATotal 100 mg ?Diphenhydramine (Benadryl?), (50mg/ 1 ml) 100mg totalN/ATotal 100 mg ?Dopamine (Intropin?) 200mg/ 5 mlN/A1 ?Epinephrine, 1:10,000, 1mg pre-loaded syringeN/A6 ?Epinephrine, 1:1,000, 1mg total Optional2 ?Epi Pen JrEpi Pen Adult2 ea. ?N/AFentanyl (Sublimaze?), 100 mcg/2 ml or 200mcg totalN/ATotal 200 mcg ?Furosemide (Lasix?), 80mg totalN/ATotal 80 mg ?Haloperidol (Haldol?), 10mg totalN/ATotal 10 mg ?Ketamine (Ketelar) 320 mgN/AOptionalLabetalol, 30mg totalN/ATotal 30 mg ?Magnesium Sulfate, 2g totalN/ATotal 2 g ?Midazolam (Versed?), 10mg totalN/ATotal 10 mg ?Morphine Sulfate, 20mg totalN/ATotal 20 mg ?Naloxone (Narcan?), 2mg/1 ml for total of 4mg 2 ?2 ?Normal Saline (0.9%), 1,000mlN/A4 ?Ondansetron (Zofran?), 4mg/ 2 ml Total 8mg N/A2 ?Ondansetron (Zofran?) 4mg/tablet ODT2 tabletsOptionalThiamine, 200mg/ 1 ml for total of 100mgN/ATotal 100 mg ?OB EquipmentSterile OB kits with bulb syringe2 ea. ?2 ea. ?Thermal absorbent blanket and head cover made of a heat-reflective material1 ea. ?1 ea. ?Safety - Quantities and sizes of all PPE must be sufficient for entire crew.Protective helmet meeting ANSI Z89.1 Type II, NFPA 1908-2007 or NFPA 1951-2007 standardsTotal Crew ?Total Crew ?Protective eyewear meeting ANSI Z87.1-2003 standardsTotal Crew ?Total Crew ?High visibility clothing compliant with 23 CFR Part 643 (Federal Highway Worker Visibility Act) ANSI/ISEA 107-2004-Class 3 or 207.Total Crew ?Total Crew ?Protective gloves, extrication-type or heavy-duty leatherTotal Crew ?Total Crew ?Current DOT Emergency Response Guidebook (paper or electronic version)1 ?1 ?Fire extinguisher, 5lb 2A-10BC1 ?1 ?Child occupant protection system1 ?1 ?Chemical light sticks or Reflective triangles3 ?3 ?MiscellaneousBlankets2 ?2 ?Sheets4 ?4 ?Pillow Fluid Resistant 1 ?1 ?Towels2 ?2 ?Cold packs4 ?4 ?Hot Packs4 ?4 ?Disposable bedpan1 ?1 ?Urinal1 ?1 ?Disposable, splash resistant emesis bags4 ?4 ?Flashlights2 ?2 ?Impermeable body bag1 ?1 ?Stair chair or suitable substitute1 ?1 ?Wheeled stretcher, multi-level, with 5-point (over shoulder) patient restraint system (Antler, Railing, and Cot Safety Hook)1 ?1 ?WV triage tags25 ?25 ?WV triage tape rolls – red, yellow, green and black1 ea. ?1 ea. ?Protocol manuals appropriate for level of staffing (paper or electronic version)??Jewelry Cuter or equivalent ?? IV and Medication Administration60gtts/ml Mini-drip IV administration set. May utilize Select-3? sets or equivalentN/A4 ?10 to 15gtts/ml Macro-drip IV administration set. May utilize Select-3? sets or equivalentN/A4 ?Extension sets. May utilize Select-3? sets or equivalentN/A4 ?IV spike to luer lock adapter (required if agency carries Add Vantage Diltiazem administration) N/A2 ?Saline locks and flushesN/A4 ?IV catheters, sizes 14g, 16g, 18g, 20g, 22g and 24gN/A4 ea. ?EZ-IO driverN/A1 ?EZ-IO needles – Adult: 16 g 25 mm (Blue)Bariatric: 16 g 45 mm (Yellow)Pedi: 15 g 15 mm (Pink)N/A2 ea. ?Adequate site preparation materials – alcohol or povidone 10 ea. ?10 ea. ?Venous tourniquetsN/A4 ea. ?Nebulizer kits2 ?2 ?Drug atomizers2 ?2 ?Syringes in appropriate quantities and sizes – 1ml, 3ml, 5ml, 10ml, 30ml, 60ml 2 ea. ?2 ea. ?Needles in appropriate quantities, sizes and lengths. Some greater than 1.5” in length for IM mediation administration2 ea. ?2 ea. ?Length/weight based pediatric drug and equipment reference – Broselow tape or Pedi Wheel or equivalent1 ?1 ?Two-Way CommunicationsBetween vehicle, dispatcher and 911 center (if applicable) can utilize Portable Radio ? ?Outside of vehicle between Partner, Dispatcher and 911 center Portable Radio2 ea. ?2 ea. ?Optional Equipment and SuppliesBlood sample tubes and supplies??Commercially available soft restraints1 set ?1 set ?Cyano-Kit1 set ?1 set ?Elastic bandages4 rolls ?4 rolls ?ET Tube IntroducerN/A?Hemostatic dressings. Must be impregnated gauze-type hemostatic agent??IV fluid warmed??IV infusion pumpN/A?Mechanical Chest Compression Device??Morgan Lens??Non-invasive vital signs monitor??Pediatric King Airways - sizes 2 and 2.51 ea. ?1 ea. ?Pediatric spinal immobilization device1 ?1 ?Pelvic immobilization device??Percutaneous Airway Kit - (example: Quick Trach 1? or Quick Trach 2? or other commercially available non-surgical kit.)??Pocket MaskN/A1Video Assisted Laryngoscope??M. Optional MedicationsEtomidate (Amidate?), 80mg totalN/ARSI ONLY80 mg ?Ketamine 500 mg, VialN/ARSI ONLY500 mg ?Sodium Bicarbonate, 50mEq pre-loaded syringeN/A2 ?Succinylcholine, 400mg total.N/AOptional400 mg ?Vecuronium (Norcuron?), 20mg totalN/ARSI ONLY20 mg ?Tetracaine (0.5%), 2mL totalN/ARSI ONLY2 ml ?Tranexamic Acid (TXA) 100mg/ml, 10mg VialN/A1 ?Rocuronium (Zemuron?)N/ARSI ONLY 2 Grams ? December 22, 2020West Virginia Department of Health and Human ResourcesOffice of Emergency Medical ServicesClass D and Ground/Air Ambulance Minimum Equipment and Supply List (CCT)This is the minimum equipment and supplies required on dedicated Class A EMS Rapid Response Vehicles operated by Licensed EMS Agencies and Fire Department Rapid Response Licensed Agencies. All supplies must be clean and organized. When applicable, items must be sealed and within current expiration period. Vehicles must have required equipment on-board during EMS response and patient treatment. Effective December 22, 2020Response TypeDGroundEAirQtyQtyAirway and VentilationFixed suction system, electric powered with disposable collection container and large bore tubing, assembled and ready for use 1 ?1 ?Portable suction unit, assembled and ready for use – manual units must be V-VAC or equivalent1 ?1 ?Yankauer suction tube. Large bore rigid oral suction catheters – must have internal diameter greater than or equal to 0.25 inches2 ?1 ?Flexible suction catheters – 6F, 10F and 14 F2 ea. ?2 ea. ?Salem sump tubes – 8, 12 and 18 Fr. with irrigation syringe2 ea. ?2 ea. ?Meconium aspirator adaptor for ET tubes1 ?1 ?Suction connectors, “Y”2 ?1 ?Suction connectors, 5 in 12 ?1 ?On-board O? system (“M” size cylinder or equivalent) with 2 outlets2 ?2 ?Adjustable liter flow regulators (float ball 15 lpm)2 ?1 ?Portable O? system with Bourdon Gauge non-gravity dependent liter flow regulator (15 lpm)1 ?1 ?Full spare portable O? cylinder (“D” size or larger)1 ?NAAdult nasal cannula4 ?2 ?Pediatric nasal cannula4 ?1 ?Adult non-rebreather masks4 ?2 ?Pediatric non-rebreather masks4 ?1 ?O? connecting tubing – may be with BVM or nebulizers2 ?2 ?Nasopharyngeal airways – assorted sizes, 16 Fr – 34 Fr No less than 5 different sizes1 ea. ?1 ea. ?Oropharyngeal airways – sizes 0 through 51 set ?1 set ?King LT airway sizes2345 1 ea.? 1 ea. ?Adult end-tidal CO? detector – colorimetric1 ?1 ?Pediatric end-tidal CO? detector – colorimetric 1 ?1 ?Laryngoscope handle with extra batteries1 ?1 ?Laryngoscope blades – 0 & 1 (Miller) straight 2, 3, 4 (Miller) straight or (Macintosh) curvedspare bulbs if applicable1 ea. ?1 ea. ?ET tubes, sizes:2 ea. ?2 ea. ?2.5 uncuffed2 ea. ?2 ea. ?3.0 or 3.5 uncuffed2 ea. ?2 ea. ?4.0 or 4.5 cuffed or uncuffed 2 ea. ?2 ea. ?5.0 or 5.5 cuffed or uncuffed2 ea. ?2 ea. ?6.0 or 6.5 cuffed2 ea. ?2 ea. ?7.0 or 7.5 cuffed2 ea. ?2 ea. ?8.0 or 8.5 cuffed2 ea. ?2 ea. ?Adult and pediatric Stylets (in not pre-packaged in ETT)1 ea. ?1 ea. ?Magill forcepsAdultPediatric1 ea. ?1 ea. ?Surgical cricothyrotomy set with 5.5 mm cuffed tube2 ?2 ?Wayne pneumothorax kits, 10 fr.2 ?2 ?Pocket mask with one-way valve1 ?1 ?Adult, Child, Infant bag valves, self-filling with O? reservoir1 ea. ?1 ea. ?Clear masks for bag valves, adult, child, infant, and neonatal (if not already pre-packaged in Ambu bag)1 ea. ?1 ea. ?Portable ventilator with:volume and pressure control, SIMV, AC, CPAP, pressure supportadjustable PEEPadjustable peak flowadjustable FIO2 range of 21% to 100%1 ?1 ?Ventilator tubing sets: – (total of 2 if tubing does both)adult pediatric 2 ea. ?2 ea. ?PEEP valves2 ?2 ?HME Ventilator filters 2 ?2 ?Closed tracheal suction catheters (Ballard suction)4 ?2 ?Heimlich valves2 ?2 ?Monitoring and AssessmentBlood pressure cuff – XL, adult, child & infant1 ea. ?1 ea. ?Stethoscope, suitable for adult and pediatric use1 ?1 ?Glucometer with supplies (lancets must be single use, fully disposable types)1 ?1 ?Doppler stethoscope with gel 1 ?1 ?Temperature monitoring device for Skin oresophageal or rectal use1 ?1 ?Patient monitoring system capable ofcardiac rhythm monitoring 12 lead acquisition, data transmissionend tidal CO2 waveform capnographypulse oximetrynon-invasive blood pressure monitoringarterial pressure monitoringtranscutaneous pacingdefibrillation and cardioversionbattery and AC power supply1 ?1 ?Adult and pediatric defibrillation and transcutaneous pacing cables and pads2 ea. ?2 ea. ?Cables, transducers, probes and supplies for ECG, CO2, blood pressure, pulse oximetry and temperature monitoring.1 ?1 ?Immobilization EquipmentCervical CollarRigid cervical collar – large, medium, small and child, OR adult and pediatric adjustable2 ea. ?1 ea. ?Head/cervical immobilization devices - towel/blanket rolls are acceptable2 sets ?1 set ?Short spinal immobilization device – (KED XP-, etc.) 1 ?NARadiolucent, impervious full-length backboards 2 ?NAFour (4) 9-foot straps or equivalent (Spider Strap, etc)2 sets ?NATraction splints, adult and child – a single splint is acceptable if adjustable for both1 ea. ?NAPadded extremity splints (Cardboard, wire, air, or SAMS)2 ea. ?NAD. Wound ManagementSterile burn sheets2 ?2 ?Sterile 10” x 30” multi-trauma dressings2 ?2 ?Sterile ABD Pads, 5” x 9” or 8” x 10”2 ?2 ?Sterile 4”x 4”s (1 bx)24 ?12 ?Sterile occlusive dressings, 3” x 8”, or equivalent2 ?2 ?Adhesive tape – assorted sizes – 1 roll must be hypoallergenic/latex-free4 rolls ?2 rolls ?Self-adhering gauze bandages - Kling or equivalent8 rolls ?4 rolls ?Triangular Bandages4 ?NAHemostatic dressings – Quick Clot or Hemcon??Commercial arterial tourniquet – CAT, MAT, etc.1 ?1 ?Heavy duty bandage scissors or shears1 ?1 ?Sterile saline irrigation, 1000 ml totalTotal 1000 ml ?NAInfection Control - Quantities and sizes of following PPE sufficient for entire crewProtective eyewear - full peripheral glasses or goggles or face shieldCrew Total ?Crew Total ? NIOSH N-95 or N-100 face masksCrew Total ?Crew Total ? Protective gowns or coveralls, shoe coversCrew Total ?Crew Total ? Disposable exam gloves meeting NFPA 1999 requirements – assorted appropriate sizes, must include hypoallergenic/latex free types (XL, L, M, S)1 bx ea. ?1 bx ea. ? Disinfectant waterless hand cleaner??Disinfectant for cleaning vehicle interior and equipment??Biohazard trash bags2 ?1 ?Fixed and portable sharps containers1 ea. ?1 ea. ? MedicationsAcetaminophen (Tylenol?), 160mg/5mL oral suspension1 BTL ?N/AAlbuterol, 2.5mg/3mL or 2.5mg/0.5mL unit dose ampule4 ?4 ?Albuterol/Ipratropium (Duo-Neb?), 2.5mg/0.5mg in 3mL unit dose ampule4 ?4 ?Combivent? -OR- Duoneb? - 2.5mg Albuterol mixed with 0.5mg Ipratropium Bromide. (Squads may also choose to carry Albuterol and Ipratropium Bromide individually and mix them per the Optional Medication List M.)2 ?2 ?Amiodarone, (150 mg/3 ml) (50 mg/ 1ml) (May be substituted with Lidocaine) 450mg totalTotal 450 mg ?Total 450 mg ?Lidocaine (Xylocaine?), 100mg pre-loaded syringe (May be substituted with Amiodarone.)3 ?3 ?Amiodarone, 150mg/100 ml pre-mixed solution (Red Bag) (May be substituted with Lidocaine)1 ?1 ?Lidocaine (Xylocaine?), 1gm/250 ml pre-mixed solution (Blue Bag) (May be substituted with Amiodarone.)1 ?1 ?Aspirin, 81mg chewable tablets1 BTL ?1 BTL ?Nitroglycerin, 0.4mg (1/150) tablets or spray1 BTL ?1 BTL ?Adenosine (Adenocard?), (6 mg/2 ml) 18mg totalTotal 18mg ? N/ATotal 18mg ?Atropine, 1mg pre-loaded syringe3 ?3 ?D50W, 25g pre-loaded syringe2 ?2 ?D5W, 250 ml bags22Oral Glucose, 15g tubes2 ?N/AGlucagon, 1mg 1 ?1 ?Dexamethasone 10mg Total 10 mg ?Total 10 mg ?Diltiazem (Cardizem?), 100mg total – Can use ADD-Vantage? system or any combination to total 100 mg (50 mg/10 ml or 25 mg/5 ml)Total 100 mg ?Total 100 mg ?Diphenhydramine (Benadryl?), (50mg/ 1 ml) 100mg totalTotal 100 mg ?Total 100 mg ?Dopamine (Intropin?) 200mg/ 5 ml or Dopamine (Intropin) 400 mg pre-mixed solution1 ?1 ?Epinephrine, 1:10,000, 1mg pre-loaded syringe6 ?6 ?Epinephrine, 1:1,000, 1mg total 2 ?2 ?Fentanyl (Sublimaze?), 100 mcg/2 ml Total of 100 mcg ?Total of 100 mcg ?Furosemide (Lasix?), 100 mg totalTotal of 100 mg ?Total 100 mg ?Haloperidol (Haldol?), 10mg totalTotal 10 mg ?Total 10 mg ?Ketamine (Ketelar) 320 mgOptional OptionalLabetalol, 30mg totalTotal 30 mg ?Total 30 mg ?Magnesium Sulfate, 2g totalTotal 2 g ?Total 2 g ?Midazolam (Versed?), 10mg totalTotal 10 mg ?Total 10 mg ?Morphine Sulfate, 20mg totalTotal 20 mg ?Total 20 mg ?Naloxone (Narcan?), 2mg/1 ml for total of 4mg 2 ?2 ?Normal Saline (0.9%), 1,000ml bag4 ?4 ?Normal saline (0.9%), 250 ml bags4 ?2 ?Normal saline (0.9%), 100 ml bag4 ?2 ?Normal saline (0.9%), 10 ml vial6 ?2 ?Ringer’s Lactate, 1,000 ml bags2 ?2 ?Thiamine, 200mg/ 1 ml for total of 100mgTotal 100 mg ? Total 100 mg ?Activated charcoal suspension, 25 gm1 ?NACalcium gluconate1 ?1 ?Cimetidine (Tagamet), 300 mg Total 300 mg ?Total 300 mg ?Clopidogrel (Plavix), 150 mg 2 tablets2 tabletsEtomidate (Amidate), 20 mg4 ?4 ?Flumazenil (Romazicon), 0.5 mg 2 ?2 ?Heparin sodium, 5,000 u2 ?2 ?Ketorolac (Toradol), 60 mg2 ?2 ?Lorazepam (Ativan) 4 mg5 ?5 ?Mannitol (Osmitrol), 100 gm2 ?1 ?Methylprednisolone (Solu-Medrol), 125 mg2 ?2 ?Norepinephrine (Levophed), 4 mg4 ?2 ?Sodium bicarbonate, 50 meq pre-loaded syringe2 ?2 ?Succinylcholine (Anectine), 200 mg5 ?5 ?Vecuronium (Norcuron), 10 mcg 6 ?4 ?Heparin sodium, 10,000 u – Class 1 only6 ?2 ?Humulin R insulin – Class 1 only1 ?NAMetoprolol (Lopressor), 5 mg – Class 1 only3 ?2 ?Nitroglycerin infusion, 50 mcg premixed – Class 1 only2 ?1 ?Racemic epinephrine, 2.25%/ 0.5 ml – Class 1 only2 ?2 ?Vasopressin (Pitressin), 20 u – Class 1 only4 ?2 ?Optional MedicationBumetanide (Bumex), 4 mg Total 4 mg ?Total 4 mg ?Cefazolin sodium (Ancef), 1 gm Total 1 mg ?Total 1 mg ?Hetastarch (Hespan), 500 ml Total 500 ml ?Total 500 ml ?Lanoxin (Digoxin). 0.5 mg Total 0.5 mg ?Total 0.5 mg ?Nitroprusside (Nitride), 50 mgTotal 50 mg ?Total 50 mg ?Phenytoin (Dilantin), 250 mg Total 250 mg ?Total 250 mg ?Potassium Chloride, 20 meq Total 20 meq ?Total 20 meq ?PRBCOptional Optional OB EquipmentSterile OB kits with bulb syringe2 ?NAThermal absorbent blanket, head cover and heat-reflective material1 ?NASafety - Quantities and sizes of PPE sufficient for entire crewProtective helmet meeting ANSI Z89.1-2003 Type II, NFPA 1907-2007 or NFPA 1951-2007 standards OR FAA approved helmets for rotor wing aircraftCrew Total ?Crew Total ?Protective eyewear meeting ANSI Z87.1-2003 standardsCrew Total ?Crew Total ?Protective gloves, extrication-type or heavy-duty leatherCrew Total ?Crew Total ?Current DOT Emergency Response Guidebook1 ?1 ?High visibility clothing compliant with 23 CFR Part 643 (Federal Highway Worker Visibility Act) meeting ANSI/ISEA 107-2004 class 3 requirementsCrew Total ?Crew Total ?Child occupant protection system1 ?1 ?Fire extinguisher, 5lb 2A-10BC1 ?1 ?Chemical light sticks or reflective triangles, etc.3 ?NAMiscellaneousAC power supply with sufficient output to run all on board portable electric equipment (inverter or generator)??Battery powered transvenous pacemaker with adjustable rate and milliamp setting??Blankets2 ?1 ?Sheets4 ?1 ?Pillow Fluid Resistant 1 ?1 ?Towels2 ?2 ?Cold packs4 ?4 ?Hot Packs4 ?4 ?Disposable bedpan1 ?1 ?Urinal1 ?1 ?Disposable, splash resistant emesis bags4 ?4 ?Flashlights2 ?2 ?Impermeable body bag1 ?N/AStair chair or suitable substitute1 ?1 ?Wheeled stretcher, multi-level, with 5-point (over shoulder) patient restraint system (Antler, Railing, and Cot Safety Hook) or FAA approved stretcher1 ?1 ?WV triage tags25 ?N/AWV triage tape rolls – red, yellow, green and black1 ea. ?N/AJewelry Cutter or equivalent1 ?N/AProtocol manuals appropriate for level of staffing (paper or electronic version)??IV and Medication Administration60gtts/ml Mini-drip IV administration set. May utilize Select-3? sets or equivalent4 ?4 ?10 to 15gtts/ml Macro-drip IV administration set. May utilize Select-3? sets or equivalent4 ?4 ?Blood administration tubing sets 4 ?2 ?Extension sets. May utilize Select-3? sets or equivalent4 ?4 ?IV spike to luer lock adapter (required if agency carries Add Vantage Diltiazem administration) 2 ?2 ?Blunt plastic cannula 10 ?4 ?Conical filters for IV2 ?1 ?3-way stopcocks 4 ?2 ?“Y” IV connectors 4 ?2 ?Pressure infusion bags 2 ?2 ?EZ-IO needles – Adult: 16 g 25 mm (Blue)Bariatric: 16 g 45 mm (Yellow)Pedi: 15 g 15 mm (Pink)2 ea. ?2 ea. ?Adequate site preparation materials – alcohol or povidone 10 ea. ?10 ea. ?Venous tourniquets4 ea. ?4 ea. ?Nebulizer kits2 ?2 ?Drug atomizers2 ?2 ?Needles in appropriate quantities, sizes and lengths. Some greater than 1.5” in length for IM mediation administration2 ea. ?2 ea. ?Length/weight based pediatric drug and equipment reference – Broselow tape or Pedi Wheel or equivalent1 ?1 ?Portable IV pump(s), AC and battery power, capability to provide 6 simultaneous infusions with independent flow settings. (or a combination)1 ?1?Pump-compatible tubing sets 6 ?6 ?6 ?Nitroglycerine tubing2 ?2 ?Syringe, 1 ml5 ?2 ?Syringe, 3 ml10 ?2 ?Syringe, 10 ml10 ?4 ?Syringe, 30 ml2 ?2 ?Syringe, 60 ml Luer tip 2 ?2 ?Syringe, insulin 2 ?NAIV ‘clip’ cannula 6 ?2 ?Two-Way CommunicationsBetween vehicle, dispatcher and 911 center (if applicable) can utilize Portable Radio ? ?Outside of vehicle between Partner, Dispatcher and 911 center Portable Radio ? ?Optional Equipment and Supplies180° searchlight 400,000 cpNA?Blood sample tubes and supplies??Elastic bandages4 ?NAFoley catheters, sizes: 12 fr, 14 fr, 16 fr, 18 fr1 ea. ?NALight to illuminate tail rotor area (Tel Tail or equivalent)NA?NVG equipped/certified NA?Non-coring (Huber) needles??Pediatric spinal immobilization device?NADecember 22, 2020 ................
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