# COMAR Title 30 — Maryland Institute for Emergency Medical Services Systems (MIEMSS)

## Subtitle 09 — Commercial Ambulance Services

### Chapter 11 — ALS Service

**Authority:** Education Article, §13-515, Annotated Code of Maryland

**Administrative History:** Effective date: October 12, 1992 (19:20 Md. R. 1816)

**Administrative History:** Regulation .02 repealed and new Regulations .02—.06 adopted as an emergency provision effective January 6, 1997 (24:2 Md. R. 114); adopted permanently effective July 7, 1997 (24:10 Md. R. 711)

**Administrative History:** Chapter recodified from COMAR 14.22.11 to COMAR 30.09.11, August, 1997

**Administrative History:** Regulation .02F amended as an emergency provision effective July 1, 1998 (25:15 Md. R. 1189); amended permanently effective October 5, 1998 (25:20 Md. R. 1534)

**Administrative History:** Regulations .01—.06, Specialized Service, repealed and new Regulations .01—.05, ALS Service, adopted effective January 10, 2000 (26:27 Md. R. 2017)

**Administrative History:** Regulation .02A amended effective November 1, 2010 (37:21 Md. R. 1437); December 12, 2013 (40:24 Md. R. 2017)

**Administrative History:** Regulation .03 amended effective January 15, 2005 (31:26 Md. R. 1866)

**Administrative History:** Regulation .04C amended effective November 1, 2010 (37:21 Md. R. 1437)

**Administrative History:** Regulation .05 repealed and new Regulation o5 adopted effective January 15, 2005 (31:26 Md. R. 1866)

**Administrative History:** Regulation .05B amended effective September 1, 2014 (41:17 Md. R. 971)

#### Regulation .01 Scope.

*COMAR 30.09.11.01*

This chapter defines additional requirements for ALS services.

#### Regulation .02 Additional Operational Requirements.

*COMAR 30.09.11.02*

A. An ALS commercial ambulance service shall retain at least one licensed paramedic to function as an ALS coordinator who:

  (1) Is approved by the ALS service medical director;

  (2) Participates on the ALS service's quality review committee; and

  (3) Oversees:

    (a) ALS operations; and

    (b) The submission of patient care reports and EMS data in accordance with COMAR 30.03.04.04.

B. An ALS commercial ambulance service may provide BLS service with an ambulance licensed as either:

  (1) ALS; or

  (2) BLS.

C. An ALS commercial ambulance service may not provide scheduled ALS service with a BLS-licensed commercial ambulance vehicle unless:

  (1) It uses a BLS-licensed ambulance for a period of not more than 30 calendar days for reasons related to:

    (a) Routine maintenance; or

    (b) Mechanical failure of an ALS-licensed commercial ambulance vehicle;

  (2) The BLS-licensed ambulance has, in addition to the equipment required in COMAR 30.09.10, all the equipment required in this chapter; and

  (3) It has notified SOCALR of the proposed use before its occurrence and has been issued a confirmation number verifying authorization.

#### Regulation .03 Additional Equipment Required for ALS Ambulances.

*COMAR 30.09.11.03*

In addition to the equipment required under COMAR 30.09.10, the following equipment and supplies shall be carried in commercial ambulances licensed to provide ALS service:

A. An onboard oxygen system that meets the requirements of COMAR 30.09.10.09;

B. Cardiac monitoring/defibrillating/transcutaneous pacing equipment including:

  (1) One monitor/defibrillator which has:

    (a) Direct current capability,

    (b) Paper print out capability,

    (c) Synchronized cardioversion and unsynchronized defibrillation,

    (d) Two adult and one pediatric defibrillator pads,

    (e) Defibrillator pads with quick look capability,

    (f) One set of EKG leads, and

    (g) Transcutaneous pacing; and

  (2) Supplies related to EKG monitoring to include the following items:

    (a) 18 ECG electrodes,

    (b) Spare set of EKG leads or equivalent,

    (c) Spare monitor/defibrillator batteries,

    (d) Two spare EKG paper rolls,

    (e) Two adult transcutaneous pacing pads,

    (f) One pediatric transcutaneous pacing pad, and

    (g) One tube of electrode paste or two packages of electrolyte pads for use in defibrillation;

C. Medications including:

  (1) All the medications listed in the Maryland Medical Protocols for Emergency Medical Services Providers in sufficient quantities to treat and care for each patient that they respond to and care for;

  (2) Sufficient quantities to provide:

    (a) At least the maximum dosage for one 100 kilogram patient for a period of 30 minutes, or

    (b) An adequate quantity to treat and care for the patient if the transport time is expected to exceed 30 minutes;

  (3) Controlled substances which are stored in a controlled access system acceptable to SOCALR; and

  (4) Two nebulizers for medication administration;

D. Intravenous equipment and supplies including:

  (1) Two 16 gauge 1 1/4 to 1 1/2 inches long intravenous catheters with needles;

  (2) Two 18 gauge, 1 1/4 to 1 1/2 inches long intravenous catheters with needles;

  (3) Two 20 gauge, 1 1/4 to 1 1/2 inches long intravenous catheters with needles;

  (4) Two 22 gauge, 1 1/4 to 1 1/2 inches long intravenous catheters with needles;

  (5) Two 24 gauge, 1 1/4 to 1 1/2 inches long intravenous catheters with needles;

  (6) Two 10 or 20 drops/milliliter or equivalent intravenous administration sets;

  (7) Two 60 drops/milliliter or equivalent intravenous administration sets;

  (8) Two 1000 cubic centimeter bags or equivalent of Ringer's lactate intravenous solution;

  (9) Site preparation materials; and

  (10) Roof-mounted hooks for hanging intravenous solutions;

E. Parenteral administration equipment including:

  (1) Four 1 milliliter syringes with 25 gauge needles;

  (2) Four 3—5 milliliter syringes with 1-inch, 18—21 gauge needles for IM injection;

  (3) Four 10 milliliter syringes; and

  (4) Four 18, 19, or 20 gauge needles;

F. Blood specimen collection equipment including:

  (1) Two red top blood tubes;

  (2) Two purple top blood tubes; and

  (3) Two vacutainer barrels;

G. Ventilation and airway maintenance equipment including:

  (1) Laryngoscope equipment and supplies:

    (a) One of each size 0, 1, 2, 3, and 4 Miller laryngoscope blades,

    (b) One of each size 1, 2, 3, and 4 MacIntosh laryngoscope blades, and

    (c) One each adult and pediatric laryngoscope handles;

  (2) Endotracheal tubes:

    (a) One of each size 6, 7, 8, and 9 millimeter cuffed, and

    (b) One of each size 2.5, 3, 3.5, 4, and 5 millimeter uncuffed;

  (3) One adult flexible stylette;

  (4) One pediatric flexible stylette;

  (5) One roll of 1-inch adhesive tape;

  (6) One 10 milliliter syringe;

  (7) One pair adult McGill forceps;

  (8) One pair pediatric McGill forceps;

  (9) One 4-ounce tube or four 3-gram packets of water soluble surgical lubricant;

  (10) One spare laryngoscope bulb for both MacIntosh and Miller blades;

  (11) One spare set of laryngoscope batteries for both adult and pediatric handles; and

  (12) One end title carbon dioxide (ETCO2) detector.

H. One direct current to alternating current inverter power supply capable of providing proper wattage to power equipment used on an ALS ambulance; and

I. Miscellaneous equipment and supplies as follows:

  (1) One glucometer;

  (2) One pulse oximeter for each in-service ALS ambulance; and

  (3) One current, printed within last 2 years, copy of a drug reference.

#### Regulation .04 Additional Requirements for Obstetrical Transports.

*COMAR 30.09.11.04*

A. An ALS-licensed ambulance may not transport an obstetrical patient from one hospital to another for a higher level of obstetrical care unless:

  (1) The admitting hospital:

    (a) Is a perinatal center;

    (b) Before designation of perinatal centers by the EMS Board, has a certificate of need issued by the Maryland Health Resources Planning Commission for its neonatal intensive care unit or approval from the Health Services Cost Review Commission for a neonatal intensive care cost center; or

    (c) Before the EMS Board has completed the process of entering into an agreement with an out-of-State hospital to serve as an out-of-State perinatal referral center, possesses all government approvals required to operate a neonatal intensive care unit under the laws of the jurisdiction in which it is located including, if required, a certificate of need and all necessary licenses;

  (2) The additional equipment required under §B of this regulation is onboard; and

  (3) In addition to the staffing required under COMAR 30.09.07.02A(4), there is a registered nurse or physician experienced in the care of obstetrical patients onboard.

B. Equipment Requirements.

  (1) The additional equipment required under §B(2) of this regulation may be provided by the referring or admitting hospital and shall be onboard when transporting an obstetrical patient.

  (2) In addition to the equipment required under COMAR 30.09.10 and this chapter, the following shall be onboard:

    (a) One doppler;

    (b) One reflex hammer;

    (c) One neonatal bag valve mask with manometer and newborn and premature infant size masks;

    (d) One IV infusion pump; and

    (e) The following medications:

      (i) Four vials oxytocin (10 units/milliliter);

      (ii) Two vials methergine (0.2 milligram/milliliter);

      (iii) Two vials 10 percent calcium gluconate (10 milliliters);

      (iv) Three vials terbutaline (1 milligram/milliliter); and

      (v) Eight vials 50 percent magnesium sulfate (10 milliliters).

C. Additional Record Keeping Requirements.

  (1) In addition to the requirements in COMAR 30.09.08, the following information shall be documented on the patient report:

    (a) Name of the referring hospital;

    (b) Name of the referring physician;

    (c) Name of the receiving hospital;

    (d) Name of the receiving physician;

    (e) Names and license or certification level of the commercial ambulance driver and commercial ambulance personnel;

    (f) Time the request for transport was received by the commercial ambulance service;

    (g) Time en route to the referring hospital;

    (h) Time of arrival at the referring hospital;

    (i) Time of departure from the referring hospital;

    (j) Time of arrival at the admitting hospital;

    (k) Maternal gestational age;

    (l) Reason for transport; and

    (m) Care provided during transport.

  (2) Patient care reports and EMS data shall be submitted in accordance with COMAR 30.03.04.04.

D. The additional requirements for obstetrical transports listed in §§A and B of this regulation may be waived when an ALS-licensed commercial ambulance is transporting an uncomplicated obstetrical patient from a hospital without an obstetrical service.

#### Regulation .05 Specialty Care Transport Restrictions.

*COMAR 30.09.11.05*

A licensed commercial ambulance service may not provide specialty care transport unless:

A. Licensed as a specialty care transport ambulance service; or

B. No more than ten times a year, if a licensed specialty care transport ambulance service is not available within a clinically reasonable time as determined by the referring physician:

  (1) The sending facility provides health care personnel authorized by law to provide the level of care required by the patient during transport, which may include a nurse meeting the requirements of COMAR 10.27.09.04C(2);

  (2) Required specialty equipment is available;

  (3) The ambulance used is licensed as at least an ALS ambulance;

  (4) Notice is made to SOCALR within 24 hours of the transport; and

  (5) A report, reviewed and signed by the medical director, is submitted to SOCALR within 7 days of the transport, documenting the patient’s condition, the care rendered, crew configuration and efforts made by the referring physician, and the service to secure appropriate SCT resources.