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

## Subtitle 09 — Commercial Ambulance Services

### Chapter 14 — Specialty Care Transport Services

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

**Administrative History:** Effective date: January 15, 2005 (32:1 Md. R. 1866)

**Administrative History:** Regulation .02G—I amended effective September 1, 2014 (41:17 Md. R. 971)

**Administrative History:** Regulation .04 amended effective May 27, 2024 (51:10 Md. R. 529)

**Administrative History:** Regulation .04B, C amended effective December 12, 2013 (40:24 Md. R. 2017); September 1, 2014 (41:17 Md. R. 971); October 16, 2023 (50:20 Md. R. 889)

**Administrative History:** Regulation .04D adopted effective September 1, 2014 (41:17 Md. R. 971)

**Administrative History:** Regulation .05 amended effective December 12, 2013 (40:24 Md. R. 2017)

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

**Administrative History:** Regulation .07 amended effective September 1, 2014 (41:17 Md. R. 971)

#### Regulation .01 Scope.

*COMAR 30.09.14.01*

This chapter governs the requirements for a specialty care transport commercial ambulance service other than neonatal ambulance services. The requirements for neonatal ambulance services are in COMAR 30.09.12.

#### Regulation .02 General.

*COMAR 30.09.14.02*

A. To be licensed as a specialty care transport commercial ambulance service, a commercial ambulance service shall comply with the requirements of this chapter in addition to the other requirements of this subtitle.

B. An applicant for a specialty care transport commercial ambulance service license shall submit an application to SOCALR on the required form.

C. A licensed specialty care transport commercial ambulance service shall retain one or more medical directors as required by COMAR 30.03.03.

D. In addition to the qualifications in COMAR 30.03.03, the medical director for a specialty care service shall:

  (1) Have educational experience in the care of the types of critically ill patients the service is transporting;

  (2) Be board-certified in an appropriate specialty;

  (3) Be actively practicing within a hospital clinical setting; and

  (4) Use the following consultants when appropriate:

    (a) Designated specialty physicians; or

    (b) The patient's receiving physician.

E. The medical director for a licensed specialty care transport ambulance service shall participate in the development and implementation of any patient care guidelines required for interfacility transport of critically ill patients, including those guidelines to be followed by nursing personnel.

F. A licensed specialty care ambulance service shall immediately advise SOCALR of any change in medical directors.

G. A licensed specialty care ambulance service shall retain one or more registered nurses or nurse practitioners who:

  (1) Are licensed by the Maryland Board of Nursing;

  (2) Have knowledge of content which includes, but is not limited to:

    (a) The transport arena (including transport team membership and role responsibility);

    (b) Regulations governing COMAR 10.27.09;

    (c) Documentation;

    (d) Coordination with other transport team members;

    (e) Knowledge and skill set appropriate to the client to be transported;

    (f) Review of safety standards specific to the transport environment;

    (g) Relevant components of the MIEMSS Base Station Course;

    (h) Review of the MIEMSS Interhospital Transfer Resource Manual;

    (i) Risk/benefit ratio assessment and triage decision-making process;

    (j) Age-appropriate advanced life saving procedures, complications associated with procedures, and complications associated with delay in intervening with any of the procedures;

    (k) Respiratory monitoring including differentiation between upper and lower airway obstruction, covert and overt signs of respiratory failure, and airway management;

    (l) Neurological and spinal cord emergences and monitoring;

    (m) Cardiovascular and hemodynamic monitoring including dysrhythmia recognition and pertinent laboratory data and interpretation;

    (n) Blood and blood product administration;

    (o) Knowledge of MIEMSS Maryland Medical Protocols for EMS Providers appropriate to the client population transported;

    (p) Age-appropriate care algorithms and protocols;

    (q) The responsibilities and accountability of the registered nurse to serve as team leader in absence of the physician;

    (r) Insuring a safe environment and operational issues related to transport, including rapid egress from a trauma incident;

    (s) Transport safety, which includes, but is not limited to:

      (i) Safety briefing related to the vehicle;

      (ii) Protective clothing; and

      (iii) Mission profile;

  (3) Demonstrate knowledge of the EMS system by:

    (a) Completing a MIEMSS-approved base station course; or

    (b) Being a currently licensed EMS provider;

  (4) Comply with the requirements of COMAR 10.27.09;

  (5) Screen all requests for specialty care transport; and

  (6) Determine, in collaboration with the referring physician and program medical director, and in accordance with Regulation .04 of this chapter, the appropriate transport team configuration required for the patient.

H. The licensed specialty care ambulance service shall credential any registered nurse retained by the service to ensure the registered nurse meets the requirements of §G of this regulation.

I. A licensed specialty care commercial ambulance service shall have a quality assurance program required by COMAR 30.03.04 which shall include:

  (1) A review by registered nurses and physicians of patient care provided during specialty care transport;

  (2) A review by the program medical director or designated specialty physician of each specialty care transport:

    (a) Requiring a change in the plan of care during transport;

    (b) Whose condition worsened during transport;

    (c) In which there was a change of destination during transport; or

    (d) In which there was an unexpected outcome or event;

  (3) Written documentation of reviews of specialty care transports which shall be available to SOCALR upon request;

  (4) Patient feedback on outcomes to the sending facility; and

  (5) A quality assurance process for call taking, call screening, and dispatch.

#### Regulation .03 Additional Requirements for Specialty Care Ambulances.

*COMAR 30.09.14.03*

A. The interior configuration of an ambulance used for specialty care transport shall:

  (1) Allow medical personnel access to the airway and at least one side of the patient from a secured, seat-belted position;

  (2) Allow medical personnel to see all monitor read-outs from secured, seat-belted positions;

  (3) Have all medical devices, supplies, and equipment stowed or adequately fastened to prevent items from becoming projectiles that can cause injury in an abrupt stop or crash; and

  (4) Have compartments used to carry heavy objects, including oxygen cylinders, suction units, intravenous pumps, monitors, or ventilators, with positively locked latches designed to remain closed in an abrupt stop or crash with both latch and hinge bolted to the door and frame structure.

B. A licensed specialty care transport ambulance service may provide specialty care transport using:

  (1) A dedicated licensed specialty care ambulance; or

  (2) An ALS licensed ambulance staffed and equipped as a specialty care ambulance.

#### Regulation .04 Additional Staffing Requirements for Specialty Care Commercial Ambulance Services.

*COMAR 30.09.14.04*

A. An ambulance providing specialty care transport service shall be staffed as provided in this regulation.

B. If the care required is within the scope of practice of Specialty Care Paramedic and the patient requires no more than one specialty care intervention, as defined in the Maryland Medical Protocols for Emergency Medical Services:

  (1) A driver who meets the requirements of COMAR 30.09.07.02A(4)(a); and

  (2) A Specialty Care Paramedic.

C. If the care required is within the scope of practice of a Specialty Care Paramedic and the patient requires two or more specialty care interventions, as defined in the Maryland Medical Protocols for Emergency Medical Services:

  (1) A driver who meets the requirements of COMAR 30.09.07.02A(4)(a);

  (2) At least one individual who is:

    (a) A Specialty Care Paramedic; or

    (b) A registered nurse with advanced training and certification in the care of specialty care patients and current knowledge of the EMS system as defined in Regulation .02G(3) of this chapter; and

  (3) At least one individual who:

    (a) Is one of the following:

      (i) A CRT initially licensed after July 1, 2001 or who has completed the CRT update program;

      (ii) A paramedic; or

      (iii) If the individual under §C(2) of this regulation is a Specialty Care Paramedic and one of the specialty care interventions involves ventilator management, a respiratory therapist; and

    (b) Has successfully completed an orientation to specialty care transport.

D. If the care required is outside the scope of practice of a Specialty Care Paramedic:

  (1) A driver who meets the requirements of COMAR 30.09.07.02A(4)(a); and

  (2) At least two additional individuals who meet the following requirements:

    (a) One shall be at least:

      (i) A Specialty Care Paramedic; or

      (ii) A paramedic who has successfully completed an orientation to specialty care transport; and

    (b) One shall be a registered nurse, physician assistant, or physician with advanced training and certification in the care of specialty care patients and current knowledge of the EMS system as defined in Regulation .02G(3) of this chapter.

E. If an SCT service is not able to provide a staffed and equipped SCT ambulance within a clinically reasonable time as determined by the referring physician, it may conduct the SCT transport if:

  (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.

#### Regulation .05 Additional Requirements for Paramedic with Specialty Care Transport Training.

*COMAR 30.09.14.05*

A. The paramedic shall provide documentation to the licensed commercial ambulance service that they have successfully completed a specialty care transport course that meets the requirements of COMAR 30.04.03.

B. The medical director is responsible for credentialing the paramedic as required in COMAR 30.03.03.06.

C. The paramedic shall receive at least 36 hours of specialty care continuing education every 3 years.

#### Regulation .06 Additional Documentation Requirements for Specialty Care Transport Ambulance Services.

*COMAR 30.09.14.06*

The specialty care ambulance service shall maintain documentation on file for each individual providing patient care including:

A. Annual review of clinical competency in the skills required for the type that are transported; and

B. Proof of training on the use of the equipment necessary to care for and transport the patient, including those items in Regulation .04 of this chapter.

#### Regulation .07 Additional Equipment and Medication Requirements for Specialty Care Transport Ambulances.

*COMAR 30.09.14.07*

A. All specialized medical devices used during transport shall:

  (1) If provided by the hospital, be maintained by the hospital; or

  (2) If provided by the licensed commercial ambulance services be maintained as recommended by the manufacturer.

B. The licensed commercial service providing specialized medical devices used during transport shall maintain records documenting maintenance and repair services.

C. There shall be a means of communicating directly with the consulting specialty care physician and medical director.

D. All on-board medical devices shall be secured.

E. In addition to the equipment required in COMAR 30.09.10 and 30.09.11, the following shall be carried in a licensed ambulance when providing specialty care and shall be age and weight appropriate for the patient being transported:

  (1) A means of blending oxygen and air to deliver varying concentrations of medical oxygen;

  (2) One portable electric suction unit which:

    (a) Meets the criteria in COMAR 30.09.10.06B; and

    (b) Is adjustable down to 60 millimeters mercury (Hg);

  (3) Intravascular Equipment and Supplies:

    (a) Four infusion pumps or equivalent;

    (b) Six intravenous (IV) pump tubing sets;

    (c) Six extension sets;

    (d) Eight stopcocks;

    (e) Two blood infusion sets;

    (f) Two intravenous (IV) filters;

    (g) Eight total needles of assorted sizes ranging from 22 gauge to 18 gauge;

    (h) When transporting adult patients:

      (i) Two 1,000 cubic centimeter bags or equivalent of normal saline or Lactated Ringer's Solution;

      (ii) Two 1,000 cubic centimeter bags or equivalent of maintenance intravenous solution; and

      (iii) Twelve total syringes of assorted sizes ranging from 1 cubic centimeter to 60 cubic centimeters;

    (i) When transporting pediatric patients:

      (i) Two 250 cubic centimeter bags or equivalent of normal saline or Lactated Ringer's Solution;

      (ii) Two 250 cubic centimeter bags or equivalent of maintenance intravenous solution; and

      (iii) Twelve total syringes of assorted sizes ranging from 1 cubic centimeter to 2 cubic centimeters;

  (4) Ventilation and airway maintenance equipment and supplies capable of at least the following:

    (a) Oxygen concentrations between 21 and 100 percent;

    (b) Peak pressures between 0 and 99;

    (c) Adjustable inspiratory time;

    (d) Selectable intermittent mandatory ventilation (IMV);

    (e) Positive end expiratory pressure (PEEP) between 2—15 centimeters of water;

    (f) Adjustable ventilatory rates between 0 and 60 breaths per minute;

    (g) Adjustable tidal volume for adult patients between 200 milliliters and 1,000 milliliters or greater;

    (h) Adjustable tidal volume for pediatric patients as low as 50 milliliters;

    (i) Adjustable high and low pressure alarms; and

    (j) Two ventilator circuits;

  (5) Monitoring Equipment:

    (a) One cardiac monitor which meets the criteria of COMAR 30.09.11.03B;

    (b) Noninvasive blood pressure monitor;

    (c) Invasive blood pressure monitor;

    (d) End tidal carbon dioxide monitor with waveform display/recorder capable of providing quantitative reading; and

    (e) Oxygen saturation monitor;

  (6) Miscellaneous supplies and equipment:

    (a) When transporting adult patients:

      (i) One surgical and one needle crichthryotomy kit with transtracheal catheter ventilation system;

      (ii) Replacement tracheostomy tubes, one of each size 6 and 8 millimeters;

      (iii) One pleurevac;

      (iv) One electronic thermometer; and

      (v) Two surgical clamps capable of clamping up to a 40 french chest tube;

    (b) When transporting pediatric patients:

      (i) One surgical and one needle crichthryotomy kit with transtracheal catheter ventilation system;

      (ii) Replacement tracheostomy tubes one each size 1, 2, 3, and 4 millimeters, and age-appropriate size during transport;

      (iii) One pleurevac;

      (iv) One electronic thermometer; and

      (v) Two surgical clamps; and

  (7) Medications including:

    (a) All ALS medications listed in the Maryland Medical Protocols for Emergency Medical Service Providers; and

    (b) Additional medications approved for use by the specialty care service medical director to meet the needs of the types of patients being transported.

F. A list of the additional medications used by the specialty care service shall be provided to SOCALR and shall be available on each ambulance when in use for a specialty care transport.

G. SOCALR shall be notified in writing of any changes to the list of additional medications used by the specialty care transport service, other than a temporary change resulting from a medication shortage, within 7 days of the change.

H. There shall be sufficient quantities of medications to care for one patient for the longer of:

  (1) 1 hour; or

  (2) Two times the estimated time of transport.

I. If the ambulance is also licensed as a neonatal ambulance under COMAR 30.09.12, the vehicle does not need to carry duplicates of required items.