Commercial Ambulance Services. Annual Renewal & Inspection Application Packet NEONATAL SERVICE INFORMATION

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1 Maryland Institute for Emergency Medical Services Systems Office of Commercial Ambulance Licensing & Regulation 653 West Pratt Street Baltimore, MD Office: (410) Fax: (410) Commercial Ambulance Services Annual Renewal & Inspection Application Packet NEONATAL SERVICE INFORMATION Company Name: For Office Use Only Application Received / / Equipment Inspected / / Licenses Issued / / Page 1 of 8 Rev. 03/13

2 CAREFULLY READ THE INSTRUCTIONS AND COMPLETE ALL AREAS. Ensure all boxes are checked and the required documents included with the application submission. SUBMIT THE REQUIRED INFORMATION AND DOCUMENTS: Check if COMPLETE Completely answer all questions Sign and date the Certification on the last page Submit the original application electronically Submit legible copies of Governmental Identification for all those listed on application Submit completed application along with the following attachments: Signed Medical Director Agreement. Your company and the medical director must engage in a Medical Director Agreement. This document must be signed by the EMS operational program medical director acknowledging the responsibilities required under COMAR Title 30. A copy of this agreement is attached to this packet. Approved Neonatal Medication List. Ensure all current personnel are appropriately affiliated with your service. Sign and date the Application Page 2 of 8

3 COMPANY INFORMATION Name of Commercial Ambulance Service (registered with the Maryland DAT): SOCALR may not issue a license to an applicant whose name is confusingly similar to another doing business in Maryland Neonatal Medical Director Name: (Last, First) Maryland Physician License #: **MUST ATTACH COPY OF LICENSE** Address: Federal DEA License #: City, State, Zip Code: Address: **MUST ATTACH COPY OF LICENSE** **REQUIRED** Telephone Number: Cell Telephone Number: Fax Number: Hospital Program Affiliation: Has the Medical Director approved and signed the Medical Director Agreement? No Yes **MUST BE ATTACHED** Associate Neonatal Medical Director Name: (Last, First) Maryland Physician License #: **MUST ATTACH COPY OF LICENSE** Address: Federal DEA License #: City, State, Zip Code: Address: **MUST ATTACH COPY OF LICENSE** **REQUIRED** Telephone Number: Cell Telephone Number: Fax Number: Hospital Program Affiliation: Has the Medical Director approved and signed the Medical Director Agreement? No Yes **MUST BE ATTACHED** Page 3 of 8

4 Primary Perinatal / Neonatal Referral Center Name of Contact Person: Title: Office Number: Address: Cellphone Number: Street Address: Suite/Apt. Number: City, State, Zip Code: Fax Number: Secondary Perinatal / Neonatal Referral Center Name of Contact Person: Title: Office Number: Address: Cellphone Number: Street Address: Suite/Apt. Number: City, State, Zip Code: Fax Number: Third Perinatal / Neonatal Referral Center Name of Contact Person: Title: Office Number: Address: Cellphone Number: Street Address: Suite/Apt. Number: City, State, Zip Code: Fax Number: Page 4 of 8

5 1. Designation Number: Year / Make / Model: Licensed Neonatal Transport Units VIN Serial Number: Tag # Inspection Cert. Date Location Page 5 of 8

6 Neonatal Transport Personnel List Only list those personnel not already listed on the general Personnel List. If some or all of these individuals are hospital employees, you may attach a list provided by the hospital. Employee Full Legal Name (PRINTED) Work Time * <20 hr/wk or >20 hr/week (Circle one) Type of Health Care License or Certification (Circle what applies) Health Care Certification or License # State or states Licensed Certification or License Expiration Date <20 hrs >20 hrs EMT-B CRT EMTP RN NP Page 6 of 8

7 Owner Certification By my signature below I hereby affirm under the penalties of perjury that; (a ) There has been no attempt for the purpose of obtaining or attempting to obtain a license, to knowingly and willfully: (i) (ii) (iii) Falsify, conceal, or omit a material fact, Make any false, fictitious, incomplete, or fraudulent statements or representations, Make or use any false writing document, or entry knowing the same to contain any false, fictitious, fraudulent statement, and (b) The signer is authorized by the commercial ambulance service identified on the application to sign the application form to execute the sworn statement. Name of Applicant: (Last, First) Title: Signature: Date: Page 7 of 8

8 NEONATAL MEDICAL DIRECTOR AGREEMENT I, the undersigned physician, acknowledge that I have received and reviewed copies of the: (a) Commercial Ambulance Services regulations (COMAR 30.09); (b) Emergency Medical Services Operational Programs regulations (COMAR 30.03) and; (c) Maryland Medical Protocols for Emergency Medical Providers, which is a document incorporated by reference in Title 30. I further attest that I meet the qualifications of a Neonatal Commercial Ambulance Service Medical Director as stated in COMAR D(2) and agree to serve as a Neonatal Medical Director for (Name of ambulance service) upon its licensure as a(n) commercial ambulance service in accordance with the requirements of COMAR Furthermore, I agree to assume the following physician responsibilities as outlined in COMAR , including: (a) Medical direction for the neonatal service, (b) Medical direction to the commercial ambulance service s personnel related to neonatal care, (c) Medical oversight of patient care, (COMAR C (1) (a)). (d) Approve, participate in and provide medical expertise for the commercial ambulance service in: (i) A comprehensive quality assurance plan covering all aspects of EMS patient care (COMAR C(1)(b)(i)); (ii) Standard operating procedures for the EMS operational program under the Maryland Medical Protocols for Emergency Medical Providers (COMAR C(1)(b)(ii)); (iii) Credentialing of EMS providers (COMAR C(1)(b)(iv)); (iv) Review and approval of medical equipment used by the commercial ambulance service (COMAR C(1)(b)(v)); and (v) All aspects of the commercial ambulance service operations which impact patient care, including planning, development and operations (COMAR C(1)(b)(vi)). (e) Timely approval of applications to MIEMSS for licensure and certification and renewal of licensure and certification for all EMS providers affiliated with the above named commercial ambulance service, (COMAR C91)(c)). (f) Provision of training as required in neonatal care, and provider training including: (i) remedial and continuing educational programs (COMAR C(1)(iii)); and (ii) skills review which meets the provider recertification and relicensing requirements (COMAR E(2)). I agree to notify the State Office of Commercial Ambulance Licensing and Regulation of any change in address or telephone number and to notify the State Office of Commercial Ambulance Licensing immediately upon termination of my status as Medical Director for the above named service, as required in COMAR I acknowledge that all medical direction to the EMS providers of the above named commercial ambulance service, shall be in accordance with the Maryland Medical Protocols for Emergency Medical Services Providers (COMAR ). Printed Name of Medical Director: Date: Signature: Maryland Physician License #: Federal DEA License #: Page 8 of 8

9 Neonatal Checklist 2016 N/A DEF PASS N/A DEF PASS Standard Commercial Ambulance Equipment Airway Equipment Meets all of the requirements of the (1) Meconium aspirator BLS Equipment Checklist (1) Portable neonatal ventilator (1) Pulse oximeter with neonatal sensor Neonatal Equipment (1) Oxygen analyzer or blender (1) Neonatal Transport incubator (1) Neonatal Bag-Valve-Mask with Powered by internal batteries and Manometer and Alternating current and (1) Newborn mask Meets GSA standards for ambulance (1) Premature infant mask Litter fasteners and anchorages. (1) 00 Miller laryngoscope blade (1) Cardiorespiratory monitor/patient (1) 0 Miller laryngoscope blade with defibrillator (2) Sets of monitoring electrodes (1) 1 Miller laryngoscope blade (2) Sets of monitoring leads (1) Pediatric laryngoscope handle (1) Patient thermometer (2) ea ET tubes 2.5, 3.0, 3.5, 4.0 (4) Infant blankets (1)Stylette (1) Infant cap (1) Neonatal stethoscope (2) Chemically activated heat packs Spare battery and bulbs (unless fiberoptic) (1) BP monitor with (2) Heimlick valves (3) size neonatal cuffs (2) Pedi caps (2) Syringes 25cc or larger (2) Specimen traps (10) Syringes 1-10 cc (1) each neonate Tracheostomy Airway (2) 3-way stopcocks (1) each suction catheter 6, 8 and 10F (1) Ea 10F, 12F salem sump tubes (1) each nasopharyngeal 12 and 14F (1) 10F replogle tube (1) size 1 laryngeal mask airway (1) Sterile bowel bag Medications Isolette straps or securing system Ampicillin (10) Syringes 1-10 cc Atropine (2) 3-way stopcocks Calcium gluconate (1) each blood pressure cuff sizes 1-5 D5W 25cc or 500cc bags D10W 150cc or 250cc bags IV Equipment and Supplies Dextrose 50% (2) Lancets Dopamine (2) Neonatal armboards Epinephrine 1:10,000 (1) Blood product infusion set Gentamycin (10) sterile gauze pads, max size 2x2 Heparin (2) infusion pumps for each patient Naloxone hydrochloride (1) Umbilical vessel cath tray Normal saline for injection (2) ea 3.5F, 5F umbilical catheters Phenobarbital Site preparation materials Prostaglandin E1 (10) venipuncture needles 25g 18g Sodium Bicarbonate 4.2% (1) Bottle glucose strips and meter Sterile water for injection (2 each) angiocaths 24g, 22g, 20g, 18g Surfactant (3 each) butterfly needles 23g and 25g One of the following (60 ml) Albumin, Normal Saline, Lactated Ringers or Plasmanate Misc. Supplies (4) Surgical Lubricant Packets Nasal Cannula CPAP prongs 2 each 2.5, 3.0, 3.5, 4.0 (7) Saline bullets Portable Emergency Kit (1) Scissors (10) Sterile gauze pads 4x4 (2) Clamps (4) Triangular bandages Aqua + N (2) or humidification system (4) Rolls 4 roller gauze (1) Pneumo kit (4) Sterile trauma dressings (2 each) chest tubes 10F, 12F (1)Pocket mask with one-way valve (1) Thoracotomy kit (1) Set oropharyngeal airways (1) each Feeding tubes 6 or 6.5F and 8F (1) Pair bandage scissors Comments

10 Neonatal Checklist 2016 N/A DEF PASS N/A DEF PASS Onboard OXYGEN System: Onboard Suction (1) Cylinder 3,000 liter capacity or > Reliable power source Yr. Symbol psi Vacuum pressure >= 300 mmhg within four seconds: Line Pressure = 50 +/- 10 Free air flow >= 20 LPM: Line Pressure: psig (2) High flow wall outlets Adjustable suction force for children (1) Plug in flowmeter and intubated patients 5 LPM (4-6) (1) wide bore tubing 10 LPM ( ) (2) ea 5F, 8F, 10F suction catheters 15 LPM (13-17) Onboard AIR System: Portable Suction (1) Cylinder 3,000 liter capacity or > Operable for 20 continuous minutes Yr. Symbol psi Vacuum pressure >= 300 mmhg in four seconds: Line Pressure = 50 +/- 10 Line Pressure: psig Free air flow >= 20 LPM: 2) High flow wall outlets (1) wide bore tubing - attached Portable Oxygen System Battery powered 5 LPM (4-6) 10 LPM ( ) 15 LPM (13-17) All cylinders without a pressure gauge shall be appropriately tagged (1) Nongravity dependent flowmeter All cylinders shall be securely stored Using DOT approved devices Oxygen: Portable Cylinders: AIR: Portable Cylinders: E / D / Super D Yr Symbol psi E / D / Super D Yr Symbol psi 1) 1) 2) 2) Comments:

Commercial Ambulance Services SPECIALTY CARE TRANSPORT (SCT) APPLICATION

Commercial Ambulance Services SPECIALTY CARE TRANSPORT (SCT) APPLICATION Maryland Institute for Emergency Medical Services Systems Office of Commercial Ambulance Licensing & Regulation 653 West Pratt Street Baltimore, MD 21201-1536 Office: (410) 706-8511 - Fax: (410) 706-8552