HB2405 - 492R

Be it enacted by the Legislature of the State of Arizona:

Section 1. Section 36-2201, Arizona Revised Statutes, is amended to read:

START_STATUTE36-2201. Definitions

In this chapter, unless the context otherwise requires:

1. "Administrative medical direction" means supervision of certified emergency medical technicians by a base hospital medical director, administrative medical director or basic life support medical director. For the purposes of this paragraph, "administrative medical director" means a physician who is licensed pursuant to title 32, chapter 13 or 17 and who provides direction within the emergency medical services system.

2. "Advanced life support base hospital" means a health care institution that offers general medical and surgical services, that is certified by the director as an advanced life support base hospital and that is affiliated by written agreement with a licensed ambulance service, municipal rescue service, fire department, fire district or health services district for medical direction, evaluation and control of emergency medical technicians.

3. "Ambulance" means any publicly or privately owned surface, water or air vehicle, including a helicopter, that contains a stretcher and necessary medical equipment and supplies pursuant to section 36‑2202 and that is especially designed and constructed or modified and equipped to be used, maintained or operated primarily for the transportation of individuals who are sick, injured or wounded or who require medical monitoring or aid. Ambulance does not include a surface vehicle that is owned and operated by a private sole proprietor, partnership, private corporation or municipal corporation for the emergency transportation and in‑transit care of its employees or a vehicle that is operated to accommodate an incapacitated or disabled person who does not require medical monitoring, care or treatment during transport and that is not advertised as having medical equipment and supplies or ambulance attendants.

4. "Ambulance attendant" means any of the following:

(a) A certified emergency medical technician whose primary responsibility is the care of patients in an ambulance and who meets the standards and criteria adopted pursuant to section 36‑2204.

(b) A first responder who is employed by an ambulance service operating under the provisions of section 36‑2202, and whose primary responsibility is the driving of an ambulance.

(d) A professional nurse who is licensed pursuant to title 32, chapter 15 and who meets the state board of nursing criteria to care for patients in the prehospital care system.

(e) A professional nurse who is licensed pursuant to title 32, chapter 15 and whose primary responsibility is the care of patients in an ambulance during an interfacility transport.

5. "Ambulance service" means a person who owns and operates one or more ambulances.

6. "Basic emergency medical technician" means a person who has been trained in specific emergency care in a basic emergency medical technician program certified by the director or in an equivalent training program and who is certified by the director as qualified to render services pursuant to section 36‑2205.

7. "Centralized medical direction communications center" means a facility that is housed within a hospital, medical center or trauma center or a freestanding communication center that meets the following criteria:

(a) Has the ability to communicate with ambulance services and emergency medical services providers rendering patient care outside of the hospital setting via radio and telephone.

(b) Is staffed twenty‑four hours a day seven days a week by at least a physician licensed pursuant to title 32, chapter 13 or 17.

8. "Certificate of necessity" means a certificate that is issued to an ambulance service by the department and that describes the following:

(a) Service area.

(b) Level of service.

(d) Hours of operation.

(e) Effective date.

(f) Expiration date.

(g) Legal name and address of the ambulance service.

(h) Any limiting or special provisions the director prescribes.

9. "Certified emergency medical technician" means an individual who has been certified by the department as a basic emergency medical technician, an intermediate emergency medical technician or an emergency paramedic.

10. "Council" means the emergency medical services care council.

11. "Department" means the department of health services.

12. "Director" means the director of the department of health services.

13. "Division" means the division of emergency medical services within the department.

14. "Emergency medical services" means those services required following an accident or an emergency medical situation:

(a) For on‑site emergency medical care.

(b) For the transportation of the sick or injured by a licensed ground or air ambulance.

(d) In the use of emergency receiving facilities.

(e) In administering initial care and preliminary treatment procedures by certified emergency medical technicians.

15. "Emergency medical services provider" means any governmental entity, quasi‑governmental entity or corporation whether public or private that renders emergency medical services in this state.

16. "Emergency paramedic" or "paramedic" means a person who has been trained in an emergency paramedic training program certified by the director or in an equivalent training program and who is certified by the director to render services pursuant to section 36‑2205.

17. "Emergency receiving facility" means a licensed health care institution that offers emergency medical services, that is staffed twenty‑four hours a day and that has a physician on call.

18. "First responder" as an ambulance attendant means a person who has been trained under the supervision of a qualified first responder instructor, who provides patient care and treatment in accordance with the United States department of transportation first responder curriculum and who meets all of the following requirements:

(a) Has successfully completed the United States department of transportation first responder national standard curriculum course.

(b) Has successfully completed the national registry first responder examination and has submitted proof of this fact to the person's current employer.

(c) Successfully completes the United States department of transportation first responder refresher national standard curriculum at least once every two years.

19. "Fit and proper" means that the director determines that an applicant for a certificate of necessity or a certificate holder has the expertise, integrity, fiscal competence and resources to provide ambulance service in the service area.

20. "Intermediate emergency medical technician" means a person who has been trained in an intermediate emergency medical technician program certified by the director or in an equivalent training program and who is certified by the director to render services pursuant to section 36‑2205.

21. "Medical record" means any patient record, including clinical records, prehospital care records, medical reports, laboratory reports and statements, any file, film, record or report or oral statements relating to diagnostic findings, treatment or outcome of patients, whether written or recorded, and any information from which a patient or the patient's family might be identified.

22. "Physician" means any a person who is licensed under the provisions of pursuant to title 32, chapter 13 or 17.

23. "Qualified first responder instructor" means a person tested and certified as a first responder instructor by the American red cross or the national safety council or an equivalent organization.

24. "Stretcher van" means a vehicle that contains a stretcher and that is operated to accommodate an incapacitated or disabled person who does not require medical monitoring, aid, care or treatment during transport.

25. "Suboperation station" means a physical facility or location at which an ambulance service conducts operations for the dispatch of ambulances and personnel and that may be staffed twenty‑four hours a day or less as determined by system use.

26. "Trauma center" means any acute care hospital that provides in‑house twenty‑four hour daily dedicated trauma surgical services.

27. "Trauma registry" means data collected by the department on trauma patients and on the incidence, causes, severity, outcomes and operation of a trauma system and its components.

28. "Trauma system" means an integrated and organized arrangement of health care resources having the specific capability to perform triage, transport and provide care.

29. "Wheelchair van" means a vehicle that contains or that is designed and constructed or modified to contain a wheelchair and that is operated to accommodate an incapacitated or disabled person who does not require medical monitoring, aid, care or treatment during transport. END_STATUTE

Sec. 2. Section 36-2202, Arizona Revised Statutes, is amended to read:

START_STATUTE36-2202. Duties of the director; qualifications of medical director

A. The director shall:

1. Appoint a medical director of emergency medical services.

2. Adopt standards and criteria for the denial or granting of certification and recertification of emergency medical technicians and deny certification of, certify and recertify emergency medical technicians. These standards shall allow the department to certify qualified basic emergency medical technicians and paramedics, without requiring completion of statewide standardized training required under section 36‑2204, paragraph 1 or passage of a standardized certification test required under section 36‑2204, paragraph 2, if the person holds valid registration with the national registry of emergency medical technicians, at the corresponding emergency medical technician level. A basic emergency medical technician or paramedic who is certified because the technician or paramedic holds a valid registration with the national registry of emergency medical technicians must complete the statewide standardized training required under section 36‑2204, paragraph 1 or pass the standardized certification test required under section 36‑2204, paragraph 2, within six months after the technician or paramedic is certified pursuant to this paragraph.

3. Adopt standards and criteria which that pertain to the quality of emergency care pursuant to section 36‑2204.

4. Adopt rules necessary to carry out the provisions of this chapter. Each rule shall identify all sections and subsections of this chapter under which the rule was formulated.

5. Adopt reasonable medical equipment, supply, staffing and safety standards, criteria and procedures for issuance of a certificate of registration to operate an ambulance.

6. Maintain a state system for recertifying emergency medical technicians, except as otherwise caused provided by section 36‑2202.01, that is independent from any national registry of emergency medical technicians recertification process. This system shall allow emergency medical technicians to choose to be recertified under the state or the national registry of emergency medical technicians recertification system subject to subsection G of this section.

B. After consultation with the emergency medical services care council the director may authorize pilot programs designed to improve the safety and efficiency of ambulance inspections for governmental or quasi‑governmental entities that provide emergency medical services in this state.

C. The rules, standards and criteria adopted by the director pursuant to subsection A, paragraphs 2, 3, 4 and 5 of this section shall be adopted in accordance with title 41, chapter 6, except that the director may adopt on an emergency basis pursuant to section 41‑1026 rules relating to the regulation of ambulance services in this state necessary to protect the public peace, health and safety in advance of adopting rules, standards and criteria as otherwise provided by this subsection.

D. The director may waive the requirement for compliance with a protocol adopted pursuant to section 36‑2205 if the director determines that the techniques, drug formularies or training make makes the protocol inconsistent with contemporary medical practices.

E. The director may suspend a protocol adopted pursuant to section 36‑2205 if the director does all of the following:

1. Determines that the rule is not in the public's best interest.

2. Initiates procedures pursuant to title 41, chapter 6 to repeal the rule.

3. Notifies all interested parties in writing of the director's action and the reasons for that action. Parties interested in receiving notification shall submit a written request to the director.

F. To be eligible for appointment as director of emergency medical services, the person shall be qualified in emergency medicine and shall be licensed as a physician in one of the states of the United States.

G. Applicants for certification shall apply to the director for certification. Emergency medical technicians shall apply for recertification to the director every two years. The director may extend the expiration date of an emergency medical technician's certificate for thirty days. The department shall establish a fee for this extension by rule. Certified emergency medical technicians shall pass an examination administered by the department as a condition for recertification only if required to do so by the advanced life support base hospital's medical director or the certified emergency medical technician's medical director.

H. The medical director of emergency medical services is exempt from the provisions of title 41, chapter 4, articles 5 and 6 and is entitled to receive compensation pursuant to section 38‑611, subsection A.

I. The standards, criteria and procedures adopted by the director pursuant to subsection A, paragraph 5 of this section shall require that ambulance services serving a rural or wilderness certificate of necessity area with a population of less than ten thousand persons according to the most recent United States decennial census have at least one ambulance attendant as defined in section 36‑2201, paragraph 4, subdivision (a) and one ambulance attendant as defined in section 36‑2201, paragraph 4, subdivision (b) staffing an ambulance while transporting a patient and that ambulance services serving a population of ten thousand persons or more according to the most recent United States decennial census shall have at least one ambulance attendant as defined in section 36‑2201, paragraph 4, subdivision (a) and one ambulance attendant as defined in section 36‑2201, paragraph 4, subdivision (a), (c), (d) or (e) staffing an ambulance while transporting a patient.

J. If the department determines there is not a qualified administrative medical director, the department shall ensure the provision of administrative medical direction for a certified basic emergency medical technician if the certified basic emergency medical technician meets all of the following criteria:

1. Is employed by a not‑for‑profit or governmental provider employing less than twelve full‑time basic emergency medical technician employees.

2. Stipulates to the inability to secure a physician who is willing to provide administrative medical direction.

3. Stipulates that the provider agency does not provide administrative medical direction for its employees. END_STATUTE

Sec. 3. Section 36-2204, Arizona Revised Statutes, is amended to read:

START_STATUTE36-2204. Medical control

The medical director of emergency medical services and the emergency medical services care council shall recommend to the director the following standards and criteria that pertain to the quality of emergency patient care:

1. Statewide standardized training, certification and recertification standards for all classifications of emergency medical technicians.

2. A standardized and validated testing procedure for all classifications of emergency medical technicians.

3. Medical standards for certification and recertification of training programs for all classifications of emergency medical technicians.

4. Standardized continuing education criteria for all classifications of emergency medical technicians.

5. Medical standards for certification and recertification of certified emergency receiving facilities and advanced life support base hospitals and approval of physicians providing medical control or medical direction for any level of emergency medical technicians who are required to be under medical control or medical direction.

6. Standards and mechanisms for monitoring and ongoing evaluation of performance levels of all classifications of emergency medical technicians, emergency receiving facilities and advanced life support base hospitals and approval of physicians providing medical control or medical direction for any level of emergency medical technicians who are required to be under medical control or medical direction.

7. Objective criteria and mechanisms for decertification of all classifications of emergency medical technicians, emergency receiving facilities and advanced life support base hospitals and for disapproval of physicians providing medical control or medical direction for any level of emergency technicians who are required to be under medical control or medical direction.

8. Medical standards for nonphysician pre‑hospital prehospital treatment and pre‑hospital prehospital triage of patients requiring emergency medical services.

9. Standards for emergency medical dispatcher training, including prearrival instructions. For the purposes of this paragraph, "emergency medical dispatch" means the receipt of calls requesting emergency medical services and the response of appropriate resources to the appropriate location.

10. Standards for a quality assurance process for components of the emergency medical services system, including standards for maintaining the confidentiality of the information considered in the course of quality assurance and the records of the activities of quality assurance process pursuant to section 36‑2401.

11. Standards for ambulance service and medical transportation that give consideration to the differences between urban, rural and wilderness areas.

12. Standards to allow an ambulance to transport a patient to a health care institution that is licensed as a special hospital and that is physically connected to an emergency receiving facility. END_STATUTE

Sec. 4. Section 36-2205, Arizona Revised Statutes, is amended to read:

START_STATUTE36-2205. Permitted treatment and medication; certification requirement; protocols

A. The director, in consultation with the medical director of emergency medical services, and the emergency medical services care council and the medical direction commission, shall establish protocols, which may include training criteria, governing the medical treatments, procedures, medications and techniques which that may be administered or performed by each class of emergency medical technician. These protocols shall consider the differences in treatments and procedures for regional, urban, rural and wilderness areas and shall require that intermediate emergency medical technicians, emergency paramedics and basic emergency medical technicians certified to perform advanced procedures render these treatments, procedures, medications or techniques only under the direction of a physician.

B. Certified emergency medical technicians, as defined in section 36‑2201, shall complete training certified by the director on the nature of sudden infant death syndrome in order to be certified by the director under this section.

C. The protocols adopted by the director pursuant to this section are exempt from title 41, chapter 6.

D. Notwithstanding subsection C of this section, a person may petition the director, pursuant to section 41‑1033, to amend a protocol adopted by the director.

E. In consultation with the medical director of emergency medical services, and the emergency medical services care council and the medical direction commission, the director of the department of health services shall establish protocols for emergency medical providers to refer and advise a patient or transport a patient by the most appropriate means to the most appropriate provider of medical services based on the patient's condition. The protocols shall consider the differences in treatments and procedures for regional, urban, rural and wilderness areas and shall require that intermediate emergency medical technicians, emergency paramedics and basic emergency medical technicians certified to perform advanced procedures render these treatments, procedures, medications or techniques only under the direction of a physician.

F. The protocols established pursuant to subsection E of this section shall include triage and treatment protocols that allow all classes of emergency medical technicians responding to a person who has accessed 911, or a similar public dispatch number, for a condition that does not pose an immediate threat to life or limb to:

1. Refer and advise a patient or transport a patient to the most appropriate health care institution, as defined in section 36‑401, based on the patient's condition, taking into consideration factors including patient choice, the patient's health care provider, specialized health care facilities and local protocols.

2. Provide a list of alternative sites available to deliver care. END_STATUTE

Sec. 5. Repeal

Sections 36-2203.01 and 36-2222, Arizona Revised Statutes, are repealed.

Sec. 6. Title 36, chapter 21.1, article 1, Arizona Revised Statutes, is amended by adding a new section 36-2222, to read:

START_STATUTE36-2222. Emergency care council; membership; duties

A. The emergency care council is established consisting of the following members:

1. The medical director of emergency medical services in the department of health services who shall serve as chairperson.

2. The director of the department of public safety or the director's designee.

3. One representative from the Governor's Office of Highway Safety. The governor shall appoint this member.

4. The following members who are appointed by the director of the department of health services:

(a) Four members representing the four local emergency medical services coordinating systems pursuant to section 36-2210.

(b) Four emergency physicians who are licensed pursuant to title 32, chapter 13 or 17 and who represent the four local emergency medical services coordinating systems pursuant to section 36-2210.

(d) One physician who is licensed pursuant to title 32, chapter 13 or 17 and who specialized in neurologic care.

(e) One professional nurse who is licensed pursuant to title 32, chapter 15 and who specializes in emergency medicine.

(f) Two hospital administrators, one of whom represents a county with a population of less than five hundred thousand persons according to the most recent United States decennial census.

(g) One representative from each of the three employers of the largest number of emergency medical technicians and paramedics in this state.

(h) One representative from the fire districts in this state.

(i) One physician who is licensed pursuant to title 32, chapter 13 or 17 and who specializes in trauma surgery.

(j) One representative of a prehospital emergency medical training program.

(k) One representative from a federal Indian health services organization.

(l) One representative from a statewide hospital association.

(m) One representative from an advanced life support base hospital that is not a trauma center.

(n) One representative from a statewide ambulance association.

(o) One full-time faculty representative of an emergency medicine residency program approved by a residency review commission.

(p) One physician who is licensed pursuant to title 32, chapter 13 or 17 and who specializes in pediatric medicine.

(q) One representative from the University of Arizona, Office of Rural Health.

(r) One physician who is licensed pursuant to title 32, chapter 13 or 17 and who specializes in toxicology.

B. Council members who are appointed by the director serve two year terms and may not serve consecutive terms.

C. Council members are not eligible to receive compensation but members who are appointed by the director are eligible for reimbursement of expenses under title 38, chapter 4, article 2.

D. The council shall make recommendations to the director regarding:

1. Medical protocols governing dispatch, triage, treatment, mode of transport and transport destination.

2. Medications and administration techniques that may be administered or performed by each class of emergency medical technicians.

3. Initial and renewal verification and designation processes of trauma centers levels, including evaluation of trauma center compliance criteria.

4. Development and implementation of comprehensive, regional, time‑sensitive injury and illness systems of care based on objective benchmarks.

5. Development of a comprehensive, nonpunitive and nondiscoverable emergency care quality assurance process encompassing dispatch, prehospital and hospital aspects of injury, illness and prevention.

E. On or before October 1 of each year, the council shall submit a written report of its accomplishments and recommendations to the director and shall submit a copy of this report to the secretary of state.

F. The chairperson shall appoint subcommittees as necessary to assist the council in meeting the requirements of this section, including the determination of issues relating to prevention, clinical care, pediatric care and quality improvement. END_STATUTE

Sec. 7. Section 36-2232, Arizona Revised Statutes, is amended to read:

START_STATUTE36-2232. Director; powers and duties; regulation of ambulance services; inspections; response time compliance

A. The director shall adopt rules to regulate the operation of ambulances and ambulance services in this state. Each rule shall identify all sections and subsections of this chapter under which the rule was formulated. The rules shall provide for the department to do the following:

1. Determine, fix, alter and regulate just, reasonable and sufficient rates and charges for the provision of ambulances, including rates and charges for advanced life support service, basic life support service, patient loaded mileage, standby waiting, subscription service contracts and other contracts for services related to the provision of ambulances. The director may establish a rate and charge structure as defined by federal medicare guidelines for ambulance services. The director shall inform all ambulance services of the procedures and methodology used to determine ambulance rates or charges.

2. Regulate operating and response times of ambulances to meet the needs of the public and to insure adequate service. The rules adopted by the director for certificated ambulance service response times shall include uniform standards for urban, suburban, rural and wilderness geographic areas within the certificate of necessity based on, but not limited to, population density, geographic and medical considerations.

3. Determine, fix, alter and regulate bases of operation. The director may issue a certificate of necessity to more than one ambulance service within any base of operation. For the purposes of this paragraph, "base of operation" means a service area granted under a certificate of necessity.

4. Issue, amend, transfer, suspend or revoke certificates of necessity under terms and conditions consistent with this article.

5. Prescribe a uniform system of accounts to be used by ambulance services that conforms to standard accounting forms and principles for the ambulance industry.

6. Require the filing of an annual financial report and other data. These rules shall require an ambulance service to file the report with the department not later than one hundred eighty days after the completion of its annual accounting period.

7. Regulate ambulance services in all matters affecting services to the public to the end that the provisions of so that this article may be fully carried out.

8. Prescribe bonding requirements, if any, for ambulance services granted authority to provide any type of subscription service.

9. Offer technical assistance to ambulance services to maximize a healthy and viable business climate for the provision of ambulances.

10. Offer technical assistance to ambulance services in order to obtain or to amend a certificate of necessity.

11. Inspect, at a maximum of twelve month intervals, each ambulance registered pursuant to section 36‑2212 to assure that the vehicle is operational and safe and that all required medical equipment is operational. At the request of the provider, the inspection may be performed by a facility approved by the director. If a provider requests that the inspection be performed by a facility approved by the director, the provider shall pay the cost of the inspection.

B. The director may require any ambulance service offering subscription service contracts to obtain a bond in an amount determined by the director that is based on the number of subscription service contract holders and to file the bond with the director for the protection of all subscription service contract holders in this state who are covered under that subscription contract.

C. An ambulance service shall:

1. Maintain, establish, add, move or delete suboperation stations within its base of operation to assure that the ambulance service meets the established response times or those approved by the director in a political subdivision contract.

2. Determine the operating hours of its suboperation stations to provide for coverage of its base of operation.

3. Provide the department with a list of suboperation station locations.

4. Notify the department at least thirty days before the ambulance service makes a change in the number or location of its suboperation stations.

D. At any time the director or the director's agents may:

1. Inquire into the operation of an ambulance service including a person operating an ambulance that has not been issued a certificate of registration or a person who does not have or is operating outside of a certificate of necessity.

2. Conduct on‑site inspections of facilities, communications equipment, vehicles, procedures, materials and equipment.

3. Review the qualifications of ambulance attendants.

E. If all ambulance services that have been granted authority to operate within the same service area or that have overlapping certificates of necessity apply for uniform rates and charges, the director may establish uniform rates and charges for the service area.

F. In consultation with the medical director of emergency medical services, and the emergency medical services care council and the medical direction commission, the director of the department of health services shall establish protocols for ambulance services to refer and advise a patient or transport a patient by the most appropriate means to the most appropriate provider of medical services based on the patient's condition. The protocols shall include triage and treatment protocols that allow all classes of emergency medical technicians responding to a person who has accessed 911, or a similar public dispatch number, for a condition that does not pose an immediate threat to life or limb to:

1. Refer and advise a patient or transport a patient to the most appropriate health care institution as defined by in section 36‑401 based on the patient's condition, taking into consideration factors including patient choice, the patient's health care provider, specialized health care facilities and local protocols.

2. Provide a list of alternative sites available to deliver care.

G. The director, when reviewing an ambulance service's response time compliance with its certificate of necessity, shall consider in addition to other factors the effect of hospital diversion, delayed emergency department admission and the number of ambulances engaged in response or transport in the affected area. END_STATUTE