Recommended Essential Equipment for Basic Life Support and Advanced Life Support Ground Ambulances 2020: A Joint Position Statement

Abstract

In continued support of establishing and maintaining a foundation for standards of care, our organizations remain committed to periodic review and revision of this position statement. This latest revision was created based on a structured review of the National Model EMS Clinical Guidelines Version 2.2 in order to identify the equipment items necessary to deliver the care defined by those guidelines. In addition, in order to ensure congruity with national definitions of provider scope of practice, the list is differentiated into BLS and ALS levels of service utilizing the National Scope of Practice-defined levels of Emergency Medical Responder (EMR) and Emergency Medical Technician (EMT) as BLS, and Advanced EMT (AEMT) and Paramedic as ALS. Equipment items listed within each category were cross-checked against recommended scopes of practice for each level in order to ensure they were appropriately dichotomized to BLS or ALS levels of care. Some items may be considered optional at the local level as determined by agency-defined scope of practice and applicable clinical guidelines. In addition to the items included in this position statement our organizations agree that all EMS service programs should carry equipment and supplies in quantities as determined by the medical director and appropriate to the agency’s level of care and available certified EMS personnel and as established in the agency’s approved protocols.

Key words:

• EMS
• equipment
• ambulance
• ALS
• BLS

Introduction

The National Association of EMS Physicians along with these coauthoring associations: American Academy of Pediatrics, American College of Surgeons Committee on Trauma, EMS for Children Innovation and Improvement Center, Emergency Nurses Association, and National Association of State EMS Officials, and as also endorsed by the National Association of Emergency Medical Technicians, believe that the delivery of high-quality and effective EMS care is dependent on several factors, including but not limited to the presence of:

• providers who have been credentialed to ensure they demonstrate appropriate cognitive knowledge, affective ability, psychomotor skills, and critical thinking (1)

• clinical protocols or guidelines that are supported by the best available scientific evidence

• equipment and supplies necessary to deliver appropriate care as directed by clinical protocols/guidelines for patients of all ages

Several documents, including previous versions of this joint position paper, the National Model EMS Clinical Guidelines Version 2.2, the 2018 National EMS Scope of Practice Model, the Clinical Credentialing of EMS Providers, Physician Oversight of Pediatric Care in Emergency Medical Services, Pediatric Readiness in Emergency Medical Services Systems, and core performance measures from the U.S. Dept of Health and Human Services Health Resources and Services Administration EMS for Children (EMSC) Program have been developed to lay the foundation of several of the concepts noted above (1–9).

Ensuring that EMS providers are properly equipped to perform their clinical duties is an important function of oversight in EMS systems. In the past this regulatory oversight has been based on the publication of minimum recommended equipment standards, including prior versions of this document (2–4). These efforts have attempted to provide a listing of the minimum items recommended for Basic Life Support (BLS) and Advanced Life Support (ALS) ground ambulances.

The field of EMS medicine continues to evolve and the EMS Scope of Practice Model continues to undergo important longitudinal revisions, reflecting ongoing improvements in clinical technology and practice (5). In effect, these advancements have caused many interventions, once limited to the scope of advanced providers, to begin transitioning into the scope of basic providers. Additionally, interventions that were once considered outside the scope of EMS medicine continue to find appropriate places in the EMS setting of care. These contemporary updates make the delivery of EMS-based interventions safer and easier for EMS providers to perform.

In 2019 our organizations undertook a review and revision of the 2014 version of this joint position statement. Part of this revision process also included review of equipment lists established by individual state/territory rules and statutes for all 56 U.S. states and territories. Our review identified that portions of either the 2014 document and/or state/territory-level equipment lists required items that:

• are no longer clinically recommended because they have been demonstrated to be either harmful, lacking efficacy, or have been replaced by clinically superior options. [ex: Military Anti Shock Trousers (MAST), syrup of ipecac];

• are no longer correctly dichotomized to BLS vs ALS levels of care [ex: CPAP, nebulized medications];

• fail to include equipment that evidence-based guidelines suggest should be available on ground ambulances [ex: Commercial arterial tourniquets are currently lacking on 29 state/territory lists]; and that

• require arbitrary quantities of items.

Establishing recommended equipment standards has value in helping build consistency across the EMS system of care. Documents such as this can be used to help guide both agency leadership and frontline staff in evaluating whether their agency is properly equipped to provide care that meets recommended community requirements. However, the process of creating and revising rules, statutes, and other legislative mechanisms at the state level of government is often onerous, time consuming, and can sometimes have unpredictable results and generate unintended consequences.

Our review of existing state and territory EMS equipment regulations showed that 39 states and territories had statutory EMS equipment lists that were more than five years old. Equipment lists should serve to facilitate advances in the delivery of quality and cost-effective EMS care, not to create a barrier to EMS system improvement and development. In light of this, we offer the following recommendation to governmental entities with jurisdiction involving the practice of EMS medicine–

Ensure that legislative and/or administrative mechanisms that establish equipment standards for ground ambulances:

• avoid requiring arbitrary minimum amounts of equipment list items;

• reflect expert and evidence-based recommendations such as those provided in this document;

• undergo review and updates at intervals not to exceed five years;

• do not create unnecessary barriers to implementation of new technology at the local level;

• allow for flexibility and adaptability in order to make rapid unplanned changes in response to unpredicted equipment or medication shortages affecting local EMS agencies; and

• reinforce that all EMS agencies should carry the age-appropriate equipment, supplies, and medications necessary for their clinical providers to effectively carry out patient care as defined by the clinical protocols and guidelines that are applicable to each agency.

It cannot be overemphasized that the mere presence of certain pieces of equipment on an ambulance does not equate to individual EMS provider competence in the use of that equipment or to an EMS program’s practice of high-quality and effective EMS medicine. In addition to establishing minimum equipment standards we also recommend that states consider establishing standards requiring local EMS agencies to demonstrate that their EMS providers are competent in their use of the equipment and supplies necessary to administer care within their scope of practice as defined or allowed by locally applicable clinical protocols or guidelines. Such assessment of provider competency in use of equipment has been established as a key component of EMS readiness in the joint position paper, Pediatric Readiness in Emergency Medical Services Systems, and also as a core performance measure by the U.S. Dept of Health and Human Services Health Resources and Services Administration through its EMS for Children (EMSC) Program (8, 9).

Furthermore, though the implementation of equipment lists at the state level is an important level of system oversight, it remains critically important that EMS agency medical directors evaluate that the equipment available on their agency’s ambulances is appropriate for the delivery of care and transport of both pediatric and adult patients in their service area. Each agency’s physician medical director should have direct involvement in the selection, approval, and deployment of the devices each agency chooses to fulfill both the clinical and regulatory equipment requirements that are germane to their agency.

In continued support of establishing and maintaining a foundation for standards of care, our organizations remain committed to periodic review and revision of this position statement. This latest revision was created based on a structured review of the National Model EMS Clinical Guidelines Version 2.2 in order to identify the equipment items necessary to deliver the care defined by those guidelines (6). In addition, in order to ensure congruity with national definitions of provider scope of practice, the list is differentiated into BLS and ALS levels of service utilizing the National Scope of Practice-defined levels of Emergency Medical Responder (EMR) and Emergency Medical Technician (EMT) as BLS, and Advanced EMT (AEMT) and Paramedic as ALS (5). Equipment items listed within each category were cross-checked against recommended scopes of practice for each level in order to ensure they were appropriately dichotomized to BLS or ALS levels of care. Some items may be considered optional at the local level as determined by agency-defined scope of practice and applicable clinical guidelines.

In addition to the items included in this position statement our organizations agree that, as modeled in the Iowa Administrative Code, “all EMS service programs shall carry equipment and supplies in quantities as determined by the medical director and appropriate to the agency’s level of care and available certified EMS personnel and as established in the agency’s approved protocols.” (10)

Finally, in addition to taking steps to determine that appropriate equipment is routinely available and that EMS providers are competent in using this equipment, our organizations also recommend that all EMS agencies include in their routine quality assurance practices efforts to evaluate that:

• their EMS providers are outfitted with all of the equipment necessary for them to perform clinical care;

• all equipment and supplies undergo appropriate preventative maintenance and routine function checks; and that

• malfunctioning or missing equipment issues are rapidly mitigated in order to preserve readiness to respond and provide patient care continuously.

List of Recommended Essential Equipment for Basic Life Support and Advanced Life Support Ground Ambulances, 2020

General Principles

This document is intended to represent minimum essential equipment recommendations and should not be used to limit the addition of items to a service’s repertoire. Carriage of items that supplement those listed herein should be based on local clinical and operational needs, including the needs of specialty transport teams, and should be left to the discretion of the physician medical director and other agency administrative and operational officers.

1. Equipment should always be appropriate for the size/age of patients. Availability and use of appropriate pediatric-sized equipment is necessary, not discretionary.

   • Adult-sized items should not be substituted or adapted for use on pediatric patients except where available pediatric-focused equipment has malfunctioned and where failure to provide further intervention by adapting an adult device for pediatric use would result in serious harm to the pediatric patient.

2. Several items that were included in previous versions of this list, including items previously listed as “optional,” are not included in this revision. Their absence from this list demonstrates lack of sufficient evidence to support inclusion of these items universally for all BLS and/or ALS ground ambulances but should not be interpreted to mean that such items should not be carried on any BLS and/or ALS ground ambulance. Local clinical protocols and scope of practice may dictate that such items are prudent and proper to carry.

3. Evidence supporting inclusion of specific items in this recommended equipment list is cited where available.

4. Certain items are included in this list based on sound judgment and logic (i.e. “portable reusable light source”) rather than based on the presence of supporting evidence.

5. Several items were identified on review of existing state/territory equipment lists or in previous versions of this document that should no longer be carried on ground ambulances due to evidence of harm or proven lack of efficacy. These items have been identified in a section that is new in this revision of this joint position paper.

6. Equipment specifications exist for several items contained in this document. The sources for those specifications are cited.

7. Latex-free items should be utilized whenever possible/practical.

8. Specific medication recommendations have been removed from this recommended equipment list due to the following:

   • The diversity of clinical protocols across the U.S., even across the same echelons of care, precludes development of an appropriately brief but comprehensive recommended medication list;

   • The frequency and unpredictable nature of medication shortages requiring frequent and rapid revision to local medication supplies preclude the development of a recommended medication list that would remain germane on a daily basis; and

   • The variability in the availability and use of therapeutic alternatives across EMS agencies precludes development of an appropriately brief but comprehensive recommended medication list.

Table

	BASIC LIFE SUPPORT (BLS)		ADVANCED LIFE SUPPORT (ALS) (All BLS equipment PLUS the following)
	All ages		All ages
CATEGORY	Adult-specific	Pediatric-specific	Adult-specific	Pediatric-specific
Airway, Ventilation, and Oxygenation	Oxygen supply, portable and on-board Devices capable of delivering oxygen in a titratable manner through nasal, partial face, or full-face mask routes in sizes to fit neonates through adults Oropharyngeal airways in sizes to fit neonates to adults Nasopharyngeal airways in sizes to fit neonates to adults Manual and/or powered suction device(s) with rigid oral and flexible pharyngeal/tracheal suction catheters in sizes to fit neonates to adults A device capable of providing non-invasive positive pressure ventilation (NIPPV) Self-inflating manual ventilation devices and masks to fit neonates to adults [11] [12]		Direct and/or Video laryngoscopy equipment appropriate for neonates to adults^a Magill forceps Supraglottic airways in sizes to fit neonates to adults^b
		PEDIATRIC SPECIFIC • Bulb suction
Bleeding, Hemorrhage Control, Shock Management, and Wound Care	Commercial arterial tourniquets Wound packing material^c Gauze sponges Adhesive bandages Adhesive tape Occlusive dressing (aka “chest seal”) Fluid for irrigation of wounds		ADULT SPECIFIC Chest Decompression needles 14g or larger diameter, minimum length 3.25 inches (8.25cm) or commercial chest decompression device [13] [14] [15] [16] [17] [18] [19]	PEDIATRIC SPECIFIC Chest Decompression needles: 14g diameter, maximum length 1.5 inches (3.8 cm) for patients less than 56 inches (144 cm) long [20] 23g diameter, maximum length 0.75 inches (2cm) for newborns
Cardiovascular & Circulation Care	Automatic External Defibrillator (AED) with adult and pediatric or combination pads		A device capable of performing automatic and/or manual defibrillation, cardiac rhythm monitoring (in at least three leads), 12 lead ECG acquisition, and transcutaneous pacing
Diagnostic Tools	Glucometer Pulse Oximeter with sensors to fit neonates to adults Stethoscope Blood Pressure Cuffs in sizes to fit neonates to adults Thermometer		Continuous waveform capnography
Infection Control	Items necessary for Universal & Standard Precautions [21] Waterless hand cleanser Sharps container Supplies for collection or absorption of patient vomit, urine, and/or feces Biohazardous materials collection bags Products appropriate for cleaning and disinfecting surfaces and equipment Items necessary for the following Transmission-based Precautions [22] [23] [24]: Contact precautions: examination gloves, eye protection, gowns Droplet precautions: surgical masks and eye protection Airborne precautions: N95 facemasks in provider-appropriate sizes AND eye protection OR Powered Air-Purifying Respirator (PAPR) General trash collection bags		No additional ALS recommendations
Medications	• Medications that are germane to approved agency BLS protocols		• Medications that are germane to approved agency ALS (and/or higher level) protocols
Medication Delivery and Vascular Access	Devices and supplies needed to administer medications via routes (Oral, Inhaled, Intramuscular, Intranasal) included in locally approved scope of practice and locally applicable protocol(s) and in sizes to fit neonates to adults Supplies for application of antiseptic to skin		Devices and supplies needed to administer medications via routes (Oral, Inhaled, Intramuscular, Intranasal, Intravenous, Intraosseous) included in locally approved scope of practice and locally applicable protocol(s) in sizes to fit neonates to adults Isotonic crystalloid fluids and administration tubing capable of adjustable fluid delivery rate A device to provide pressure infusion of IV fluids
		PEDIATRIC SPECIFIC Tools that provide pre- calculated weight-based dosing and preclude the need for calculation by EMS providers can reduce dosing errors. [25]		PEDIATRIC SPECIFIC A device suitable for administering a fluid bolus to pediatric patients that limits risk for inadvertent over-administration of fluid
Neonatal Care		PEDIATRIC SPECIFIC Newborn delivery supplies: 2 umbilical cord clamps Tool for cutting umbilical cord Bulb suction Infant head cover Towels Blanket Gauze dressings Material or device intended to maintain body temperature	No additional ALS recommendations
Orthopedic Injury Care	Splinting material or commercial devices for immobilization of orthopedic extremity injuries including but not limited to: Femoral splinting materials which may include either simple non-traction devices or devices that provide femoral traction.^d [26]^, [27] Pelvic splinting materials which may include either a commercial pelvic circumferential compression device (PCCD) designed specifically to splint the pelvis, or a dedicated bedsheet and towel clips to perform circumferential pelvic antishock sheeting [28] [29] [30] [31] [32] Cold packs Elastic bandages		No additional ALS recommendations
Patient Packaging, Evacuation, and Transport	Extrication board/device^e [33] Materials or devices that can be utilized to provide spinal motion restriction of the cervical, thoracic, and lumbar spine for neonates to adults Portable stretcher or litter Collapsible “stair chair” Wheeled multi-level gurney		No additional ALS recommendations
		PEDIATRIC SPECIFIC Pediatric-specific restraint system or age/size-appropriate car safety seat^f [34] [35]
Safety	Fire Extinguisher (5lb ABC) [36] ANSI Class 2 or 3 reflective vest or outerwear [37] Impact-resistant eye protection (ANSI Z87.1) [38] Nonflammable reflective and/or illuminated roadside warning devices Portable reusable light source		No additional ALS recommendations
Temperature Management and Heat-loss Prevention	Blankets Towels Heat packs		No additional ALS recommendations
Miscellaneous items	Bandage/trauma shears A device that allows for two-way communication between the field and EMS communications/dispatch centers, direct medical control, and receiving hospitals Triage Marking System (colored tape, tags, or other system) that is interoperable with other local healthcare system entities and that follows recommendations from the U.S. Dept of Health and Human Services Assistant Secretary for Preparedness and Response (ASPR) [39]		No additional ALS recommendations
Items that should no longer be carried on BLS or ALS ground ambulances due to evidence of harm or proven lack of clinical efficacy
Military Antishock Trousers (MAST), aka Pneumatic Antishock Garment (PASG) [40] Syrup of Ipecac [41]

^a Laryngoscopy equipment is included to facilitate ALS provider identification and mechanical removal of upper airway foreign bodies using Magill forceps, regardless of whether the ALS agency includes pediatric or adult endotracheal intubation within their ALS provider scope of practice.

^b Depending on locally approved scope of practice and locally applicable protocol(s) other invasive airways (endotracheal tubes, needle or surgical cricothyrotomy supplies) may also be carried but are not recommended to be universally required on all ALS ground ambulances.

^c Wound packing material may include plain gauze and/or hemostatic dressings.

^d Traction is not a necessary or required element of prehospital stabilization of suspected femur fracture(s) and is often contraindicated [26] [27].

^e Devices used for extrication, such as backboards, should not be used for transport. Whenever feasible, patients should be removed from extrication devices prior to transport. Spinal Motion Restriction can be maintained by securing the patient to the transport stretcher. [33].

^f Restraint devices should meet applicable crash-testing standards, as they are developed and published, and should appropriately meet individual patient weight, length, and developmental status needs [34] [35]