Pierce County EMS INSPECTION CHECKLIST
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- Joella Beasley
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1 Pierce County EMS Ambulance and Aid Service Rules & Regulations EQUIPMENT, SUPPLY & MEDICATIONS LIST INSPECTION CHECKLIST Agency Name: Agency DOH/EMS #: Inspector: Rep. Name: Vehicle ID: Date: This is the master list of equipment, supplies and medications. Jump packs or boxes shall be drawn from this master list. Items in bold type are state requirements. Items not in bold type are other Pierce County requirements. The county may exceed state requirements, these are underlined. asst =Assorted sizes/types. Ambulance Aid Vehicle AIRWAY MANAGEMENT Airway Adjuncts Oral airway, adult (asst sizes) 2 ea 2 ea 1 ea 1 ea Oral airway, pediatric (asst sizes) 2 ea 2 ea 1 ea 1 ea Nasopharyngeal airway, adult (sm, med, lg) 2 ea 2 ea 1 ea 1 ea ET tubes, adult (asst) (5, 6, 7, 7.5, 8) 2 ea -- 1 ea -- ET tubes, pediatric (asst) (2.5, 3, 3.5, 4, 4.5) 1 ea -- 1 ea -- Laryngoscope handle, spare batteries 1 ea -- 1 ea -- Adult Blades set, curved (2, 3, 4) straight (3) 1 ea -- 1 ea -- Pediatric Blades set, curved (2), straight (0, 1, 2) 1 ea -- 1 ea -- Video Laryngoscope/assist device (e.g. King Vision) optional optional Adjunctive airways; per protocol asst -- asst -- Supraglottic Airways per MPD protocol asst -- asst -- King LT (size 2, 2.5, 3, 4, 5, 6) or asst optional asst optional i-gel (size 3, 4, 5) asst optional asst optional McGill forceps, adult & pediatric 1 ea -- 1 ea -- Stylet, adult & pediatric 1 ea -- 1 ea -- Eschmann catheter (bougie ETT introducer) 1ea -- 1 ea -- Esophageal Detector Device (EDD) optional -- optional -- End-tidal CO2 detector 1 ea optional 1 ea optional Oxygen saturation monitor 1 ea optional 1 ea optional Water Soluble lubricant 3 ea 1 ea 1 ea 1 ea Catheters, IV (10 or 12 ga. x 3 ) 2 ea -- 2 ea -- Cricothyrotomy kit 1 ea -- 1 ea -- Scalpel 1 ea -- 1 ea -- Syringe (10 cc) 4 ea -- 2 ea -- N:\EMS\ALS\Inspection form\arrequip_&_arrmeds_inspec Rev_19 Jan 2018.doc 1
2 Suction Suction, portable 1 ea 1 ea 1 ea 1 ea Spare suction container 1 ea 1 ea 1 ea 1 ea Suction, vehicle mounted and powered, providing: minimum of 30 L/min. & vacuum>300 mm Hg 1 ea 1 ea Spare suction container 1 ea 1 ea Tubing, suction 1 ea 1 ea 1 ea 1 ea Rigid suction tips 2 ea 2 ea 1 ea 1 ea Bulb syringe, pediatric 1 ea 1 ea 1 ea 1 ea Catheters, suction (per local protocol) Adult (14 Fr or 16 Fr or 18 Fr x 22 ) 1 ea 1 ea 1 ea -- Pediatric (6, 8, 10 Fr) 1 ea 1 ea Nasogastric tube (14 or 16 Fr) 1 ea (8, 10 Fr) 1 ea Syringe, catheter tip (60 cc) 1 ea Oxygen Delivery Oxygen delivery system, built in 1 ea 1 ea L oxygen supply, with regulator, 500 PSI minimum, or equivalent liquid oxygen system (size M or larger) 1 ea 1 ea L oxygen cylinder, with regulator, 500 PSI minimum, or equivalent liquid oxygen system (size D or larger) 2 ea 2 ea 1 ea 1 ea Cannula, nasal, adult 4 ea 4 ea 2 ea 2 ea O2 mask, non-rebreather, adult 4 ea 4 ea 2 ea 2 ea O2 mask, non-rebreather, pediatric 2 ea 2 ea 1 ea 1 ea BVM with O2 reservoir, adult 1 ea 1 ea 1 ea 1 ea BVM with O2 reservoir, pediatric (child) 1 ea 1 ea 1 ea 1 ea BVM with O2 reservoir, infant 1 ea 1 ea 1 ea 1 ea CPAP (e.g. Pulmodyne) 1 ea 1 ea 1 ea 1 ea Nebulizer 2 ea -- 1 ea -- Meconium aspirator 1 ea -- optional -- PATIENT ASSESSMENT AND CARE Sphygmomanometer, adult, large (portable) 1 ea 1 ea 1 ea 1 ea Sphygmomanometer, adult, regular (portable) 1 ea 1 ea 1 ea 1 ea Sphygmomanometer, pediatric (portable) 1 ea 1 ea 1 ea 1 ea Stethoscope, adult 1 ea 1 ea 1 ea 1 ea Thermometer, per county protocol hypothermia and hyperthermia capable 1 ea 1 ea Thermometer, disposable covers 1 ea 1 ea 1 ea -- Flashlight w/spare or rechargeable batteries & bulb (e.g. penlight)1 ea 1 ea 1 ea 1 ea Cardiac Care: Defibrillation capability appropriate to the level of personnel Monitor/defibrillator (manual capable) with necessary supplies 1 ea -- 1 ea -- Automated External Defibrillator with necessary supplies -- 1 ea -- 1 ea N:\EMS\ALS\Inspection form\arrequip_&_arrmeds_inspec Rev_19 Jan 2018.doc 2
3 EKG/defibrillation Quik-Pads 2 ea -- 1 ea -- EKG paper 1 rolls -- 1 roll -- Electrodes, adult 10 sets -- 3 sets -- Needle, spinal (18 ga. x 3 ½ ) 1 ea -- 1 ea -- Automated mechanical chest compression devices, AHA and MPD approved AutoPulse, or optional optional optional optional LUCAS Device optional optional optional optional IV Access Intravenous Fluids per protocol D5W and/or D10W (IV Solution) optional -- optional -- Lactated Ringers (IV solution) 1000 cc optional -- optional -- Sodium Chloride 0.9% (IV solution) 1000 cc 4 ea -- 2 ea -- Sodium Chloride 0.9% (IV solution) 250 cc 1 ea -- 1 ea -- Administration Sets per protocol Adult (maxi-drip) 4 ea -- 2 ea -- Adult (mini-drip) 2 ea -- 2 ea -- Pediatric, volume control device, or 2 ea -- 1 ea -- 3-way stopcocks 2 ea -- 2 ea -- Catheters, intravenous (asst) (14 24 ga.), safety 2 ea -- 2 ea -- Needles, Hypodermic (asst), safety 6 ea -- 3 ea -- Needles, Intraosseous, per protocol (adult & pediatric) IO driver (optional) 1 1 Sharps container 1 ea 1 ea 1 ea 1 ea Syringes (asst) ~(1 cc, 5 cc, 10 cc, 20 cc) 4 ea -- 2 ea -- (60 cc or equivalent) 1 ea Nasal Medication Atomizer Device 2 ea 2 ea 2 ea 2ea Glucose measuring device (with supplies) 1 ea 1 ea 1 ea 1 ea Blood chemistry measurement device (e.g. istat) optional -- optional -- Pressure infusion device 1 ea -- optional -- Chlorhexidine preps optional optional optional optional Alcohol preps 12 ea 12 ea 12 ea 12 ea Provodine preps 12 ea ea -- Blood tubes, (asst color tops) optional -- optional -- Razor 1 ea 1 ea 1 ea 1 ea Dressings, transparent 12 ea -- 4 ea -- Tourniquets (IV type) 3 ea -- 3 ea -- Wound Care Bandage strips, self-adhesive asst asst asst asst Dressing, sterile asst asst asst asst Gauze pads, 4 x 4 12 ea 12 ea 12 ea 12 ea Dressing, sterile, trauma 2 ea 2 ea 2 ea 2 ea Dressing, occlusive 2 ea 2 ea 2 ea 2 ea Roller gauze bandage asst asst asst asst Tape, medical asst asst asst asst Hemostatic dressing (asst) optional optional optional optional N:\EMS\ALS\Inspection form\arrequip_&_arrmeds_inspec Rev_19 Jan 2018.doc 3
4 Tourniquet, commercial 2ea 2 ea 2 ea 2ea Cold packs 4 ea 4 ea 2 ea 2 ea Hot packs 2 ea 2 ea 2 ea 2 ea Scissors, bandage 1 ea 1 ea 1 ea 1 ea Irrigation solution 2 ea 2 ea 1 ea 1 ea Bandage, triangular 4 ea 4 ea 4 ea 4 ea Ring Cutter optional optional optional optional Splinting Backboard with straps 2 ea 2 ea 1 ea 1 ea Stretcher, scoop optional optional optional optional Backboard padding (e.g. Back Raft) optional optional optional optional Head immobilization equipment 1 ea 1 ea 1 ea 1 ea Pediatric Immobilization device 1 ea 1 ea 1 ea 1 ea Immobilizer, cervical/thoracic, adult (e.g. KED, OSS) 1 ea 1 ea Extrication collars, rigid Adult (small, medium, large) asst asst asst asst Pediatric or functionally equivalent sizes asst asst asst asst Splint, traction, adult with straps 1 ea 1 ea Splint, traction, pediatric with straps 1 ea 1 ea Splint, adult (arm and leg) 2 ea 2 ea 1 ea 1 ea Splint, pediatric (arm and leg) 1 ea 1 ea 1 ea 1 ea Pelvic stabilization device (e.g. PelvicBinder, SAM sling) optional optional optional optional PERSONAL INFECTION CONTROL GENERAL Personal infection control and protective equipment as required by the Department of Labor and Industries Yes Yes Yes Yes Gloves, exam, non-sterile, per size 1 box 1 box 1 box 1 box Gowns, disposable 2 ea 2 ea 2 ea 2 ea Shoe covers 4 ea 4 ea 2 ea 2 ea Eye protection, one per member, sized to fit 1 ea 1 ea 1 ea 1 ea HEPA filter, one per member, sized to fit 1 ea 1 ea 1 ea 1 ea Infectious waste container 1 ea 1 ea 1 ea 1 ea Masks, surgical 6 ea 3 ea 3 ea 3 ea Plastic sacks (regular and bio-hazard) 2 ea 2 ea 2 ea 2 ea Disinfectant spray 1 ea 1 ea 1 ea 1 ea Litter, wheeled, collapsible with a functional restraint system per the manufacturer 1 ea 1 ea Child Restraint System (e.g. Pedi-Mate) 1 ea 1 ea Limb Restraints, soft (e.g. Posey, Skil-Care) 1 ea 1 ea 1 ea 1 ea Pillows (plastic covered or disposable) 2 ea 2 ea Pillow cases (cloth or disposable) 4 ea 4 ea N:\EMS\ALS\Inspection form\arrequip_&_arrmeds_inspec Rev_19 Jan 2018.doc 4
5 Sheets (cloth or disposable) 4 ea 4 ea 2 ea 2 ea Blankets 2 ea 2 ea 2 ea 2 ea Towels, cloth or disposable, 12 x 23 minimum 4 ea 4 ea 2 ea 2 ea Emesis collection device 1 ea 1 ea 1 ea 1 ea Urinal 1 ea 1 ea Bed pan 1 ea 1 ea OB kit 1 ea 1 ea 1 ea 1 ea Communication Equipment, 1 ea* 1 ea* 1 ea* 1 ea* 2-way capable between vehicle and Dispatch & Medial Control (*if cell phones are used, there must be also be another method of radio contact with Dispatch & Medial Control) Forms and charts Pierce County Protocol per person, or on unit 1 ea 1 ea 1 ea 1 ea AHA Handbook (current edition) 1 ea 1 ea 1 ea 1 ea EMS EMIR forms (or agency-issued forms) or 10 ea 10 ea 10 ea 10 ea Portable computer for EPCR (if doing electronic charts) optional optional optional optional Patient AMA/Refusal-of-Care/ROR forms 2 ea 2 ea 2 ea 2 ea Length based tool for estimating pediatric medication and equipment sizes 1 ea 1 ea 1 ea 1 ea Triage identification for 25 patients per county protocol 25 ea 25 ea 25 ea 25 ea StatBand -SB Triage version EXTRICATION plan- Agency must document how extrication will be provided when needed. Provider must be able to articulate how to access extrication equipment MEDICATIONS according to local patient care protocols- See page 6 for Medications Storage and handling of pharmaceuticals in ambulances and aid vehicles must be in compliance with the manufacturers recommendations. Note: If a BLS agency is stocking Epinephrine 1:1000 in vials or ampules in place of EpiPen autoinjectors they must carry required supplies to draw up and administer the medication via syringe/needle. Ambulance Aid Vehicle BLS BLS Epinephrine 1:1000, 1mL ampule, or 2 ea 2 ea Epinephrine 1:1000, 1 ml vial 2 ea 2 ea Needles, Hypodermic (asst), safety 22 or 23 gauge needles ½ inch length for pediatric patients 2 ea 2 ea 5/8 1 inch length for adults 2 ea 2 ea 21 gauge filter needles to draw med from the ampule 2 ea 2 ea Sharps container 1 ea 1 ea Syringes (1 cc) 2 ea 2 ea Alcohol preps 2 ea 2 ea Chlorhexidine gluconate prep swab opt opt 2x2 gauze pads 2 ea 2 ea Bandage strips, self-adhesive 2 ea 2 ea N:\EMS\ALS\Inspection form\arrequip_&_arrmeds_inspec Rev_19 Jan 2018.doc 5
6 Pierce County EMS Minimum Stock of Medications Medication Strength ALS Amb BLS Amb ALS Aid BLS Aid Acetaminophen (Optional) tablets, gtts, susp, suppository 1 dose 1 dose 1 dose 1 dose Adenosine (Adenocard) 6 mg or 12 mg 18mg 18mg Afrin Spray bottle 1 1 Albuterol (Provental) 0.5 ml of 0.5% sol. in 2.5 ml NS 5 3 Amiodarone (Cordarone) (Optional) 150 mg 3 3 Aspirin 81 mg tablets Atropine 1 mg pre-load 3 3 Atropine MDV (Optional) 8 mg 20mL 1 0 Atropine Auto-injector (Optional) 2mg auto-injector 3 3 Calcium Chloride, or 10% 10mL pre-load 1 gm 1 1 Calcium Gluconate 10%, 100 mg/ml 30 ml 30 ml Cyanokit (Hydroxcobalamin) (Optional) 5 gm vial Note #1 Dexamethasone (Decadron) (Optional) 10 mg vial 1 1 Dextrose 5% (Optional) D5W 100 ml 2 1 Dextrose 10% (Optional or Note #2) D10W 250 ml 2 1 Dextrose 25% (Note #2) D25 Preload 2 1 Dextrose 50% (Note #2) D50 Preload 2 1 Diazepam (Valium) (Note #3 Optional) 10 mg 20 mg 20 mg Diltiazem (Cardizem) (Optional) 50 mg 50 mg 50 mg Diphenhydramine 50 mg 2 2 Dopamine 200 mg/5ml or pre-mix bag 1 1 Epinephrine 1:1,000 multi-dose vial 1 1 Epinephrine (Note #4), or 1:1000 1mg/1 ml vial or ampule Epinephrine Auto-injector (Note #4) Adult 0.3mg pen and Jr. 0.15mg pen 0 1 ea 0 1 ea Epinephrine 1:10,000 pre-load 6 6 Etomidate (Optional) 40 mg 40 mg 40 mg Fentanyl (Optional or Note #5) 100 mcg 300 mcg 300 mcg Glucagon 1mL/10 unit single dose 1 1 Glucose, Oral tube/packet- minimum 15 gm dose Ibuprofen (Optional) tablets, gtts, suspension 1 dose 1 dose 1 dose 1 dose Ipratropium (Atrovent) (Optional) 0.5 ml of 0.5% sol. in 2.5 ml NS 1 1 Ketamine (Optional) 500 mg 1 1 Lidocaine 100 mg/10 ml pre-load 3 3 Lidocaine (Optional) 1 gm for dilution or pre-mix bag 1 1 Magnesium Sulfate 5 gm 1 1 Methylprednisolone (SoluMedrol)(Optional) 125 mg 1 1 Midazolam (Versed) (Note #3 Optional) 5mg/mL or 10mg/2mL 20 mg 20 mg Morphine Sulfate (Note #5) 10 mg 2 2 Naloxone (Narcan) 0.4 mg - 2mg 10 mg 4 mg 4 mg 4 mg Nitroglycerine Spray or tablets, bottle 1 1 Nitrous Oxide (Nitronox) (Optional) Unit 1 1 Ondansetron (Zofran) (Optional) 8 mg ODT, 4 mg ODT, or vial 8 mg 8 mg Pralidoxime Chloride (Optional) 600 mg auto-injector 3 3 Rocuronium (Zemuron) (Optional or Note #6) 50 mg 2 1 Sodium Bicarbonate 1 meq/ml pre-load 2 1 Succinylcholine (Anectine)(Optional or Note #6) 200 mg (20 mg/ml) 10 ml 2 1 Vecuronium (Norcuron) (Optional) 10 mg 1 1 Xylocaine (Lidocaine), 2% jelly tube 1 1 Note # 1- Can be carried on the BC vehicle Note # 2- Must carry either 2 each Dextrose 50% and 25% preloads, or 2 D10w 250mL bags Note # 3- Must carry either 20 mg Diazepam (Valium) or 20 mg of Midazolam (Versed) Note # 4- Every licensed EMS service must make epinephrine (and supplies to administer it) available in every licensed ambulance and aid vehicle responding where an EMT might be the highest level of responder. Note # 5- Must carry either 20 mg of Morphine Sulfate or 300 mcg of Fentanyl Note # 6- Must carry either Succinylcholine or Rocuronium N:\EMS\ALS\Inspection form\arrequip_&_arrmeds_inspec Rev_19 Jan 2018.doc 6
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