Fillable Operation Type (North Carolina)

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Operation Type (North Carolina)

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SPECIALIZED AMBULANCE
PROTOCOL SUMMARY (SAPS)
This document has been developed to expedite the permitting and compliance process. A separate document should be completed for
each type of vehicle/mode of transportation operated in the program.
PROVIDER INFORMATION
Provider Name
Operation Type
System Affiliation
Agency Number
Program Coordinator
Phone
Email
Medical Director
Phone
Email
Ramp Inspections Require Mandatory Items – Spot Inspections Require a Full Inspection
– For NCOEMS Use Only –
VEHICLE INFORMATION
Type of Vehicle/Mode of Transport
Level of Service
VIN/FAA N#
Assigned Vehicle / Aircraft #
Chassis/Aircraft Manufacturer
Chassis/Aircraft Year
Box Manufacturer
Box Year
Fuel Type
Ambulance Type
4 x 4
Backup 911
NFPA / CAAS Certification Number
VIPER ID
INSPECTION SCORING
Missing an entire mandatory item may result in “Summary Suspension” or “Refusal of Permit.”
≤ 2 missing items = Satisfactory > 2 missing items = Unsatisfactory
INSPECTION DETAILS
Inspection Date
Inspection Location
Inspection Type
Permitting Compliance (Ramp) Compliance (Spot)
Inspection Results
Passed Failed Deficiencies Corrected During Inspection
Inspection Action
Permit Issued Permit Refused Summarily Suspended
Provider Representative
Personnel 1 P Number
Level
Paramedic AEMT EMT EMR Nurse Other
Personnel 2 P Number
Level
Paramedic AEMT EMT EMR Nurse Other
NCOEMS Regional Specialist
Date Entered into Continuum
Before implementation of an initial program or changes to equipment and medications lists, this document must be approved by the NC
Office of Emergency Medical Services.
I, as Medical Director, have reviewed this form and approve the content as submitted. I understand any missing equipment or medications
shall result in an unsatisfactory rating and shall be considered grounds for refusal or suspension of a permit by the NCOEMS inspector.
Medical Director Name: __________________________ Medical Director Signature: ___________________________ Date: ____________
– For NCOEMS Use Only –
Date Received by Regional Office: ______________________ Date Forwarded to State Medical Director: ___________________________
Approved:
Yes No Approved By: _____________________________________ State Medical Director’s Initials: ______________
Office of Emergency Medical Services
2707 Mail Service Center
Raleigh, NC 27699-2707
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GENERAL INSPECTION ITEMS
MANDATORY / REQUIRED EQUIPMENT
(Ground/Pediatric & Air Ambulances)
Mandatory Items (Automatic Failure)
Required Items (Continued)
0
2
Cylinder with Regulator (2 Sources)
ET Stylettes (Adult & Pediatric)
Suction Apparatus (2 Sources)
Endotracheal Tube Introducer (Adult & Pediatric)
Bag Valve Masks (Adult and Child Size Bags with Adult, Child, Infant, & Neonatal Masks)
IV Administration Sets (Micro/Macro)
Sphygmomanometer (Cuffs & Devices) (Pediatric, Adult, Large Adult)
IV Catheters (At Least 4 Sizes)
Stethoscope
Monitor / Defibrillator (Electrodes, Adult & Peds Pads, 12 Lead Capability)
Trauma Tourniquet
External / Transcutaneous Pacemaker
Blind Insertion Airway Device with Syringe (Adult & Pediatric Sizes)
Transvenous Pacemaker (Available in Program/Mission Specific)
Magill Forceps (Adult & Pediatric)
Intraosseous Device (Adult & Pediatric)
EtCO
2
Waveform Capnography/Capnometry Monitoring Device
Chest Decompression Needle (3” or Longer & 14 Gauge or Larger)
Surgical Cricothyroidotomy Airway Kit
Mechanical Ventilator
ET Handle (Extra Batteries & Bulbs if Applicable)
Copy of Protocols (Printed or Electronically Accessible)
ET Blades (Adult & Pediatric)
Fire Extinguisher
ET Tubes (Adult & Pediatric)
Required Items
Nasal Cannula (Adult & Pediatric)
Burn Sheet
Non-Rebreather with Tubing (Adult & Pediatric)
Cold Packs
Nebulizer
Dressings, Bandages, Roll Gauze
Nasopharyngeal Airways (Adult & Pediatric)
Triangular Bandages (At Least 2)
Oropharyngeal Airways (Adult & Pediatric)
Heavy Duty Scissors
Wide Bore Suction Tubing
Occlusive Dressing
Rigid Pharyngeal Suction Device
Lubricating Jelly
Suction Catheters (One Between 6FR & 10FR)
Thermal Blanket (Or Other Heat Conserving Device)
Suction Catheters (One Between 12FR & 16FR)
Thermometer (Low Temperature Capability)
Gastric Tubes
Triage System
Syringes (In at Least 3 Sizes)
Disinfectant Hand Wash/Sanitizer
Needles (Various Sizes, 1 Must be 1.5” for IM Injections)
Disinfectant for Cleaning Equipment
Alcohol Wipes
Disposable Biohazard Trash Bags
Sterile Saline Irrigation Solution
Infection Control Kit (Mask, Gown, Jumpsuit, Eye Protection, Shoe Covers)
Sterile OB Kit (Scissors/Scalpel, Bulb Suction, Cord Clamps)
Gloves (Latex Free)
Bulb Syringe (Separate from OB Kit)
Sharps Container (2 Sources)
Glucose Measuring Device
Emesis Collection Device
Pulse Oximeter (Adult & Pediatric)
Bed Pan (Ground/Peds Ambulances Only)
Pediatric Restraint Device (To Restrain <40lbs.)
Urinal (Ground/Peds Ambulances Only)
Pediatric Medication/Equipment System Guide
Pillow, Pillowcases, Sheets, & Towels (Ground/Peds Ambulances Only)
Ground / Pediatric Ambulances
Air Ambulances
Mandatory Items
Mandatory Items
CAAS / NFPA GVS Compliant (Current Standard)
Aircraft Body & Function (Patient & Crew Compartment)
Vehicle Body & Function
Appropriate Restraints for Crew & Non-Patients
Appropriate Restraints for Crew & Non-Patients
Internal Voice Communications (Rotor Wing Only)
Warning Devices (Lights & Siren)
Two Way Radio (For EMS Communications – Rotor Wing Only)
Mounted Two-Way Radio with Patient Compartment Controls
Litter with Adjustable Head Elevation
Interior Dimensions (Minimum 48” x 102”)
Survival Gear (Appropriate for Service Area & Number of Occupants)
Wheeled Cot with Securing Straps
Patient Compartment Lighting
Reflective Tape on All Sides
Heating & Cooling Source
Heating & Cooling Source
Provider Name Displayed on Each Side
Provider Name Displayed on Each Side
Required Items
Required Items
Equipment Secured in Patient Compartment
Equipment Secured in Patient Compartment
Medications & Fluid Kept in Climate Controlled Environment
Medications & Fluid Kept in Climate Controlled Environment
Exterior Cleanliness
Exterior Cleanliness
Interior Cleanliness
Interior Cleanliness
Required Medications / Medication Classes
(Ground & Air Ambulances)
Required Medications
Acetaminophen or NSAID
Epinephrine
Adenosine
Glucagon
Aspirin
Magnesium Sulfate
Atropine
Narcotic Antagonist
Calcium Chloride / Calcium Gluconate
Nitroglycerin
Diphenhydramine
Sodium Bicarbonate
Listed below are the REQUIRED and OPTIONAL medication classes for Specialty Care Transport Programs. Choose from the dropdown
list your “first” and “second” choices for the specific classes. If the medication of choice is not listed, provide the name of the medication
in the “Other Choice” space provided.
Required Medication Classes
(Program Drug Choice)
Medication Class
First Choice
Second Choice
Other Choice
Antiarrhythmic
Antiemetic
Benzodiazepine
Beta Agonist
Beta Blocker
Calcium Channel Blocker
Crystalloid Solution
Glucose Solution
Narcotic Analgesic
Steroid Preparation
Vasopressor
Paralytic
Induction Agent (for DAI)
Optional Medication Classes
Medication Class
First Choice
Second Choice
Other Choice
ACE Inhibitors
Antibiotics
Barbiturates
Histamine 2 Blockers
Immunizations
Non-Prescription Medications
Phenothiazines
Phenytoin Preparations
Proton Pump Inhibitors
Thrombolytic Agents
Topical Hemostatic Agents
Other Medications
(As approved by the North Carolina Medical Board for Paramedics)
Class
Medication
Class
Medication
DHHS/DHSR/EMS 4932
Revised 2/2022
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Operation Type (North Carolina)

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Completed 20 April 2022

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