Republic of the PhilippinesDepartment ofHealth

HEALTH FACILITIES AND SERVICES REGULATORYBUREAU

ANNEX CA.O. No. 2018- 000i

ASSESSMENT TOOL FOR LICENSING A LAND AMBULANCE ANDAMBULANCE SERVICE PROVIDER

I. GENERAL INFORMATION

Name ofAmbulance Service Provider (ASP):

Complete Address:

EmailTel/Fax Nos: Address:

Name ofOwner:

Category:

E Type I - BLS Ambulance Cl Type 11— ALS Ambulance

Ownership:

E] Government: Cl Private

I: National |:l Single Proprietorship

El Local D Corporation

Others (specify) Others (specify)

Institutional Character:

D Institution-based [:l Non-institution-based/Free-Standing

Type of application:

El Initial Cl Renewal

DOH License Number (ASP):

DOH—A ASP-LTO-AT—Annex CRevisionIOO01/26/2018

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II. TECHNICALREQUIREMENTSInstruction: In the appropriate box, place a check mark (\/) if the ambulance or ambulance serviceprovider is compliant or X-mark ifnot compliant.

ANNEX CA.O. No. 2018- OOOI

1. Land Transportation OfficeRegistration under the name ofthe Ambulance Service Provider

For Institution-based:

Designated area that will housethe policies, files, records, etc. ofthe ASP and which shall serve asthe operations control anddispatch center of ambulance/s.

For Non-institution-based:

Operations control and dispatchcenter of ambulance/s whether itbe a business office or spaceASP office has adequate parkingspaces for the ambulance/s theyown (when applicable).

A. SERVICEDELIVERYEvery ambulance service provider shall ensure that the services delivered to patients comply with thestandard quality embodied in the Assessment Tool for licensure of land ambulances, other policy guidelinesand/or related issuances.

1. Documented policies andprocedures on:a. Administrative and technical

standard operatingprocedures (SOP) for theprovision of its services

b. Establishment of its referralsystem

For health facilities (ex.hospitals, infirmaries andbirthing facilities) withoutsourced ambulance services:

Notarized Memorandum ofAgreement (MOA) between thehealth facility and ASP

DOH-A ASP—LTO—AT-AnnexcRevision:0001/26/2018Page 2 of 12

ANNEX CA.O. N0. 2018- 000!

For Non-institution-based/ Free-Standing ambulance serviceproviders servicing the publicindependently:

Notarized Memorandum ofAgreement (MOA) with ahospital

3. Schedule of Retention andDisposal of Records and otherrelevant information

4. Quality Assurance Program5. Continuous Quality

Improvementa. Client satisfaction surveywith analysisb. Handling and resolution ofcomplaints

6. Copies of the clinical protocolfor each specific case

B. INFORMATIONMANAGEMENTEvery ambulance service provider shall maintain a system of communication, recording and reporting of thepatient’s condition as well as the results of examinations which may include electronic communications orotherwise allowed under RA. 8792 known as “Electronic Commerce Act of 2000.” Moreover, managementof data or information should be in adherence to RA. 10173 also known as the “Data Privacy Act of2012.”

1. Hospital Referral Form-completely and accurately filledout; kept secured andconfidential

2. Logbook - completely andaccurately filled out with thefollowing contents:

a. Name, sex and age of patientb. Name of attending physician(when applicable)

0. Origin and destinationd. Date and time of dispatch andreturn of ambulance

e. Reason for transfer/transportf. Disposition of patient

3. File of the Annual StatisticalReport (for renewal) -completely and accurately filledout

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ANNEX CA.O. N0. 2018- 000!

STANDARDS, TypeI

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C. ENVIRONMENTALMANAGEMENTEvery ambulance service provider shall ensure that the environment is safe for its patients and staffincluding members of the public as necessary and that the following measures and/or safeguards shall beobserved.

1. The ambulance shall be properlyventilated, lighted, clean andsafe.

2. Written plan and program ofproper disinfection andpreventive maintenance of theambulance vehicles

3. Adequate personal protectiveequipment (PPEs)

4. Procedures for the properdisposal of infectious wastes andtoxic and hazardous substancesin accordance with RA. 6969known as “Toxic and HazardousSubstances and Nuclear WastesAct” and other related policyguidelines and/or issuances

D. EQUIPMENT,MEDICINESAND SUPPLIESEvery ambulance shall have available and operational prescribed equipment, medicines and supplies.

1. There shall be a program forcalibration, preventivemaintenance and repair ofequipment, includingdecontamination anddisinfection.There shall be a contingencyplan in case of equipmentbreakdown and malfunction,especially during patienttransport.There shall be a program for themanagement of temperaturesensitive medication.

DOH-A ASP-LTO-AT-AnnexCRevision:0001/26/2018Page 4 of 12

ANNEX C50- No- 2.9185 0

,

, V Tylpel «\ TypeIllCéll’Itl ”

LTO PLATE OR CONDUCTION STICKER NUMBER:

E. AMBULANCE BODYAn ambulance vehicle shall be able to accommodate the patient, and the required number of personnel andequipment.

1. Safety non-porous partition(separating the driver and thebody of the ambulance

2. Electric (internal and external)supply bulbs

3. Overhead grab rail on theceiling on top of thepatient/stretcher

4. Inverter power source5. Licensed Ambulances shall bear

the following markings:a. Front: The reflectorized and

capitalized word“AMBULANCE” which isspelled out in reverse (mirrorimage). The height of eachletter shall be no less than 10centimeters and the wordshall be seen at least six (6)meters away.

b. Side: Each side of theambulance body shall havethe capitalized word“AMBULANCE” not lessthan 15 cm in height.

c. Rear: The reflectorized andcapitalized word“AMBULANCE” not lessthan 15 cm in height and theprescribed DOH ambulancelogo to be issued by theDOH once the applicationfor a license is approvedNo other signage or picturesoutside ofwhat is prescribed.(May opt to mount the blue“Star of Life” emblem onany part of the ambulancevehicle)

6. Adequate and stable cabinet/sthat can appropriately store therequired equipment, medicinesand supplies

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ANNEX CA.O. N0. 2018- 0001

STANDARDS ANDREQUIREMENTS

(AMBULANCE VEHICLE)Type I Type II , COMPLIANT REMARKS

7. Emergency Warning LightSystem and Siren-PublicAddress System

F. PERSONNELEach ambulance shall be manned by an adequate number of qualified, trained and competent staff to ensureefficient and effective delivery of quality ambulance services.

1. Minimum of two (2) ambulancepersonnel excluding the driver isrequired for every ambulancedispatched.

Each staff shall be trained from aDOH-recognized trainingprovider, in the following:

a. Standard First Aidb. Basic Life Supportc. Advanced Cardiac Life

gtSupport \ ._

’

. ,

d, Emergency Medical Starting CY 2020 Starting CYTechnician (EMT) onwards: 2020 onwards:

Tram??? W1” be m EMT Training- EMT Training-transztlon Basic Advanced

/ParamedicTraining

2. DriverThere shall be one (1) driver forevery shift. Each driver shallhave the following:

a. Valid professional driver’slicense

b. Certificate of Proficiencyfrom TESDA (NC 11)

3. Complete 201 files of eachpersonnel containing:

a. PRC IDb. Certificate ofTrainings attended

c. Job descriptiond. Notarized Contract ofEmployment

4. Schedule of duties or shift ofpersonnel

5. Staff development andcontinuing education program toupgrade the knowledge, attitudeand skills of staff

DOH-A ASP-LTO-AT-AnnexCRevision:0001/26/2018Page 6 of 12

ANNEX CA.O. No. 2018- ODQI

LIST OF EQUIPMENT,MEDICINESAND SUPPLIES‘Each amublance sahl b adquately equlpped with appropriate quipment’ediinsand suoplies.

"

A. ‘véfiiiléfidii 51a“Aiiwaymagma'

1. Suction apparatus and accessoriesa. Portable or Mounted Suction

Machineb. Flexible suction catheters

Fr. 5,8,12 and 142. Portable oxygen

equipment/installeda. Portable oxygen tank with

regulatorb. Oxygen mask No. 2,3 and 4

(for newborn, infant and adult)3. Bag valve mask resuscitator with

rebreather bag for adult, pediatricand infant

4. Endotracheal tubes (pedia andadult)

5. Airways (pedia and adult)6. Nebulizer with nebulizer kit7 Laryngoscope set (pedia and adult)

B. Monitoring and/or Defibrillation1. Defibrillator AED Manual with

cardiac monitor2. Defibrillator pads — disposable3. Sphygrnomanometer,Non-

mercurial- Pediatric cuff- Adult cuff

4. Stethoscope (pediatric and adult)C. ImmobilizationDevices

1. Rigid cervical collars (small,medium, large)

2. Firm padding or commercial headimmobilization device

3. Lower extremity traction devices(supporting slings, padding,traction strap)

4. Upper and Lower extremityimmobilization devicesa. Joint above and joint below

fractureb. Rigid-support appropriate

material (cardboard, metal, pneumatic,vacuum, wood or plastic)—various sizes

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ANNEX C

c. Resistant straps or cravatsd. Orthopedic (scoop)

stretcher/ Long back boardD. Dressings and Bandages

1. Sterile burn sheets2. Triangular bandages3. Sterile Dressings

a. lO”x30” or largerb. ABDs, 10”x12” or largerc. 4”x4” gauze spongesSterile gauze rolls (varioussizes)Non-sterile elastic bandages(various sizes)Sterile occlusive dressing3”x8” or largerAdhesive tape rolla. Various sizes of 2” or 3”

hypoallergenicb. Various sizes of 2” or 3”

non-hypoallergenic/ordinary

E. Obstetrical Delivery Set1. Sterile delivery kit2. Wrap / blanket for newborn

F. InfectionControl1. Eye protection (full peripheral

glasses or goggles or faceshield)

.N HEPA Masks / SurgicalMasksNon-sterile and Sterile GlovesJumpsuits or GownsShoe coversHand sanitizer or 70% alcohol

NQP‘PP’

Sharps container (punctureproof)

G. Miscellaneous1 . Blood Glucose Meter with

strips2. Thermometer, non-mercurial3. Heavy bandage or paramedic

scissors for cutting clothes,belts and boots

4. Alcohol swabs5. Heat and Cold packs or their

equivalent

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ANNEX CA.O. N0. 2018- 01

.M

6. Flash lights w1th extra batter1esand bulbs

7. Blankets, sheets, linen or paper8. Pillows, pillow case and towels9. Disposable emesis bags or

basins10. Bed pan1 1. Urinal12. Incontinence pads — disposable13. Lubricating jelly

H. CommunicationEquipmentCommunication devices exclusive forambulance use between the OPCEN,ambulance vehicles and referralfacilities which may be any of thefollowing:

1. Radio Licensed hand-held radio withbase station

2. Cellular PhoneI. Patient Transport

1. Ambulance wheeled cot withmounted cot fastening system

J. Injury Prevention Equipment1. Fire Extinguisher I

K. IV Therapy Supplies1. IV Administration set

(Macro/Micro)2. IV cannula (019, 20, 21, 23, 25,26)3. Syringes (50ml, 30ml, 10m1, 3ml lml)

L. Medicines / Fluids1. Activated Charcoal

Salbutamol nebules3. Sterile water for irrigation, 1

liter4. Sterile water for injection,

10ml5. Intravenous fluids

- D5 LRS 1 Liter- D5 NSS 1 Liter- D5 Water 1 Liter- D5 0.3NaCl 500ml- Plain LRS- Plain NSS

6. Normal saline water(injectable)

7. Dextrose 50%/50ml vial8. Plasma Expander

DOH-A ASP-LTO-AT-AnnexCRevision:0001/26/2018Page 9 of 12

ANNEX C

"

M. ControlledMedicationsSealed Drug / Code Box to be opened only under a Physician 0r Paramedics supervision.

This should be regularly checkedfor expired items by Physician-in—charge 0r Paramedics1. Atropine Sulfate 1mg/m1

ampuleE9 Epinephrine 1mg/1ml tubaxes

(1M, Intracardial, IV) ampuleDiazepam 10mg ampule/vialDobutamine 250mg ampuleLidocaine 1gm/25m1 VialAdenosine 6mg/2ml ampule

>19???“

Human Regular Insulin1 00mg/ml vial

8. Calcium Gluconate 10%1mg/1Oml ampule/Vial

9. Potassium Chloride20mg/10ml Vial

10. Furosemide 100mg/10m1 vialand 20mg/2ml ampule

11. Magnesium Sulfate 50%l gm/2ml ampule

12. Dopamine 400mg5m1 Viall3. Diphenhydramine 50mg/ml

ampule14. Sodium bicarbonate 10ml

ampule15. Digoxin 0.1mg/m1 ampule and

0.5mg/2ml ampule16. Nitroglycerine spray /

sublingual / patch17. Verapamil 5mg/2ml ampule

DOH-A ASP-LTO-AT-AnnexCRevisionzoo01/26/2018Page100f12

ANNEX C

Name ofAmbulance A°O' N0' 2018'Ml_Service Provider:Date of Inspection:

RECOMMENDATIONS:For Licensing

[ ] For Issuance of License To Operate as AMBULANCE SERVICE PROVIDER

Validity from to

LTO Plate or Conduction Sticker Number (Vehicle/s):1. 4.2. 5.3 6.*Use additional sheet/s if needed

[ ] Issuance depends upon compliance to the recommendations given and submission of the followingwithin days from the date of inspection

[ ] Non-issuance. Specify reason/s:

Inspected by:Printed name Signature Position/Designation

Received by:

Signature:

Printed Name:

Position/Designation:

Date:

DOH-A ASP-LTO-AT-AnnexCRevision:0001/26/2018Page 11 of12

Name ofAmbulance

ANNEX CA.O. N0. 2018- QQQ]

Service Provider:Date ofMonitoring:DOH License Number(ASP):LTO Plate or Conduction Sticker Number (Vehicle/s):

1.2.3.*Use additional sheet/s if needed

RECOMMENDATIONS:For Monitoring

[ ] Issuance ofNotice ofViolation

.V'

[ ] Non-issuance ofNotice ofViolation

[ ] Others. Specify

Monitored by:Printed name Signature Position/Designation

Received by:

Signature:

Printed Name:

Position/Designation:Date:

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