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

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, believes that the delivery of high-quality and effective EMS care is dependent on several factors, including but not limited to the presence of the following:

• providers who have been credentialed to ensure they demonstrate appropriate cognitive knowledge, affective ability, psychomotor skills, and critical thinking¹ ;

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

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

Several documents, including previous versions of this joint position statement, 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 US Department 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 previous 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 and territory rules and statutes for all 56 US states and territories. Our review identified that portions of either the 2014 document and/or state- and territory-level equipment lists required items that:

• are no longer clinically recommended because they have been demonstrated to be either harmful or lacking efficacy or have been replaced by clinically superior options. (eg, military antishock trousers [MAST], syrup of ipecac);

• are no longer correctly dichotomized to BLS versus ALS levels of care (eg, continuous positive airway pressure [CPAP], nebulized medications);

• fail to include equipment that evidence-based guidelines suggest should be available on ground ambulances (eg, commercial arterial tourniquets are currently lacking on 29 state and territory lists); and

• 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 and time consuming and can sometimes have unpredictable results and generate unintended consequences.

Our review of existing state and territory EMS equipment regulations revealed that 39 states and territories had statutory EMS equipment lists that were more than 5 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 position statement;

• 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 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 conduct 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 statement, “Pediatric Readiness in Emergency Medical Services Systems,” and also as a core performance measure by the US Department of Health and Human Services Health Resources and Services Administration through its EMS for Children (EMSC) Program.^8,9 

Furthermore, although 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 on the basis of a structured review of the National Model EMS Clinical Guidelines Version 2.2 to identify the equipment items necessary to deliver the care defined by those guidelines.⁶  In addition, to ensure congruity with national definitions of provider scope of practice, the list is differentiated into BLS and ALS levels of service by using the National Scope of Practice-defined levels of emergency medical responder (EMR) and emergency medical technician (EMT) as BLS and advanced emergency medical technician (AEMT) and paramedic as ALS.⁵  Equipment items listed within each category were cross-checked against recommended scopes of practice for each level 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 preventive maintenance and routine function checks; and

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

This document is intended to represent minimum essential equipment recommendations (Table 1) 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 and age of patients. Availability and use of appropriate pediatric-sized equipment is necessary, not discretionary.

   • a. Adult-sized items should not be substituted or adapted for use on pediatric patients except in cases in which available pediatric-focused equipment has malfunctioned and in which 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 on the basis of sound judgment and logic (eg, “portable reusable light source”) rather than on the basis of the presence of supporting evidence.

5. Several items were identified on review of existing state and territory equipment lists or in previous versions of this document that should no longer be carried on ground ambulances because of 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 statement.

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

7. Latex-free items should be used whenever possible and practical.

8. Specific medication recommendations have been removed from this minimum recommended equipment list because of the following:

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

   • b. 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

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

ALS

advanced life support

BLS

basic life support

EMS

emergency medical services