RESTRICTED MOH STANDARDS FOR MEDICAL TRANSPORT SERVICE (2014) These standards are for the reference of agencies operating or intending to

Transcription

1 MOH STANDARDS FOR MEDICAL TRANSPORT SERVICE (2014) These standards are for the reference of agencies operating or intending to operate a Medical Transport Service (MTS). The standards spell out the minimum requirements which the agency must comply with when operating an MTS vehicle. Contents: 1. Definitions MTS Service Provider MTS Service Vehicle MTS Service Crew Composition Medical Transporter/Ambulance Driver Emergency Medical Technician Ambulance Paramedic Ambulance Nurse MTS Vehicle Equipment and Medical Equipment. 7 APPENDIX 1: Definition of Medical Emergency.. 8 APPENDIX 2: List of Approved Qualifications. 10 APPENDIX 3: List of Medical Equipment for MTS. 11 RESTRICTED 1

2 MEDICAL TRANSPORT SERVICE (MTS) STANDARDS 1. Definitions 1.1 Medical Transport Service or MTS means a conveyance, including a ground, air or sea craft, that is used or intended to be used for the transport of patient(s) (as described in section 1.2) accompanied by available, immediate and continuous medical care for such patient(s). 1.2 Suitable cases for MTS include:- a. Patients requesting for transport for elective outpatient clinic attendances or other hospital ambulatory services; b. Patients requesting for transport for other clinical services such as rehabilitation therapy, nursing care and/or day care in a community-based setting; c. Inter-hospital transfers of patients who are clinically stable; d. Patients discharged from hospital to home or a step-down facility such as a community hospital or a nursing facility; and e. Patients with medical conditions that do not fulfil the Ministry of Health (MOH) s criteria for medical emergencies (Appendix 1). 1.3 Non-emergency medical problems include:- a. Conditions that do not require immediate treatment and for which there is no imminent threat to the patient s life or limb; b. Pre-existing illnesses or injuries that are stable; and c. Pre-existing conditions that give rise to problems of ambulation and mobility. 1.4 MTS means a service provided that is available for the public for the conveyance of patients. 1.5 MTS Provider or MTSP means any entity that is recognised by MOH to operate MTS vehicles. 1.6 Emergency patient means a patient who has or sustains a medical emergency as defined in Appendix 1. Such patients include those being conveyed to emergency departments of hospitals for immediate attention or critically ill patients being transferred from one hospital to another for continuation of medical treatment. 2. Medical Transport Service Provider (MTSP) 2.1 All entities that provide or intend to provide the MTS must be recognised as MTSP by MOH. The MTSP must be a company or a business entity registered with the Accounting and Corporate Regulatory Authority or a bona fide registered RESTRICTED 2

3 voluntary or charitable organisation. 2.2 The MTSP must have the following to run the MTS: a. A qualified person (Singapore Medical Council registered medical practitioner, or Singapore Nursing Board registered Staff Nurse, as approved by the Director of Medical Services) engaged by the MTSP, to supervise and advise on the patient care provided and to ensure the required training, competency and certification of the MTS staff. b. A system compatible for communication with the Singapore Civil Defence Force (SCDF) or other designated medical dispatch system for ambulances. c. Written protocols of care for patients transported and a training programme to ensure the proficiency of MTS staff in carrying out these protocols in accordance with such standards/guidelines issued by the Director of Medical Services. d. MTS medical equipment and medical supplies as detailed in section 5. e. A system for performance monitoring, reporting and evaluation of the services provided. f. A medical record system and an MTS log system (manual and/or electronic recording system) for purposes of quality assurance and audit. g. Safety standards to ensure that patients and the MTS crew are protected from unnecessary risks as provided under any written law or as directed by the Land Transport Authority (LTA). 2.3 The MTSP shall have in place a system for infection control, including: a. Protocols for handling patients with infectious diseases, including instructions on appropriate action to take in the event of an exposure to blood or body fluids/substances including needle-stick injuries and other incidents. b. Protocols for training and use of Personal Protective Equipment (PPE) such as N95 mask, hair cover, gloves, gown/apron, face shield/goggles and disinfectants. c. Decontamination of vehicles after transport of patients with infectious diseases, or in the event of contamination by body fluids, and protocols for storage, transportation and disposal of waste in accordance with any written law or such standards/guidelines issued by the Director of Medical Services from time to time. d. Immunisations for vehicle crew as stipulated by MOH for health care workers. 2.4 The MTSP shall be subjected to a system of medical oversight as determined by MOH. This will include an audit of the MTSP as a service, including equipment audit, provider currency RESTRICTED 3

4 3. MTS Vehicle certification, transport record review and a proficiency assessment of providers. 3.1 Each MTS vehicle shall meet such vehicle specifications as may be prescribed by LTA, including any requirements for inspection and maintenance to ensure that the vehicle is fit for its purpose. 3.2 The minimum equipment in each vehicle shall be maintained as listed in section 5. Such equipment shall be functional and effective at all times when the MTS is in operation. 3.3 Each MTS vehicle shall bear the letterings MEDICAL TRANSPORT on the front, both sides and rear of the vehicle. 3.4 The MTS vehicle will not be permitted the use of sirens and beacon lights. [Note: All vehicles that are not recognised by MOH as emergency ambulances will be required to modify the lights and sirens in a way that precludes their usage once the legislation governing Emergency Ambulances and MTS vehicles is brought into force. (This may include physical dismantling, painting over of lights and disconnection of the wiring)] 4. MTS Crew 4.1 Each MTS shall be staffed by at least a 2-man crew: A Medical Transporter with one crew leader who is an Emergency Medicine Technician (EMT)/Paramedic/Nurse. 4.2 Medical Transporter/Ambulance Driver a. The Medical Transporter shall have the minimum qualifications/experience as follows: i. Possess a valid licence to drive the vehicle ii. Trained in defensive driving iii. Be currently certified in Cardio-Pulmonary Resuscitation (CPR) and Automated External Defibrillation (AED) by a National Resuscitation Council (NRC) - accredited agency iv. Understand the usage of stretchers and able to assist in the care of and evacuation of a patient/casualty 4.3 Emergency Medical Technician (EMT) a. The EMT shall be certified through an EMT course, approved by MOH (see Appendix 2). RESTRICTED 4

5 b. The EMT shall also be currently certified in Basic Cardiac Life Support (BCLS) and AED by an NRC-accredited agency and in first aid by an NRC- or a National First Aid Council- (NFAC) accredited agency. c. For MTS, the crew leader may also be an Enrolled Nurse with the Singapore Nursing Board and have clinical capability equivalent to or exceeding the Emergency Medical Technician (EMT) (see 4.3e below) including current Basic Cardiac Life Support (BCLS) and AED by an NRC-accredited agency. d. The EMT shall undergo recertification by agents approved by MOH at least once every two years. e. The EMT shall be able to: i. Use all equipment on board and be familiar with the relevant medical protocols. ii. Use various types of stretchers and body immobilisation devices. iii. Perform basic life support on infants, children and adults. Proficient with the use of bag valve mask. iv. Independently initiate the use of an AED. v. Perform standard first aid and give oxygen supplement. vi. Measure and monitor the patient s vital signs, i.e. pulse rate, blood pressure, temperature, respiratory rate and give SaO2. vii. Monitor intravenous peripheral lines and flow of drip of stable patients. viii. Transfer and maintain patients with nasogastric tubes, tracheostomy tubes, and/or urinary catheters. ix. Perform basic emergency procedures such as control of external bleeding and application of dressings, bandages, slings and splints. x. Establish contact with the receiving hospital if the need arises. xi. Appropriately use PPE and apply standard precautions to prevent the transmission of infectious agents during patient care. 4.4 Ambulance Paramedic a. The Ambulance Paramedic shall be qualified under a paramedic course approved by MOH (see Appendix 2). b. The Ambulance Paramedic shall also be currently certified in Basic Cardiac Life Support (BCLS) and AED by an NRCaccredited agency RESTRICTED 5

6 c. The Ambulance Paramedic shall undergo recertification by agents approved by MOH at least once every two years. d. The Ambulance Paramedic shall be able to: i. Assess and independently manage trauma and nontrauma emergencies in patients of all age groups within the framework of medical protocols provided by the Emergency Ambulance Service. ii. Organise and prioritise treatment and evacuation in multiple casualty incidents. iii. Use various types of stretchers and body immobilisation devices provided by the Emergency Ambulance Service. iv. Carry out emergency basic procedures to control external haemorrhage, apply dressings, bandages, slings and splints. v. Provide immediate care to casualties during the process of extrication and disentanglement from entrapments. vi. Assess and maintain the patient s airway, including the use of adjuncts such as the oropharyngeal airway or Laryngeal Mask Airway (LMA). vii. viii. Perform basic life support on infants, children and adults. Be currently certified in CPR and AED usage by an NRCaccredited agency. ix. Perform a 12-lead electrocardiogram, monitor the patient s electrical rhythm and transmit the 12-lead electrocardiogram to the receiving hospital, if appropriate and required. x. Independently initiate the use of an AED. xi. Obtain intravenous access, administer designated intravenous medications and perform intravenous infusions as per ambulance care protocols. xii. Obtain capillary blood glucose sample and institute treatment for hypoglycaemia. xiii. Assess and manage an emergency childbirth. xiv. Administer basic emergency medications including nebulisation. xv. Auscultate chest for abnormal chest sounds. xvi. Appropriately use PPE and apply standard precautions to prevent the transmission of infectious agents during patient care. xvii. 4.5 Ambulance Nurse Manage patients with nasogastric tubes, intravenous plugs or urinary catheters or other tubes and cannula. a. Must be a registered Staff Nurse with the Singapore Nursing Board and have clinical capability equivalent to or exceeding the Ambulance Paramedic (see 4.4d above), including current Basic Cardiac Life Support (BCLS)/AED certification. RESTRICTED 6

7 5. MTS Vehicle and Medical Equipment 5.1 Each MTS service vehicle shall contain the following vehicle and medical equipment:- a. Vehicle Equipment i. VHF Radio Network Communication or Mobile Phone or Other Ambulance to Hospital Communication Equipment ii. Fire Extinguisher iii. Current Singapore Street Directory or electronic equivalent iv. Passenger Seat and Safety Belts v. Attendant Seat and Safety Belts vi. Frosted or Tinted Side and Rear Window Glass (excluding the front side windows) vii. Any other equipment specified by MOH or any other authority b. Medical Equipment see Appendix 3 RESTRICTED 7

8 Appendix 1 DEFINITION OF MEDICAL EMERGENCY A Medical emergency is an injury or a condition of acute or sudden onset that poses an immediate threat to a person's life or long term health. These include bleeding, severe or increasing pain or a change in the vital signs of life, such as the level of consciousness or signs of difficulty in breathing. A chronic condition or a condition for which a patient is currently receiving treatment may suddenly deteriorate into a Medical emergency. An MTS vehicle should not be transporting such patients and an Emergency Ambulance should be called as soon as is practicable. Should an MTS vehicle, instead of an Emergency Ambulance, be wrongly called to attend to the case, basic life support and resuscitation should be provided until proper assistance (from Emergency Ambulance crew) arrives. Common Situations Involving Medical Emergencies Road traffic accident Industrial accident Fall from heights Mass casualties Transfer of critically ill patients between hospitals/nursing homes Severe burns Stroke Heart attack Poisoning Breathing difficulty from a variety of causes Altered mental states Common Causes of Medical Emergencies All limb or life threatening cases or any case of doubt Multiple injuries Large or open wound Head injury Fracture or dislocation Laceration, stabbing or other penetrating injury Burn (thermal or chemical) or scald Near-drowning, poisoning or suicide Bee and insect sting, snake or animal bite Acute coronary syndrome Haemorrhagic or ischaemic stroke or other acute neurological disorders Acute, non-traumatic surgical emergencies Examples of Medical Emergencies Acute chest pain, including angina or acute myocardial infarct Difficulty breathing Acute abdomen RESTRICTED 8

9 Internal bleeding, including haematuria, haematemesis or melena Loss of consciousness or acute change in mental state or behaviour Sudden onset weakness or paralysis Seizures Severe allergic reaction (anaphylaxis) Severe pain or increasing pain Sepsis NB The above descriptions serve only as a guide. Wherever possible, and in situations of doubt, appropriate medical advice should be sought from a registered medical practitioner. RESTRICTED 9

10 Appendix 2 LIST OF APPROVED QUALIFICATIONS 1. Emergency Medical Technician a. WSQ Higher Certificate for Emergency Medical Technician (effective 31 Dec 2014) b. Any other Emergency Medical Technician (Basic) qualification as approved by the Director of Medical Services from time to time 2. Paramedic a. Singapore Civil Defence Force (SCDF) or Singapore Armed Forces (SAF) Paramedic Level 3 or equivalent (SAF Medical Training Institute) b. Higher National Institute of Technical Education Certificate (NITEC) in Paramedic and Emergency Care c. Justice Institute of British Columbia (JIBC) Paramedic Academy s Primary Care Paramedic d. Nanyang Polytechnic Advanced Diploma in Paramedicine e. Any other Paramedic or Emergency Medical Technician (Intermediate) qualification as approved by the Director of Medical Services from time to time 3. Medical Transporter To have obtained all of the following: a. Valid driving license b. Current NRC-accredited CPR/AED certificate c. Certificate in Defensive driving issued by any of the driving centres below: i. Bukit Batok Driving Centre (BBDC) ii. Singapore Safety Driving Centre (SSDC) iii. ComfortDelGro Driving Centre (CDC) RESTRICTED 10

11 Appendix 3 MEDICAL EQUIPMENT FOR MEDICAL TRANSPORTS (Note: this list is aimed at describing the MINIMUM STANDARDS required, rather than to be a comprehensive, prescriptive list) A. Airway and Ventilation Equipment 1. Portable oxygen apparatus capable of metered flow with adequate tubing 2. Portable and fixed oxygen-supply equipment o Variable flow regulator 3. Oxygen-administration equipment o sizes), Adequate-length tubing; oxygen face mask (adult and child non-rebreathing mask (adult and child sizes), nasal cannulas 4. Bag-valve mask (manual resuscitator) o Hand-operated, self re-expanding bag; adult (>1000 ml) and child ( ml) sizes, with oxygen reservoir/accumulator; valve (clear, disposable); and mask (adult, child, infant, and neonate sizes) 5. Airways o Oropharyngeal (sizes 0 5; adult, child, and infant sizes) 6. Portable Pulse Oximeter B. Cardiac 1. Automated External Defibrillator (AED). The AED should have paediatric capabilities, including child-sized pads and cables C. Trauma Kit/Bag 1. Commercially packaged or sterile burn sheets 2. Triangular bandages (minimum of 2 safety pins each) 3. Elastic or crepe or gauze roll bandages of various sizes (large and small) 4. Sterile gauzes and pads (various sizes) 5. Adhesive tape (various sizes (including 1 and 2 in), hypoallergenic D. Miscellaneous 1. Sphygmomanometer/blood pressure monitor (paediatric and adult regular- and large-sized cuffs) 2. Ear thermometer or digital thermometer 3. Paramedic scissors for cutting clothing, belts, and boots 4. Flashlights 5. Blankets, trolley sheets or linens and pillows 6. Folding stretcher with restrainers 7. Patient care charts/forms 8. Canvas litter RESTRICTED 11

12 9. First Aid box (standard)/ Medical bag 10. Wheeled cot (conforming to national standard at the time of manufacture) E. Infection Control Kit/Bag 1. Eye protection (full peripheral glasses or goggles, face shield) 2. Face protection (for example, surgical masks per applicable local guidance) 3. Gloves, non-sterile 4. Coveralls or gowns 5. Hair covers 6. Shoe covers 7. Waterless hand cleanser, commercial antimicrobial (towelette, spray, liquid) 8. Disinfectant solution for cleaning equipment 9. Disposable trash bags for disposing of bio hazardous waste 10. Respiratory protection (for example, N95 or N100 respirator---per applicable local guidance) OPTIONAL EQUIPMENT This is intended to assist ambulance providers in choosing equipment that can be used to ensure delivery of quality pre-hospital care. Use should be based on certified capability of providers. 1. Traffic-signaling devices (reflective material triangles or other reflective, non-igniting devices) 2. Reflective safety wear for each crew member. 3. Stair chair or carry chair 4. Cervical collars o Rigid for children aged 2 years or older; child and adult sizes (small, medium, large, and other available sizes) 5. Head immobilisation device (not sandbags) o Firm padding or commercial device 6. Upper and lower extremity immobilisation devices o Joint-above and joint-below fracture (sizes appropriate for adults and children), rigid support constructed with appropriate material (cardboard, metal, pneumatic, vacuum, wood, or plastic) 7. Impervious backboards (long, short; radiolucent preferred) 8. Pulse oximeter with paediatric and adult probes 9. Saline drops and bulb suction for infants 10. Portable and fixed suction apparatus with a regulator. Wide-bore tubing, rigid pharyngeal curved suction tip; tonsillar and flexible suction catheters. 11. Disposable emesis bags or basins 12. Disposable bedpan 13. Disposable urinal 14. Arterial tourniquet RESTRICTED 12

13 PRE-HOSPITAL EMERGENCY CARE 2014 MEDICAL TRANSPORT SERVICE STANDARDS Frequently Asked Questions Medical Transport Service (Please refer to the 2014 Medical Transport Service Standards for more details) 1. What are Medical Transport Services? Ans: Medical Transport Services or MTS vehicles are modes of transport intended to be used for patients who do not require an emergency ambulance. Please refer to section 1.2 of the 2014 Medical Transport Service Standards for more details. The category of Non- Emergency Ambulance will be replaced by Medical Transport Services. 2. Why is the 2014 Medical Transport Service Standards introduced? Ans: Over the years, there have been instances of ambulances being ill-equipped and/or manned by poorly-trained personnel. Such deficiencies present a risk to patients in situations of medical emergencies. As reported in the media in November 2013, the private ambulance driver lied about having a driver s license to get the job. He lost control of the ambulance vehicle while speeding, resulting in the patient sustaining multiple injuries and subsequently dying. There have also been complaints of ambulances not being properly equipped with oxygen tanks and medical devices, malfunctioning of the Automated External Defibrillator, and of ambulances abusing their privileges, such as turning on their emergency lights and siren to get priority in traffic, when there is no emergency case on board. The 2014 Medical Transport Service Standard is introduced to ensure a higher standard of patient care and medical capability with enhanced proficiency requirements for the MTS crew and a revised list of equipment. Please refer to the 2014 Medical Transport Service Standard for more details. 3. Are there any specifications on naming and dimensions for the vehicle façade? Ans: The front, rear and both sides of the vehicle should indicate MEDICAL TRANSPORT. Wordings on the vehicle façade would be acceptable as long as they can be easily read. Please refer to the enclosed Annex for illustration. 4. Would there be references provided for the required protocols mentioned in sections 2.2 and 2.3 of the 2014 Medical Transport Service Standards? Ans: Guidelines will be provided to assist Private Ambulance Operators (PAOs) in developing their respective protocols for: a) Infection control; b) Management of patient records and vehicle log system (manual and/or electronic recording system); and c) Care for patients being transported. These guidelines serve to provide the minimum standards of care. PAOs should develop their own protocols based on these minimum standards, under the supervision of a qualified person (minimally a registered Staff Nurse under the Singapore Nursing Board for MTS vehicle). 5. What are the technical requirements that the MTS vehicle must meet? Ans: The Land Transport Authority (LTA) requires all vehicles, including MTS vehicles, to be registered for use in Singapore to comply with the registration and technical requirements et out in the Road Traffic Act and its subsidiary legislations. For more details on the technical requirements, including seat belts, exhaust emission standards, safety glass, etc, please 1

14 refer to the document Self-Import and Register A Goods Vehicle at LTA s OneMotoring wesite via the following url link: ew_vehicle/self_importation_.html On 2014 Medical Transport Service Standards - Manpower and Crew 1. Who are Emergency Medical Technicians (EMTs)? Where can I go to be certified as an EMT? Ans: EMTs is a category of healthcare workers with specific skill sets to handle patients with less acute/serious conditions as compared to Paramedics. For the purpose of EMT training and certification, the Workforce Development Agency (WDA), has launched a Workforce Skills Qualifications (WSQ) Higher Certificate in Pre-Hospital Emergency Medical Services for Emergency Medical Technician, conducted by SingHealth Alice Lee Institute of Advanced Nursing (IAN). The participant will receive the full certification of an EMT upon successful completion of this training. 2. Who are Medical Transporters (MTs)? Ans: Medical Transporters are drivers of emergency ambulances and MTS vehicles who need to fulfil the following requirements: (i) Possessing a valid driving license, (ii) Possessing a defensive driving certificate, and (iii) Being currently CPR-AED certified 3. Can individuals sign up for training courses without existing employment? Ans: Yes, individuals who have no prior experience, and are interested in a career in the prehospital care sector can register for WSQ Higher Certificate in Healthcare Support (PHEMS) as long as they meet the admission criteria. 4. What are the admission criteria and charges for the training courses? Ans: The list of recognised courses and institutions are stipulated in Appendix 2 of the 2014 Standards. Please refer to the respective institutions websites for their admission criteria and charges for these courses. 5. Are nurses under conditional registration allowed to practice in an MTS vehicle? Ans: With reference to section 4.3c of the 2014 Medical Transport Service Standards, an Enrolled Nurse with conditional registration is allowed to practice as crew leader in the MTS vehicle fleet for the organisation they are registered under. All requirements specific to the roles of crew members are stipulated in the 2014 Medical Transport Service Standards. 6. What are the recognised qualifications of foreign paramedics/emts? Ans: MOH is developing a framework to recognise the credentials of foreign paramedic/emt. More information will be released at a later date. For PAOs with existing Non-Emergency Ambulances 1. When will the 2014 Enhanced Standards come into force? Ans: PAOs are given until September 2017 to comply with the 2014 Enhanced Standards. PAOs can voluntarily comply with the 2014 Enhanced Standards starting September Why is there a long lead time between the release of 2014 Enhanced Standards and its implementation? 2

15 Ans: The long lead time allows PAOs sufficient time to ramp-up capabilities in manpower and medical equipment, to comply with the 2014 Enhanced Standards by September To assist PAOs in meeting the new manpower requirements, SingHealth Alice Lee Institute of Advanced Nursing (IAN), which is the provider for EMT training, will work with PAOs who may be interested to participate in healthcare job fairs to offer train and place positions. 3. Will non-emergency ambulance be required to de-register now that they are known as MTS? Ans: Should the non-emergency ambulance choose to a) Comply with the 2014 Enhanced Standards, LTA will update the vehicle s registration upon MOH s confirmation; or b) Discontinue the non-emergency ambulance service when the 2014 Enhanced Standards kick in, the PAO will no longer be allowed to provide emergency ambulance and medical transport services. 4. What happens if I cannot meet or I do not want to comply with the 2014 Enhanced Standards? Ans: By 2017, all PAOs of emergency ambulances and MTS vehicles must be licensed by the Ministry of Health. Unlicensed PAOs will no longer be allowed to provide ambulance and medical transport services. 5. What if I want to comply earlier with the new 2014 Enhanced Standards? Ans: PAOs are strongly encouraged to comply with the Enhanced Standards early so as to allow ample time for PAOs to level up their fleet and manpower to meet the 2014 Enhanced Standards. PAOs can voluntarily comply with the 2014 Enhanced Standards starting September MOH will conduct audits to assess if PAOs who voluntarily comply meet these standards. An MOH-issued documentary proof of compliance will be awarded to PAOs who have complied. More information on the voluntary compliance will be released at a later date. 6. How would VWOs, which operate emergency or non-emergency ambulances with volunteers, be regulated? Ans: Emergency or Non-Emergency Ambulances operated by VWOs will be required to meet the stipulated 2014 Emergency Ambulance and MTS Standards respectively. Implications to Operations 1. What are the implications for PAOs providing services listed in the directory or to healthcare institutions? Ans: The implications to PAOs are as such: (a) PAOs listed in the directory must ensure that their vehicles comply with the 2014 Enhanced Standards by September (b) All PHMCA-licensed Healthcare Institutions (including nursing homes) will only engage the services of emergency ambulances and MTS vehicles that have complied with the 2014 Enhanced Standards. More information will be release at a later date. 2. Section 2.2 of the 2014 Emergency Ambulance Standards indicates that a qualified person [is] to be engaged by the service providers to ensure the required training, competency and certification of the staff. Who does a qualified person refer to? Ans: PAOs running MTS vehicles will be required to minimally engage a Singapore Nursing Board registered Staff Nurse to provide oversight of MTS vehicles. 3. Can PAO engage Emergency Medicine (EM) specialists on a part-time basis (as opposed to full-time) to supervise and advise on the patient care provided? 3

16 Ans: Yes, PAO can engage part-time EM specialists, provided sufficient oversight is ensured. The PAO and the engaged EM specialist will be held accountable for any malpractice during the course of operations of the emergency ambulance. 4. Can EM specialists supervise more than one PAO? Ans: Yes, EM specialists can supervise more than one PAO, provided sufficient oversight is ensured. The PAO and the engaged EM specialist will be held accountable for any malpractice during the course of operations of the emergency ambulance. 4

17 Annex VEHICLE MOCK-UP FOR FAÇADE SPECIFICATION MEDICAL TRANSPORT 5