WAC 246-976-161   Education requirements for certification.  (1) Education is required for the recertification of all certified EMS personnel. This education may be obtained by completing the continuing medical education (CME) method, or through the ongoing training and evaluation program (OTEP) method, identified below.

     (a) CME topic content:

     (i) Must meet annual and certification period educational requirements identified in Table A of this section, utilizing:

     (A) Cognitive, affective and psychomotor objectives found in curricula identified in WAC 246-976-021, for the level of certification being taught.

     (B) Current national standards published for CPR, foreign body airway obstruction (FBAO), and automatic defibrillation.

     (C) County medical program director (MPD) protocols, regional patient care procedures, and county operating procedures.

     (D) Training updates in standards as identified by the department.

     (ii) Must be approved by the MPD.

     (iii) May incorporate nationally recognized training programs as part of CME for content identified in (a)(i)(A) of this subsection.

     (b) To complete the CME method you must:

     (i) Complete and document the educational requirements, indicated in Table A of this section, appropriate to your level of certification.

     (ii) Complete and document the skills maintenance requirements, indicated in Table B of this section, appropriate to your level of certification.

     (A) IV starts for IV technicians, combined IV/airway technicians, ILS technicians, combined ILS/airway technicians, or paramedics:

     (I) During your first certification period, you must perform a minimum of one hundred eight successful IV starts.

     • During the first year, you must perform a minimum of thirty-six successful IV starts.

     • During the second and third year, you must perform a minimum of thirty-six successful IV starts per year, which may be averaged over the second and third years of the certification period.

     (II) If you have completed a certification period, you must demonstrate proficiency in starting IVs to the satisfaction of the MPD (see later certification periods in Table B of this section).

     (B) Endotracheal intubations for airway technicians, combined IV/airway technicians, combined ILS/airway technicians or paramedics:

     (I) During your first certification period, you must perform a minimum of thirty-six successful endotracheal intubations.

     • During the first year, you must perform a minimum of twelve successful endotracheal intubations of which four of the endotracheal intubations must be performed on humans.

     • During the second and third year, you must perform a minimum of twelve endotracheal intubations per year, which may be averaged over the second and third years of the certification period. Four of these endotracheal intubations per year must be performed on humans.

     (II) If you have completed a certification period, you must perform a minimum of four successful human endotracheal intubations per year, which may be averaged over the three-year certification period (see later certification periods in Table B of this section).

     (III) Upon approval of the MPD, individuals unable to complete the required endotracheal intubations during the certification period, may meet the endotracheal intubation requirements by completing a MPD and department-approved intensive airway management training program, utilizing cognitive, affective and psychomotor objectives covering all aspects of emergency airway management.

     (iii) Successfully complete the Washington state written examination and practical skills examination as identified in WAC 246-976-171.

     (c) Any applicant changing from the CME method to the OTEP method must meet all requirements of the OTEP method.

     (d) Ongoing training and evaluation programs:

     (i) Must meet annual and certification period educational requirements identified in Table A, utilizing:

     (A) Cognitive, affective and psychomotor objectives found in curricula identified in WAC 246-976-021, for the level of certification being taught, in the following core content areas:

     (I) Airway/ventilation (including intensive airway management training for personnel with advanced airway qualifications to determine competency).

     (II) Cardiovascular.

     (III) Medical emergencies/behavioral.

     (IV) Trauma (including intensive IV therapy training for personnel with qualifications to determine competency).

     (V) Obstetrics and pediatrics.

     (VI) Operations.

     (B) The current national standards published for CPR, foreign body airway obstruction (FBAO), and defibrillation and patient care appropriate to the level of certification.

     (C) County medical program director (MPD) protocols, regional patient care procedures, and county operating procedures.

     (D) Training updates in standards as identified by the department.

     (ii) Must provide cognitive, affective and psychomotor evaluations following completion of each topic presentation to determine student competence of topic content.

     Psychomotor skill evaluations must be recorded on skill evaluation forms from nationally recognized training programs, or on forms provided in approved curricula identified in WAC 246-976-021, for the level of certification being taught. If an evaluation form is not provided, a skill evaluation form must be developed and approved by the MPD to evaluate the skill.

     (iii) Must be approved by the MPD; any additions or major changes to an approved OTEP require documented approval from the county MPD and the department.

     (iv) Must be presented and evaluated by course personnel meeting the following qualifications:

     (A) Evaluators must:

     (I) Be a currently certified BLS or ALS provider who has completed at least one certification cycle. Certification must be at or above the level of certification being evaluated.

     (II) Complete an MPD approved evaluator's workshop, specific to the level of certification being evaluated, and teach proficiency in utilizing skill evaluation forms identified in (d) (ii) of this subsection;

     (III) Complete the evaluator application, DOH Form 530-012;

     (IV) Be approved by the county MPD and the department.

     (B) Instructors must:

     (I) Be a currently certified BLS or ALS provider who has completed at least one certification cycle at or above the level of certification being taught.

     (II) Be a currently approved evaluator at the level of certification being taught.

     (III) Be approved by the county MPD to instruct and evaluate EMS topics.

     (C) Guest lecturers, when utilized, must have specific knowledge and experience in the skills of the prehospital emergency care field for the topic being presented and be approved by the county MPD to instruct EMS topics.

     (v) May incorporate nationally recognized training programs within an OTEP for the core content areas identified in (d)(i)(A) of this subsection.

     (e) To complete the OTEP method you must:

     (i) Complete a department- and MPD-approved OTEP that includes requirements indicated in Table A of this section, appropriate to your level of certification.

     (ii) Complete and document the skills maintenance requirements, indicated in Table B of this section, appropriate to your level of certification.

     (A) IV starts for IV technicians, combined IV/airway technicians, ILS technicians, combined ILS/airway technicians, or paramedics:

     (I) During your first certification period, you must perform a minimum of thirty-six successful IV starts.

     • During the first year, you must perform a minimum of twelve successful IV starts.

     • During the second and third year, you must perform a minimum of twelve successful IV starts per year, which may be averaged over the second and third years of the certification period.

     (II) If you have completed a certification period, you must demonstrate proficiency in starting IVs to the satisfaction of the MPD (see later certification periods in Table B of this section).

     (B) Endotracheal intubations for airway technicians, combined IV/airway technicians, combined ILS/airway technicians or paramedics:

     (I) During your first certification period, you must perform a minimum of twelve successful endotracheal intubations.

     • During the first year, you must perform a minimum of four successful human endotracheal intubations.

     • During the second and third year, you must perform a minimum of four human endotracheal intubations per year, which may be averaged over the second and third years of the certification period.

     (II) If you have completed a certification period, you must perform a minimum of two successful human endotracheal intubations per year, which may be averaged over the three-year certification period (see later certification periods in Table B of this section).

     (C) Skills maintenance requirements may be obtained as part of the OTEP.

     (D) Individuals participating in an OTEP meet skill maintenance requirements by demonstrating proficiency in the application of those skills to the county MPD during the OTEP.

     (f) Any applicant changing from the OTEP method to the CME method must meet all requirements of the CME method.

     (g) Education requirements for recertification - Table A:

TABLE A: EDUCATION REQUIREMENTS FOR RECERTIFICATION	Basic Life Support		Intermediate Life Support (EMT-Intermediate Levels)					Paramedic (ALS)
	FR	EMT	IV	Air	IV/Air	ILS	ILS/Air	Paramedic
Annual Requirements
CPR & Airway	X	X	X	X	X	X	X
Spinal Immobilization	X	X	X	X	X	X	X
Patient Assessment	X	X	X	X	X	X	X
Certification Period Requirements
Infectious Disease	X	X	X	X	X	X	X	X
Trauma		X	X	X	X	X	X	X
Pharmacology		X	X	X	X	X	X
Other Pediatric Topics	X	X	X	X	X	X	X	X
*Additional education course hours totaling:	15 hrs	30 hrs	45 hrs	45 hrs	60 hrs	60 hrs	75 hrs	150 hrs

	"X" indicates an individual must demonstrate knowledge and competency in the topic or skill.
	*Individuals obtaining education through the CME method must complete the total number of educational course hours indicated above. However, due to the competency-based nature of OTEP, fewer class hours may be needed to complete these requirements than the total course hours indicated above.

     (h) Skill maintenance requirements - Table B:

TABLE B: SKILLS MAINTENANCE REQUIREMENTS		Intermediate Life Support (EMT-Intermediate Levels)					Paramedic (ALS)
		IV	Air	IV/Air	ILS	ILS/Air	Paramedic
First Certification Period
• First Year of Certification
IV Starts
	Continuing Education Method may not be averaged	36		36	36	36	36
	OTEP Method	12		12	12	12	12
Endotracheal intubations (4 must be performed on humans for each method)
	Continuing Education Method may not be averaged		12	12		12	12
	OTEP Method		4	4		4	4
Intraosseous infusion placement		X		X	X	X	X
• Second and Third Years of Certification
• Annual Requirements
IV Starts*
	Continuing Education Method	36		36	36	36	36
	OTEP Method	12		12	12	12	12
Endotracheal intubations* (4 per year must be performed on humans for each method)
	Continuing Education Method		12	12		12	12
	OTEP Method		4	4		4	4
Intraosseous infusion placement		X		X	X	X	X
• During the Certification Period
Pediatric airway management			X	X		X	X
Multi-lumen airway placement					X	X
Defibrillation					X	X
Later Certification Periods
• Annual Requirements
IV Starts		X		X	X	X	X
Endotracheal intubations (2 per year must be performed on humans for each method)
	Continuing Education Method		4	4		4	4
	OTEP Method		2	2		2	2
Intraosseous infusion placement		X		X	X	X	X
• During the Certification Period
Pediatric airway management			X	X		X	X
Multi-lumen airway placement					X	X
Defibrillation					X	X

	"X" indicates an individual must demonstrate proficiency of the skill to the satisfaction of the MPD.
	*The second and third year requirements may be averaged over the two years.

     (i) Skill maintenance requirements for individuals requesting reciprocal certification:

     (i) Reciprocity candidates credentialed less than three years must meet Washington state's skill maintenance requirements for the initial certification period identified above.

     (ii) Reciprocity candidates credentialed three years or more must meet Washington state's skill maintenance requirements for second and subsequent certification periods.

     (iii) The county MPD may evaluate an individual's skills to determine if the individual is proficient in the application of those skills prior to recommending certification. The MPD may recommend an individual obtain specific training to become proficient in any skills deemed insufficient by the MPD or delegate.

     (j) Description of selected terms used in Tables A and B:

     (i) Class hours: Actual hours spent to become knowledgeable in a topic(s) or proficient in a skill(s).

     (ii) Course hours: The predetermined time scheduled to conduct a course or topic.

     (iii) CPR and airway management includes foreign body obstruction (FBAO) and the use of airway adjuncts appropriate to the level of certification, for adults, children and infants following national standards, assuring the following pediatric objectives are covered.

     Pediatric objectives - The EMS provider must be able to:

     (A) Identify and demonstrate airway management techniques for infants and children.

     (B) Demonstrate infant and child CPR.

     (C) Demonstrate FBAO technique for infants and children.

     (iv) Endotracheal intubation: Proficiency includes the verification of proper tube placement and continued placement of the endotracheal tube in the trachea through procedures identified in county MPD protocols.

     (v) Infectious disease: Infectious disease training must meet the requirements of chapter 70.24 RCW.

     (vi) Intraosseous infusion: Proficiency in intraosseous line placement in pediatric patients.

     (vii) IV starts: Proficiency in intravenous catheterization performed on sick, injured, or preoperative adult and pediatric patients. With written authorization of the MPD, IV starts may be performed on artificial training aids.

     (viii) Multi-lumen airway placement: Proficiency includes the verification of tube placement and continued placement of the multi-lumen airway through procedures identified in county MPD protocols.

     (ix) Other pediatric topics: This includes anatomy and physiology and medical problems including special needs patients appropriate to the level of certification, assuring the following pediatric objectives are covered.

     (A) Anatomy and physiology - The EMS provider must be able to:

     (I) Identify the anatomy and physiology and define the differences in children of all ages.

     (II) Identify developmental differences between infants, toddlers, preschool, school age and adolescents, including special needs children.

     (B) Medical problems including special needs patients - The EMS provider must be able to:

     (I) Identify the differentiation between respiratory distress and respiratory failure.

     (II) Identify the importance of early recognition and treatment of shock in the infant and child patient.

     (III) Identify causes and treatments for seizures.

     (IV) Identify life-threatening complications of meningitis and sepsis.

     (V) Identify signs and symptoms of dehydration.

     (VI) Identify signs and symptoms of hypoglycemia.

     (VII) Identify how hypoglycemia may mimic hypoxemia.

     (VIII) Identify special needs pediatric patients that are technologically dependant (tracheotomy tube, central line, GI or feeding tubes, ventilators, community specific needs).

     (IX) Identify the signs and symptoms of suspected child abuse.

     (X) Identify the signs and symptoms of anaphylaxis and treatment priorities.

     (XI) Identify the importance of rapid transport of the sick infant and child patient.

     (x) Patient assessment: This includes adult, pediatric and geriatric patients appropriate to the level of certification, assuring the following pediatric objectives are covered.

     Pediatric objectives - The EMS provider must be able to:

     (A) Identify and demonstrate basic assessment skills according to the child's age and development.

     (B) Demonstrate the initial assessment skills needed to rapidly differentiate between the critically ill or injured and the stable infant and child patient.

     (C) Identify and demonstrate the correct sequence of priorities to be used in managing the infant and child patient with life threatening injury or illness.

     (D) Identify that the priorities for a severely injured and critically ill infant and child are:

     • Airway management,

     • Oxygenation,

     • Early recognition and treatment of shock,

     • Spinal immobilization,

     • Psychological support.

     (E) Demonstrate a complete focused assessment of an infant and a child.

     (F) Demonstrate ongoing assessment of an infant and a child.

     (G) Identify the differences between the injury patterns of an infant and a child compared to that of an adult.

     (H) Identify the psychological dynamics between an infant and a child, parent or caregiver and EMS provider.

     (xi) Pharmacology: Pharmacology specific to the medications approved by the MPD (not required for first responders).

     (xii) Proficiency: Ability to demonstrate and perform all aspects of a skill properly to the satisfaction of the MPD or delegate.

     (xiii) Spinal immobilization and packaging: This includes adult, pediatric and geriatric patients appropriate to the level of certification, assuring the following pediatric objectives are covered.

     Pediatric objectives - The EMS provider must be able to:

     (A) Demonstrate the correct techniques for immobilizing the infant and child patient.

     (B) Identify the importance of using the correct size of equipment for the infant and child patient.

     (C) Demonstrate techniques for adapting adult equipment to effectively immobilize the infant and child patient.

     (xiv) Trauma: For adult, pediatric and geriatric patients appropriate to the level of certification, assuring the following pediatric objectives are covered.

     Pediatric objectives - The EMS provider must be able to:

     (A) Identify the importance of early recognition and treatment of shock in the infant and child patient.

     (B) Identify the importance of early recognition and treatment of the multiple trauma infant and child patient.

     (C) Identify the importance of rapid transport of the injured infant and child patient.



[Statutory Authority: Chapters 18.71 and 18.73 RCW. 04-08-103, § 246-976-161, filed 4/6/04, effective 5/7/04. Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW. 00-08-102, § 246-976-161, filed 4/5/00, effective 5/6/00.]