COMMENT: Concerning §157.11(c)(7)(S), Southeast Texas Regional Advisory Council (SETRAC) is concerned that allowing an EMS provider to either attest or provide documentation that the EMS provider met the RAC's participation requirements has the potential to cause an EMS provider to turn in an attestation that is in conflict to what the regional advisory committee shows on record for that provider's participation. SETRAC recommends that the rule require EMS providers to produce documentation from the respected regional advisory committee, stating that the provider has meet the regional advisory committee participation requirements.

RESPONSE: The commission acknowledges the comments; however, the rule allows for newly involved or initial EMS providers to meet the requirement, as written. No change was made to the rule as a result of these comments.

COMMENT: Concerning §157.32(c)(2)(B), Jeff Davis County Ambulance is concerned that the requirement to have a licensed EMS provider in attendance during their emergency department rotation will negatively impact their ability to complete education programs in rural and frontier areas. This statement is also true for §157.32(c)(3)(B) and §157.32(c)(4)(B).

RESPONSE: The commission agrees with the comments and has changed §157.32(c)(2)(B), §157.32(c)(3)(B), and §157.32(c)(4)(B) to state "…shall include supervised experiences in the emergency department and with a licensed EMS provider and in other settings as needed…"

COMMENT: Concerning §157.32(c)(4)(B), College of the Mainland is concerned about the amount of hours required to complete a paramedic program.

RESPONSE: The commission acknowledges the comment; however, the rule is sufficient as written. No change was made to the rule as a result of this comment.

COMMENT: Concerning the Jurisprudence Exam in §157.33(a)(4), §157.33(i)(1)(E), §157.33(i)(2)(D), §157.33(j)(2)(D), §157.34(b)(1)(G), §157.34(b)(2)(B), §157.34(b)(3)(B), §157.34(b)(4)(C), and §157.34(b)(5)(D), Arlington Fire Department submits to SB 1899 in the requirement of the exam, however is strongly opposed to any fees associated with the administration of the exam. The City of Arlington recommends and encourages the department to seek alternatives to initiating the jurisprudence exam requirement that result in no costs to the local governments.

Texas EMS Alliance (TEMSA) supports the jurisprudence exam because it provides the certificate holder with an overview of the rules, however is concerned about the impact on EMS agencies regarding the cost of the jurisprudence exam. TEMSA recommends that the department seek other entities that may be able to offer the exam at little to no cost for EMS agencies and EMS professionals or to find other allocated funds to offset the overall cost of the exam, thereby minimizing costs to the certified individuals.

RESPONSE: The commission acknowledges the comments; however, the rule language is sufficient as written and consistent with Health and Safety Code, §773.050(i). The department is finalizing the development of a process which will allow for over 300 continuing education providers to offer this education, as the department does with all continuing education requirements currently. The expected cost for personnel to complete this requirement would range from $0 to as high as $40.00. It is expected that most EMS personnel will have no additional cost to complete the intent of SB 1899. No change was made to the rule as a result of these comments.

COMMENT: Concerning §157.43(e), Jeff Davis County Ambulance stated that the requirement of an Advanced Coordinator to possess, at a minimum, an associate's degree places an undue burden on rural/frontier services.

RESPONSE: The commission acknowledges the comment; the rule is substantial due to the complexity of the advanced education. This is current standard and there has been no proposed changes to this section in this rule packet. No change was made to the rule as a result of this comment.

COMMENT: Association of Texas EMS Professionals (ATEMSP) submitted a comment in support of the proposed rules. ATEMSP believes the new rules will help sustain Texas EMS as the premier leader in out-of-hospital and pre-hospital care in the United States and that the success of EMS is tied directly to the professional success of EMS policy and legislation that will facilitate us in providing the most comprehensive, evidence-based care to our patients in order to lower or prevent disease or morbidity and mortality.

RESPONSE: The commission acknowledges the comments of support.

In addition to the comments received at the public hearing, the department received additional comments during the comment period and are addressed as follows.

The department, on behalf of the commission, has reviewed and prepared responses to the comments received regarding the proposed rules during the comment period, which the commission has reviewed and accepts. The department received comments from ADAPT Pharma, Air Evac Lifeteam, Arlington Fire Department, Brookhaven College, CareFlite, College of the Mainland, Cook Children's Medical Center, Coryell Memorial Healthcare System, Cypress Creek EMS, El Paso Fire Department, Garland Fire Department, Industrial EMS, Jeff Davis County Ambulance, Lake Jackson EMS, Lamar Institute of Technology, Las Colinas Medical Center, Lifeguard Aeromed Inc., PERCOM Online, PHI Air Medical, Terlingua Fire and EMS, Travis County STAR Flight, Williamson County EMS, Association of Texas EMS Professionals (ATEMSP), City of Arlington, Southeast Texas Regional Advisory Council (SETRAC), State Firefighters' and Fire Marshals' Association of Texas (SFFMA), Texas EMS Alliance (TEMSA), and three individuals. The commenters were not against the rules in their entirety; however, the commenters suggested recommendations for change as discussed in the summary of comments.

COMMENT: Concerning §157.2, one individual stated that EMT is defined at §157.2(37) and EMT-P is defined at §157.2(38); however, there is not a definition for ECA or AEMT.

RESPONSE: The commission disagrees with the comment, ECA is defined at §157.2(29) and AEMT is defined at §157.2(5). No change was made to the rule as a result of this comment.

COMMENT: Concerning §157.2(33), department staff recommended adding "emergency medical technician intermediate (EMT-I)" to be consistent throughout the rule.

RESPONSE: The commission agrees with the comment and added "emergency medical technician intermediate (EMT-I)" in §157.2(33)(D).

COMMENT: Concerning §157.2, the City of Arlington recommended adding a definition for "protocols" since it is referenced in several places throughout the rule.

RESPONSE: The commission agrees with the comment and added a definition for "Protocols" in §157.2(68).

COMMENT: Concerning §157.2(52), Licensee, one individual stated that there seems to be a repeat or redundant statement "…to provide EMS and holds a paramedic license from the department" that seems to be covered in the beginning of the definition.

RESPONSE: The commission agrees with the comment and revised §157.2(52).

COMMENT: Concerning §157.2(62), one individual recommended using the State Comptroller's Office (Comptroller) to check names or require that a business be registered with the Comptroller since the Comptroller does not allow repeats or similar names to be registered that are within a certain area.

RESPONSE: The commission acknowledges the comment; for the purpose of these rules, the definition is clear as written. No change was made to the rule as a result of this comment.

COMMENT: Concerning §157.11(c)(7)(G), the Garland Fire Department recommended leaving the AOR exempt for governmental agencies.

RESPONSE: The commission acknowledges the comment. The rule as written does not change the impact on governmental agencies. No change to the rule was made as a result of this comment.

COMMENT: Concerning §157.11(c)(7)(O), ADAPT Pharma questioned if "naloxone" is addressed in the rules.

RESPONSE: The commission acknowledges the comment. The authority to list supplies, medications, and equipment is the responsibility of the medical director and is not addressed in the rules. No change was made to the rule as a result of this comment.

COMMENT: Concerning §157.11(c)(7)(S), one individual is concerned about what would be required for the attestation and documentation that it and/or its management staff participate in the local regional advisory council.

State Firefighters' and Fire Marshals' Association of Texas (SFFMA) stated that requiring participation is dangerous and could have cost impacts for smaller agencies that must pay varied membership rates across the state. The commenters understand that the desire of this rule change was to insure proper facilities receive proper patients.

Southeast Texas Regional Advisory Council (SETRAC) is concerned that allowing an EMS provider to either attest or provide documentation that the EMS provider met the regional advisory committee's participation requirements has the potential to cause an EMS provider to turn in an attestation that is in conflict to what the regional advisory committee shows on record for that provider's participation. SETRAC recommends that the rule require EMS providers to produce documentation from the respected regional advisory committee, stating that the provider has meet the regional advisory committee participation requirements.

RESPONSE: The commission acknowledges the comments; however, the rule allows for newly involved or initial EMS providers to meet the requirement, as written. No change was made to the rule as a result of these comments.

COMMENT: Concerning §157.11(c)(7)(W)(ii), Cook Children's Medical Center suggested adding language to include captive policies since they are not licensed or deemed eligible by the Texas Department of Insurance.

RESPONSE: The commission agrees with the comment and has added language to include captive policies in §157.11(c)(7)(W)(ii).

COMMENT: Concerning §157.11(e)(1), SFFMA expressed concern for the change requiring neonatal equipment and suggested replacing neonatal equipment with child birth equipment.

RESPONSE: The commission disagrees with the comment; the language is inclusive of child birth equipment as written. No change was made to the rule as a result of this comment.

COMMENT: Concerning §157.11(e)(3), Coryell Memorial Healthcare System and Garland Fire Department are concerned with ambulances meeting minimum national ambulance safety criteria standards. The most current safety recommendations would eliminate a tremendous number of vehicles from fleets in the state.

Garland Fire Department stated they are against §157.11(e)(3) if the national standard means the adoption of the National Fire Protection Association standard. This minimum standard would make a new ambulance very expensive.

RESPONSE: The commission acknowledges the comments; the rule allows for the recognition of multiple national vehicle construction standards as written. No change was made to the rule as a result of these comments.

COMMENT: Concerning §157.11(e)(5), SFFMA is concerned how field inspectors will address in service and out of service units and the issues that will arise with serial number tracking assigned to units when those units are taken out of service during emergency events or with large agencies rotating units in and out of service status.

RESPONSE: The commission acknowledges the comment; however, this language as written, continues to support the prevention of fraud and abuse in the EMS industry. No change was made to the rule as a result of this comment.

COMMENT: Concerning §157.11(g)(3), El Paso Fire Department stated there is no reason other than the entity administering the jurisprudence exam to gain profit from it. The cost of personnel taking the exam may have a significant fiscal impact on a service and/or department.

Garland Fire Department recommended replacing the jurisprudence examination with required continuing education.

RESPONSE: The department is finalizing the development of a process which will allow over 300 continuing education providers to offer this education, as the department does with all continuing education requirements currently. This will allow for multiple options for the jurisprudence exam in order to comply with the intent of SB 1899. The expected cost for personnel to complete this requirement would range from $0 to as high as $40.00. It is expected that most EMS personnel will have no additional cost to complete the intent of SB 1899. The rule language is sufficient as written and consistent with Health and Safety Code, §773.050(i). No change was made to the rule as a result of these comments.

COMMENT: Concerning §157.11(h)(2), one individual suggested using "AEMT" instead of "EMT-I" to be consistent with the language of the rule.

RESPONSE: The commission agrees with the comment and has added "AEMT" to §157.11(h)(2).

COMMENT: Concerning §157.11(h)(4), department staff recommended adding "or EMT-Intermediate" to be consistent throughout the rule.

RESPONSE: The commission agrees with the comment and added "or EMT Intermediate".

COMMENT: Concerning §157.11(h)(5), one individual and El Paso Fire Department suggested using "AEMT" instead of "EMT-I" to be consistent with the language of the rule.

RESPONSE: The commission agrees with the comments and has added "AEMT" to §157.11(h)(5).

COMMENT: Concerning §157.11(j)(3), one individual suggested that manufacturers should be possessive as well as plural.

RESPONSE: The commission agrees with the comment and has revised §157.11(j)(3).

COMMENT: Concerning §157.11(k)(2)(F), Williamson County EMS expressed strong support for the requirement for waveform capnography during intubation. The commenter understands the fiscal impact that this requirement can have on small departments; it is clearly standard of care for prehospital medicine. It is necessary for safe practice.

RESPONSE: The commission acknowledges the comment of support.

COMMENT: Concerning §157.11(k)(3)(C) and information in the Small and Micro Business Impact Analysis that the cost range of an active 12-lead capability cardiac monitor/defibrillator for each advance life support ambulance by January 1, 2020, will have a cost range between $4000 to $10,000 per device, Lake Jackson EMS stated that most modern such equipment starts at $30,000 per unit, the cost estimate should be reevaluated. These are a must for Mobile Intensive Care Unit ambulances, but cost prohibitive for a Basic Life Support or Advanced Life Support ambulance.

RESPONSE: The commission acknowledges the comment; however the cost in the Small and Micro Business Impact Analysis reflects the additional costs of enhancing existing cardiac monitors and not an entirely new monitor. The Health and Safety Code, §773.052 provides authority to the department to grant variances with a specific hardship in meeting the minimum staffing and equipment standards. A process is already in place to request and grant these variances. No change was made to the rule as a result of this comment.

COMMENT: Concerning §157.11(k)(3)(C), Williamson County EMS expressed strong support for the requirement of 12-lead capability. The commenter understands the fiscal impact that this requirement can have on small departments; it is clearly standard of care for prehospital medicine. It is necessary for safe practice.

RESPONSE: The commission acknowledges the comment of support; the Health and Safety Code, §773.052 provides authority to the department to grant variances with a specific hardship in meeting the minimum staffing and equipment standards. A process is already in place to request and grant these variances. No change was made to the rule as a result of this comment.

COMMENT: Concerning §157.11(k)(7), the City of Arlington, suggested adding ". . . listed above, EMS vehicles must also have:"

RESPONSE: The commission agrees with the comment and has changed §157.11(k)(7) to state "In addition to medical supplies and equipment as defined in subsection (k) of this section, EMS vehicles must also have."

COMMENT: Concerning §157.11(m)(1)(A), one individual suggested using "provide" instead of "provider."

RESPONSE: The commission agrees with the comment and has changed §157.11(m)(1)(A).

COMMENT: Concerning §157.11(n)(10)(A), Las Colinas Medical Center seeks to understand if this means delivered or does this mean provide access to the completed patient care report.

RESPONSE: The commission acknowledges the comment; as written, it is the responsibility of the EMS provider to provide the patient care report. No change was made to the rule as a result of this comment.

COMMENT: Concerning §157.11(n)(10)(B), Las Colinas Medical Center is concerned that the verbal patient care report given by an EMS provider will not meet the intent and if not, an abbreviated report has to be given in writing.

RESPONSE: The commission acknowledges the comment; as written it would allow for a verbal report, but it is the responsibility of the EMS provider to ensure the information is documented. No change to the rule was made as a result of this comment.

COMMENT: Concerning §157.11(n)(10)(C), Garland Fire Department would like to see an allowance for the ability to do an oral hand off report in the event of a taxed system, with the understanding that the actual report will be delivered to the hospital within 24 hours.

Las Colinas Medical Center questioned if the report is in verbal format only, is the department going to ensure that all this information is being given to the emergency department of a health care facility at the time of the patient hand off.

RESPONSE: The commission acknowledges the comments; as written it would allow for a verbal report, this is a patient safety issue and it is the responsibility of the EMS provider to ensure the information is documented. No change was made to the rule as a result of these comments.

COMMENT: Concerning §157.11(n)(15)(E), one individual suggested adding the word "and" between "records maintains."

RESPONSE: The commission agrees with the comment and has revised §157.11(n)(15)(E).

COMMENT: Concerning §157.11(n)(15)(G), one individual suggested revising "medical director must attestation" to "medical director must attest."

RESPONSE: The commission agrees with the comment and has revised §157.11(n)(15)(G).

COMMENT: Concerning §157.11(n)(27)(F), Garland Fire Department seeks to understand if more than one person can be designated as an infection control officer for entities.