Microsoft word - bls nebulized albuterol collaborative agreement v2.doc
BLS Nebulized Albuterol Collaborative Agreement
Between an Emergency Medical Service (EMS) agency and a Physician Medical Director for the Provision of
Nebulized Albuterol Administration in New York State, in the Westchester EMS Region
The following agreement stands between the ____________________________________________ (Participating EMS
Agency) and ___________________________________________, (Physician) as Medical Director, authorizing the use
of nebulized Albuterol for the treatment of asthma, by members who are certified as Emergency Medical Technicians
(EMT). The following conditions must be observed by the Agency and its participating EMTs:
1. The EMT shall administer nebulized Albuterol according to the terms set forth by the NYS DOH BLS Treatment
Protocols and the Westchester Regional Medical Advisory Committee (REMAC) EMT-B Special Procedure Protocols. This includes;
a) Administration is limited to NYS DOH certified EMTs who have received the required training and are
working for an agency that has received REMAC authorization to provide this care.
b) Use of Albuterol is limited to patients between one and sixty-five years of age, who are experiencing
an exacerbation of their previously diagnosed asthma.
c) For severe respiratory distress, advance life support (ALS) is requested, and transport to the hospital
d) Medical Control is contacted prior to administering Albuterol to patients with a history of Angina,
Myocardial Infarction, Arrhythmia, or Congestive Heart Failure.
2. The Agency is responsible for the purchase of Albuterol and nebulizer equipment, and to maintain an adequate
stock so that Albuterol is available at all times.
3. Providers of the Agency are responsible to store Albuterol in accordance with New York State Department of
Health (NYS DOH) Policy Statement 00-15 Re: Storage and safeguarding of medications administered by EMT-B’s, or any superceding policy.
4. Providers of the Agency are responsible to inspect the Albuterol for expiration date and replace the units as
5. Prior to the provision of BLS Administered Nebulized Albuterol, an EMS Agency shall file with the WREMSCO a
completed Application to Provide Nebulized Albuterol and this collaborative agreement.
6. The Agency must participate in any Quality Assurance (QA) / Quality Improvement (QI) projects designated by
the REMAC in regards to provision of Nebulized Albuterol by EMTs. The Agency agrees to include the review all BLS Nebulized Albuterol administrations in the Agency’s quality improvement plan that is required by the NYS DOH.
The responsibilities of the Medical Director shall include, but not be limited to the following:
1. Approve and provide initial instruction and continuing education for all participating agency EMTs in the
assessment of asthma and proper use of Albuterol based upon the NYS DOH EMT-B and Westchester REMAC approved BLS Nebulized Albuterol Administration Training curriculums;
2. Provide the agency with the authorization to purchase Albuterol. 3. Review all uses of Albuterol under this agreement and provide appropriate quality assurance feedback.
Signature of EMS Agency Executive Officer
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