Attatchment D.2 CCT Confirmation.docx
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- Solicitation number
- 36C25624R0038
About this file
This document is an attachment confirming capabilities for critical care transport. A prospective ambulance service provider must be able to transport drugs and equipment required for critical care patients up to tier III capabilities as defined by the local EMS region. This includes supplies such as chest tubes, ventilators, IV pumps and lines, cardiac and vascular access devices, and cardiac and other specialty drugs. The provider must use a Zoll X series monitor and confirm in writing that they can meet these requirements for critical care transports ordered under the Department of Veterans Affairs contract for ground ambulance services in Shreveport, Louisiana issued by Veterans Health Administration VISN 16.
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Attachment D.1
Critical Care Transport Capabilities Confirmation If a transport is classified as a Critical Care Transport (CCT) the offeror must be capable of transporting the drugs and/or equipment as required by the patient (listed below), up to and including Tier III, if necessary, based on the EMS region the ambulance provider is functioning in. Prospective offerors must sign and return this form confirming they can meet these criteria for CCTs ordered under this contract.
| Drug Supply List: | Equipment List: | ||
| Acetylcysteine (Acetadote, Mucomyst) | Chest tubes | ||
| Amiodarone (Cordarone) | Portable mechanical vents; including CPAP | ||
| Antibiotics | All VADs | ||
| Blood and Blood Products | CVP lines | ||
| Diltiazem (Cardizem) | Swan-Ganz line | ||
| Dobutamine | SmartPump Capability: up to 6 IV drips |
Dopamine Fentanyl (Sublimaze) *Any pump(s) capable for up to and including 6 infusion lines or IV drips as required by the patient. If the pumps are not compatible with VA supplied IV tubing, the contracted ambulance would need to provide their own tubing and be able to switch the tubing over prior to transport. *
Furosemide (Lasix) Heparin Hyperalimentation (TPN and lipids) Insulin Labetalol (Trandate) Lidocaine Lorazepam (Ativan) Magnesium Sulfate Mannitol Midazolam (Versed)Zoll X Series Critical Care Monitor Capabilities:
Continuous 12-lead EKG monitoring 2-Temperature Monitoring Automatic Blood Pressure Capnography 2 arterial lines monitoring
Milrinone (Primacor) Nicardipine (Cardene) Nitroglycerin (NitroStat, Nitro-Dur, Nitro-Bid) Norepinephrine (Levophed) Octreotide (Sandostatin) Ondansetron (Zofran) Pantoprazole (Protonix) Phenylephrine (Neo-Synephrine) Potassium Chloride Propofol Sodium Bicarbonate Vasopressin (Pitressin) TPA* (Pending)
I hereby confirm that _______________________________ can meet the criterion for Critical Care Transports. (Company Name)
| _____________________________________ | ______________ | |
| Signature of Company Representative | Date |
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