D.4 Critical Care Transport Capabilities Confirmation.pdf
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- Solicitation number
- 36C25724R0007
About this file
This document is a confirmation form for critical care transport capabilities required under federal solicitation number 36C25724R0007 for ALS ambulance transport services with the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 17. Offerors must confirm they can supply medications from the listed formulary including Acetadote, Cordarone, antibiotics, blood products, and others, as well as equipment such as chest tubes, portable ventilators including CPAP, vascular access devices, and critical care monitors with 12-lead EKG and temperature monitoring capabilities. Offerors must also confirm their pumps are compatible with VA tubing and can accommodate up to six simultaneous infusion lines or IV drips as required for patient care.
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D.4 36C25724R0007 Critical Care Transport Capabilities Confirmation
Critical Care Transport Capabilities Confirmation If a transport is classified as a Critical Care Transport (CCT), then the offeror must be capable of transporting the medication 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.
Medication 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)
Furosemide (Lasix)
Heparin
Hyperalimentation
(TPN and lipids)
Insulin
Labetalol (Trandate)
Lidocaine
Lorazepam (Ativan)
Magnesium Sulfate
*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. *
Mannitol
Midazolam (Versed)
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
Zoll X Series Critical Care Monitor Capabilities:
Continuous 12-lead EKG monitoring
2-Temperature Monitoring l d
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