An ambulance transfusion service is defined as an ambulance service certified by the Department of Health that administers blood components during transport from one hospital to another hospital. Section 58-2.20 of Title10 of the New York State Codes, Rules and Regulations (NYCRR) requires ambulance transfusion services to have a written agreement with each hospital issuing blood components to the ambulance service for possible administration during transport to another hospital.
There are two ways to apply for approval as an ambulance transfusion service. Each ambulance service may apply individually or the Emergency Medical Service Program Agency may apply for multiple ambulance transfusion service approvals for those ambulance services within the EMSPA service area.
Individual Ambulance Transfusion Service Application
Complete and submit the following:
- Ambulance Transfusion Service Checklist
- DOH-5208 Ambulance Service Application to Provide Ambulance Transfusion Service
- Signed written agreement between the ambulance service and the issuing blood bank
- Blood administration training program documentation
- Policy requiring 100% case review by the ambulance service medical director when blood was administered during interfacility transport
- Sample blood transfusion record form, if not using DOH-5209
- Sample blood transfusion order form, if not using DOH-5210
Program Agency Application for Agreements with Multiple Blood Banks
The Emergency Medical Services Program Agency (EMSPA) submits the following:
- DOH-5765 Program Agency Application to Provide Ambulance Transfusion Services
- DOH-5208 Ambulance Service Application to Provide Ambulance Transfusion Service FOR EACH AMBULANCE SERVICE
- Signed written agreement(s) between the ambulance service and each issuing blood banks(s). The EMSPA is responsible for obtaining these agreements.
- EMSPA-derived and Regional Emergency Medical Services Council approved blood administration training program documentation
- Policy regarding 100% case review by EMSPA medical director or ambulance service medical director when blood was administered during interfacility transport
- Sample blood transfusion record form, if not using DOH-5209
- Sample blood transfusion order form, if not using DOH-5210
Questions regarding ambulance transfusion services should be directed to brp@health.ny.gov.