NEOM BLS Ambulance Checklist

Work Region:
PMC:
Contractor Name: Multiple selection
Date of Evaluation:
Report by: Multiple selection – include signatures.
Work order: Multiple selection
Clinic Location:

Compliance Score:

Closure Rate:
N/A

Inspection Observations

Checklist:

Question Answer Selection Comments Photos

General Criteria
Is the ambulance equipped with four wheels Yes
(4WD),
> OPTIONAL, BASED ON THE RISK ASSISSMENT

Does the ambulance have sufficient warning Yes

lights installed?

Is the ambulance clearly marked with Yes

ambulance signage on the exterior?
 Does the ambulance have air conditioning in Yes
the patient compartment?

Is the ambulance equipped with a small fire Yes

extinguisher?

Is the ambulance equipped with the Yes

appropriate communication device? E.g.,
radio, cellular or satellite phone

Is the patient's privacy protected while Yes

maintaining an efficient mode of
communication inside the patient's
compartment?
Staff & Qualification
Is there (2) Paramedics, for each shift, both Yes Both nurses have a MOH
have: License issued by SCFHS
- SCFHS & MoH licenses, good experience
in medical emergency >3years.
- the ambulance driving skills and holding
Saudi driving license >3years.
- Good command of English language
skills is recommended.

Is the paramedic having the following training Yes Both nurses have first aid
courses and they are current: and BLS License
- BLS & ACLS (mandatory)
- PHTLS or ATLS (recommended)
- Defensive driving (recommended)

Have all paramedics received the below Yes - Paramedic already

training within 2 days of arriving on site: attended safety
induction before shift
- Familiarization with ambulance to site
equipment, devices, and how to perform - All paramedic did
basic function. orientation about
- Site location orientation and potential ambulance, equipment
risks and role and
- Role and responsibility in the event of an responsibilities.
emergency and/or disaster response
- Ambulance routine checks and preventive
maintenance
 Yes

Medical Emergency and Resuscitation Supplies

AED; automated external defibrillator Full Compliance

Backup battery for AED Full Compliance

A heart rate monitor Full Compliance

2 X Blood oxygen monitor; Pulse Oxymeter Full Compliance

2 X Thermometers Full Compliance

2 X Blood pressure devices Full Compliance

2 X Stethoscope Full Compliance

Electrocardiogram (12 Leads ECG) No

5 sets of ECG Leads No

2 X Glucometer and single-use fully Full Compliance

disposable lancets and glucose strips

Continuous positive airway pressure (CPAP) No

2 X Bag valve mask (BVM) or Ambu Bag Partial Compliance Additional 1

Otoscope Full Compliance

2 X Medical penlights Full Compliance

2 Surgical scissors No

Stretchers: Minimum required: Full Compliance

- Backboard stretcher, head fixation
device and spider straps
- Basket stretcher with lifting slings.
- Scoop Stretcher

Note: Further types & Number of stretchers

are based on the worksite risk assessment.
2 Neck collar (Hard & Adjustable) Partial Compliance Additional 1

5 X Nasopharyngeal airways, different sizes Unavailable

5 X Oral airways, different sizes. Partial Compliance Available size 14 and 15

Needed: size 0.0-5

5 Nasal cannula (Adult size) Unavailable

5 Face mask different sizes Partial Compliance Available standard face

mask

5 non-rebreather face masks Unavailable

5 Nebulizer masks Unavailable

2 Orthopedic fixation devices, different sizes Unavailable

Pelvic binder/compression device Unavailable

2 X Chest decompression large bore needles Not applicable Used by specialists.

Emergency baby delivery full kit. No

> OPTIONAL, BASED ON THE RISK ASSISSMENT

5 X Urine incontinence disposable bed pads Unavailable

2 X Blankets Partial Need additional 1 item

5 X Vomiting bags Unavailable

Gloves; 2 boxes of different sizes Full Compliance

Surgical masks; 2 boxes Full Compliance

2 X Eye protection (full peripheral glasses or Available

goggles and face shield)

5 X Ice bags Unavailable

2 X Hands sanitizer bottles Unavailable

Burn bandages. Unavailable

2 X small size
2 X large size
2 X XLarge size

2 X Face burn bandages. Unavailable

5 X Gauze boxes, various sizes Full Compliance

5 X Elastic bandages, big size Full Compliance

2 X tourniquets Unavailable

Dental container Unavailable

5 X Gauze pads for wound, different sizes Full Compliance

5 X disposable razor blades Unavailable

2 X Portable oxygen cylinders Full Compliance
(Able to deliver 15L/min, for not less than
30min.)

5 X Gel tubes, sterile for lubrication Unavailable

2 X Tongue depressors box Unavailable

Magill forceps Unavailable

Portable suction device Full Compliance

5 X Gowns Unavailable

5 X Triangular bandages Unavailable

2 X Asherman Chest Seal (ACS) Unavailable

2 X Elastic fixing straps Unavailable

Alcohol swaps or alcohol spry (2 boxes) Full Compliance

Triage Cards (10 sets) Unavailable

3 X Spill kit Choose an item.

Unavailable

Ambulance bag contents

Blood oxygen monitor (Pulsoxymeter) Full Compliance

Glucometer with single-use fully disposable Full Compliance

lancets and glucometer strip

Blood pressure cuffs, different sizes. Full Compliance

Stethoscope, suitable for adult and pediatric Full Compliance

use

Surgical scissors and dressing scissors Unavailable

6 Gauze + 6 bandages + 6 plasters (Various Full Compliance
sizes),

3 X Sterile infusion solutions (Saline, Partial Compliance Available only normal

Ringer & Dextrose) saline

6 X Syringes (10ml and 5ml) Unavailable

6 X I.V lines

20 X I.V Cannulas Unavailable

(Sizes 16, 18, 20, 22, 24)

5 X N95 mask Unavailable

2 X Gloves and alcohol swaps Full Compliance

The contents of oxygen bag

Portable O2 Cylinder with regulator Full Compliance

Complete set of Laryngoscope and different No

sizes ET tubes.
Mask with bag and valve (Ambu Bag) Full Compliance

3 X Oxygen mask Full Compliance

2 X Oral and nasal airway kit Unavailable

Medicine
5 X Adrenaline (1:1000 & 1:10000) Unavailable

5 X Amiodarone Unavailable

Aspirin Unavailable

Adenosine Unavailable

5 X Atropine Unavailable
Ipratropium bromide Unavailable Unavailable

Furosemide Unavailable Unavailable

Glucose 50% Unavailable Unavailable

Glucagon Unavailable Unavailable

Lidocaine Unavailable Unavailable

Magnesium Sulfate Unavailable Unavailable

Magnesium chloride Unavailable Unavailable

Metoclopramide Unavailable Unavailable

Naloxone Unavailable Unavailable

Nurofen Unavailable

2 X Normal Saline Unavailable

Salbutamol Unavailable

Burn cream Full Compliance

Ibuprofen Unavailable

Paracetamol Full Compliance

Ranitidine Unavailable

Diphenhydramine Unavailable

Midazolam Unavailable
Diazepam Unavailable

Morphine Unavailable

Fentanyl Unavailable
Choose an item.

Nitrate Unavailable

Haloperidol Unavailable

Suxamethonium chloride Choose an item.

Unavailable

Prednisolone Unavailable

Sodium chloride Unavailable

Procedures and Records

Are there records available that the ambulance Full Compliance
equipment and supplies are checked daily and
after every patient trip?

Are there records available that the ambulance Full Compliance

is taken on a daily test run and has the
vehicles condition checked?

Are there records available to indicate the Full Compliance

ambulance is thoroughly cleaned inside and
washed outside on a weekly basis?

Are there records available that the ambulance Full Compliance

has been through a period quarterly
maintenance inspection?

Non – Medical items

10 X Waste bags Unavailable

10 X Belongings bags Unavailable

2 X Blanket Partial Compliance Need additional 1 blanket

2 X Mattress Unavailable
2 X Pillows Partial compliance Need additional 1 pillow

2 Pillowcases Unavailable

Pen Unavailable

Notebook with papers Unavailable

The ambulance transport record containing 3 Unavailable

copies for each record (even if the medical
service system uses and electronic record)

10 X Drinking water bottles Full compliance

Face wipes (2 X box) Unavailable

Copy of Medical Evacuation Response Plan Unavailable

(MERP) with business cards