The purposes of the emergency medical services systems legislation are to establish and/or identify specific roles and responsibilities in regard to emergency medical services in Delaware in order to reduce morbidity and mortality rates for the citizens of Delaware and to ensure quality of emergency care services, within available resources, through the effective coordination of the emergency medical services system.

63 Del. Laws, c. 383, §  1;  67 Del. Laws, c. 152, §  5; 

As used in this subchapter:

(1) “Acute health-care facility” means any facility which is established, maintained and operated for the purpose of providing immediate and emergent care to individuals suffering from a life-threatening medical condition.

(2) “Advanced emergency medical technician” (AEMT) shall mean a person who has successfully completed a course approved by the Board of Medical Licensure and Discipline or its duly authorized representative, which meets the objectives of the national scope of practice.

(3) “Advanced life support” (ALS) shall mean the advanced level of prehospital and interhospital emergency care that includes basic life support functions including cardiopulmonary resuscitation, plus cardiac monitoring, cardiac defibrillation, telemetered electrocardiography, administration of antiarrhythmic agents, intravenous therapy, administration of specific medications, drugs and solutions, use of adjunctive medical devices, trauma care and other authorized techniques and procedures.

(4) “Ambulance” shall mean any publicly or privately owned vehicle, as certified by the State Fire Prevention Commission, that is specifically designed, constructed or modified and equipped, and is intended to be used for and is maintained or operated for the transportation upon the streets and highways of this State for persons who are sick, injured, wounded or otherwise incapacitated or helpless.

(5) “Ambulance attendant” shall mean a person trained in emergency medical care procedures and currently certified by the Delaware State Fire Prevention Commission or its duly authorized agent in accordance with standards prescribed by the Commission. Such course shall be classified as basic life support and shall be the minimum acceptable level of training for certified emergency medical personnel.

(6) “Basic life support” (BLS) shall mean the level of capability which provides prehospital, noninvasive emergency patient care designed to optimize the patient’s chances of surviving an emergency situation.

(7) “Consumer” shall mean a recipient or potential recipient of the services provided by an emergency medical services system, who receives no direct or indirect personal, financial or professional benefit as a result of association with health care or emergency services other than that generally shared by the public at large, and who is not otherwise considered a “provider” within the intent of this subchapter.

(8) “Controlled substance” means as defined in § 4701 of this title.

(9) “Director” shall mean the program chief of the Office of Emergency Medical Services responsible for the duties of the Office as set forth in Chapter 97 of this title.

(10) “Disaster” shall mean a sudden unexpected event which disrupts normal community functions and/or quickly exhausts local facilities so as to require outside help.

(11) “Early defibrillation provider” shall mean a member or employee of an early defibrillation service certified to operate Semi-Automatic External Defibrillator (SAED) equipment under the requirements set forth in regulations promulgated by the Department of Health and Social Services.

(12) “Early defibrillation service” shall mean any agency, organization or company, certified as such by the State Office of Emergency Medical Services, that employs or retains providers certified in the use of semi-automatic defibrillation equipment.

(13) “Emergency medical services systems” (EMSS) shall mean a statewide system which provides for the utilization of available personnel, equipment, transportation and communication to ensure effective and coordinated delivery of medical care in emergency situations resulting from accidents, illness or natural disasters.

(14) “Emergency medical technician” (EMT) shall mean a person trained, and currently certified by the State Fire Prevention Commission, in emergency medical care procedures through a course which meets the objectives of the national scope of practice.

(15) “Health planning agencies” shall mean the federally designated health system agency and/or statewide health planning and development agency for Delaware.

(16) “Hospital” means as defined in § 1001 of this title.

(17) “Inclusive statewide stroke care system” means a stroke system in which all current and future providers of hospital and/or prehospital health-care services may participate, at a level commensurate with the scope of their resources, as required in a stroke facility.

(18) “Inclusive statewide trauma care system” means a trauma system in which all current and future providers of hospital and/or pre-hospital health-care services may participate, at a level commensurate with the scope of their resources, as required in a specialty care unit of this section.

(19) “Law-enforcement officer” means a sworn member of a police force or other law-enforcement agency of this State, or of any county or municipality within this State, who is responsible for the prevention and detection of crime and the enforcement of the laws of this State, or the laws of any county or municipality within this State.

(20) “Medical control” shall mean directions and advice normally provided from a centrally designated medical facility operating under medical supervision, supplying professional support through radio or telephonic communication for on-site and in-transit basic and advanced life support services given by field and satellite facility personnel.

(21) “Mutual aid agreements” shall mean the establishment of appropriate arrangements with EMS systems of other states for the provision of emergency medical services on a reciprocal basis.

(22) “Opioid use disorder” means a substance use disorder involving the use of opioids, whether as controlled substances or as narcotic drugs.

(23) “Overdose” means an acute condition resulting from the use of alcohol or a controlled substance, or a narcotic drug, or a combination of substances, including physical illness, coma, mania, hysteria, or death.

(24) “Overdose System of Care Committee” means the Committee established under § 9711 of this title.

(25) “Paramedic” shall mean a person who has successfully completed a course approved by the Board of Medical Licensure and Discipline or its duly authorized representative, and who acts under the direct or radio control of a physician or physician surrogate.

(26) “Provider” shall mean a person who, as an individual or member of a corporation or organization, whether profit-making or nonprofit, on a regular basis gives or offers for sale any supplies, equipment, professional or nonprofessional services, or is capable of giving or offering for sale supplies, equipment or services vital or incidental to the functions of an emergency medical services system.

(27) “Public safety personnel” shall mean law-enforcement officers, lifeguards, park rangers, firefighters, ambulance and rescue personnel, communications and dispatch specialists, and other public employees and emergency service providers charged with maintaining the public safety.

(28) “Secretary” means the Secretary of the Department of Health and Social Services.

(29) “Semi-automatic external defibrillator” shall mean a device capable of analyzing a cardiac rhythm, determining the need for defibrillation, automatically charging and advising a provider to deliver a defibrillation electrical impulse.

(30) “Specialty care unit” shall mean sophisticated treatment facilities that provide advanced specialized definitive care for critically ill patients. The units shall be available for the diagnosis and care of specific patient problems including major trauma, burns, spinal cord injury, stroke, poisoning, acute cardiac, overdose, substance use disorder, opioid use disorder, high-risk infant and behavioral emergencies.

(31) “Stabilization center” means a facility designated by the Secretary to receive patients from Emergency Medical Services who are experiencing a nonlife threatening overdose or who require acute management for substance use disorder.

(32) “Stroke facility” shall mean an acute care hospital or freestanding emergency department that has received and maintains current State of Delaware designation as a stroke center, as determined by the Secretary of Health and Social Services, or an acute care hospital or freestanding emergency department that has not achieved such a designation but participates in the care of stroke patients and contributes data to the Delaware Stroke System Registry and Quality Improvement Program.

(33) “Stroke patient” shall mean any person with an episode of neurological dysfunction or headache caused by focal cerebral, spinal, or retinal infarction or by a focal collection of blood within the brain parenchyma, ventricular system, or subarachnoid space that is not caused by trauma.

(34) “Substance use disorder” means the psychological or physical dependence on alcohol, a controlled substance, a narcotic drug, or a combination of substances, that causes clinical and functional impairment or distress. “Substance use disorder” often includes a strong desire to use alcohol, a controlled substance, or a narcotic drug, increased tolerance to alcohol, a controlled substance, or a narcotic drug, and withdrawal syndrome when use of alcohol, a controlled substance, or a narcotic drug is abruptly discontinued.

(35) “Trauma facility” means an acute care hospital which has received and maintains current State designation as a Trauma Center. Categories of trauma facilities in Delaware are as follows:

a. Regional Level 1 Trauma Center. — A regional resource trauma center that has the capability of providing leadership and comprehensive, definitive care for every aspect of injury from prevention through rehabilitation.

b. Regional Level 2 Trauma Center. — A regional trauma center with the capability to provide initial care for all trauma patients. Most patients would continue to be cared for in this center; there may be some complex cases which would require transfer for the depth of services of a Regional Level 1 or specialty center.

c. Community Trauma Center. — An acute care hospital that provides assessment, resuscitation, stabilization and triage of all trauma patients, arranging for timely transfer of those patients requiring the additional resources of a Regional Trauma or Specialty Center and delivering definitive care to those whose needs match the resources of the Community Trauma Center.

d. Participating hospital. — An acute care facility which transfers trauma patients with moderate or severe injuries to trauma centers after initial resuscitation. When necessary, this facility may provide care to trauma patients with minor injuries. Participating hospitals contribute data to the Delaware Trauma System Registry and Quality Improvement Program.

(36) “Trauma patient” means any person with actual or potential bodily damage subsequent to an event which exposed the body to an external force or energy.

(37) “Treatment protocols” shall mean written uniform treatment and care plans for emergency and critical patients. The treatment plans for advanced life support must be approved and signed by appropriate physicians and/or medical groups.

63 Del. Laws, c. 383, §  1;  67 Del. Laws, c. 152, §  5;  70 Del. Laws, c. 192, §§  1, 2;  70 Del. Laws, c. 453, §§  1, 2;  72 Del. Laws, c. 137, §§  20, 21;  77 Del. Laws, c. 319, §  1;  78 Del. Laws, c. 310, §  1;  80 Del. Laws, c. 404, §  3;  81 Del. Laws, c. 265, § 3;  81 Del. Laws, c. 428, § 1; 

(a) There is established the Delaware Emergency Medical Services Oversight Council (DEMSOC). The Council shall consist of the following members:

(1) A representative of the Office of the Governor appointed by the Governor.

(2) The Secretary of the Department of Safety and Homeland Security.

(3) The Director of the Delaware Emergency Management Agency.

(4) The Secretary of the Department of Health and Social Services.

(5) The Chair of the Delaware State Fire Prevention Commission.

(6) The President of the Delaware Volunteer Firefighter’s Association.

(7) The Chief of the New Castle County Emergency Medical Services.

(8) The Kent County Administrator.

(9) The Sussex County Administrator.

(10) The President of the Delaware Chapter of the American College of Emergency Physicians.

(11) The State EMS Medical Director.

(12) The Chair of the Trauma Systems Committee.

(13) A practicing paramedic, certified and employed in the State, appointed by the Governor.

(14) The Chair of the DVFA Ambulance Advisory Committee.

(15) Three at-large members, 1 from each county, appointed by the Governor.

(16) The President of the Delaware Healthcare Association.

(17) The Executive Director of the Medical Society of Delaware.

(18) The Chair of the Delaware Police Chiefs’ Council.

(19) The Paramedic Commander of the Delaware State Police Aviation Unit.

(20) The Chair of the Emergency Medical Services for Children (EMSC) Advisory Committee.

(21) The Chair of the Stroke System Committee.

(b) Members serving by virtue of position may appoint designees to serve in their stead.

(c) The Council shall meet at a minimum of 1 time per year.

(d) An appointed member serves for a term of up to 3 years and is eligible for reappointment. The Governor shall appoint members for staggered terms so that no more than 3 members’ terms expire in any 1 calendar year.

(e) A majority of the membership of the Council shall constitute a quorum. A vacant position is not counted for quorum purposes.

(f) If an appointed member fails to attend 3 successive meetings of the Council without just cause, that member’s position may be deemed vacant and the Governor may appoint a replacement.

(g) The Chairperson of the Council shall be designated from among the members by the Governor and shall serve at the pleasure of the Governor. The Chairperson shall select a Vice Chairperson from the membership of the Council to serve in the Chairperson’s absence.

(h) The Council may adopt bylaws for adopting operating procedures including the election of officers, the conducting of meetings, and other matters to promote the efficient operation of the Council in this performance of its duties under this section.

(i) The Council shall monitor Delaware’s emergency medical services system to ensure that all elements of the system are functioning in a coordinated, effective, and efficient manner in order to reduce morbidity and mortality rates for the citizens of Delaware and to ensure quality of emergency care services.

(j) The Council shall have the following duties and responsibilities:

(1) To examine policies and procedures and evaluate the effectiveness of the EMS system, specifically the respective roles, responsibilities, effectiveness and efficiency of the Office of Emergency Medical Services (OEMS), the State Fire Prevention Commission, the Department of Safety and Homeland Security, the EMS provider agencies and the medical community;

(2) To study, research, plan, evaluate as well as offer guidance to, cooperate with and assist public agencies and private institutions and organizations on methods for the coordination and effective utilization of their emergency medical service programs;

(3) To formulate goals and recommendations, based on objective criteria and data, to be used in evaluating EMS provider agency performance;

(4) To review and make recommendations concerning quality improvement efforts pursuant to this chapter;

(5) To make recommendations to the Office of EMS, the Department of Safety and Homeland Security, the EMS provider agencies and the medical community for improving EMS in Delaware;

(6) To make legislative recommendations to the Governor and General Assembly;

(7) To provide an annual report on or before April 15 of each year to the Governor, General Assembly, interested parties and the public which will outline the performance of all EMS system agencies, comparing that performance to established goals and performance measures. The report shall also estimate the costs of Delaware’s EMS medical system. Automatic external defibrillator and cardio-pulmonary resuscitation program performance shall be included in this report. The first report will cover service provided in calendar year 2000 and will be delivered by April 15, 2001;

(8) To make recommendations concerning EMS to the State Fire Prevention Commission. The Commission will consider and act upon those recommendations; and

(9) To conduct a full review of EMS in the State at a minimum of every 5 years.

(k) The Council may request and shall receive from any department, division, commission or agency of the State such reasonable assistance and data as will enable it to properly carry out its functions hereunder.

(l) OEMS shall staff the Council.

61 Del. Laws, c. 164, §  1;  67 Del. Laws, c. 47, §  50;  67 Del. Laws, c. 152, §  1;  69 Del. Laws, c. 78, §  1;  69 Del. Laws, c. 326, §  1;  70 Del. Laws, c. 186, §  1;  70 Del. Laws, c. 453, §  9;  72 Del. Laws, c. 137, §  2;  72 Del. Laws, c. 421, §  1;  73 Del. Laws, c. 218, §§  1, 2, 3, 4;  73 Del. Laws, c. 368, §  10;  74 Del. Laws, c. 110, §  138;  74 Del. Laws, c. 261, §  1;  77 Del. Laws, c. 378, §  1;  78 Del. Laws, c. 326, §  1;  80 Del. Laws, c. 404, §  4;  81 Del. Laws, c. 118, §  1;  83 Del. Laws, c. 225, § 1; 

(a) The Office of Emergency Medical Services is hereby created. The Office shall be responsible for ensuring the effective coordination and evaluation of the emergency medical services system in Delaware which includes providing assistance and advice for activities related toward the planning, development, improvement and expansion of emergency medical services.

(b) The Office of Emergency Medical Services shall be a state agency within the Division of Public Health, Department of Health and Social Services. The Office of Emergency Medical Services shall report directly to and be responsible to the Director of the Division of Public Health, which is consistent with the health plan for Delaware.

(c) As used in this subchapter, the term “Office” shall refer to the State Office of Emergency Medical Services. In the performance of the functions mandated by this legislation which relate to the planning and evaluation of the emergency medical services system in Delaware, the Office of Emergency Medical Services shall coordinate with the Bureau of Health Planning and Resources Development for technical assistance in emergency medical services planning activities. Specifically, the Bureau of Health Planning and Resources Development shall have the primary responsibility for all data analysis related to the emergency medical services system. This coordination should minimize duplication of effort between the 2 agencies and allow for the effective use of available staff resources within the Department of Health and Social Services.

(d) Except for those activities and responsibilities for basic life support, which are under the jurisdiction of the State Fire Prevention Commission, the Office of Emergency Medical Services shall have jurisdiction over the development, implementation and maintenance of a Statewide Trauma System.

(e) A memorandum of agreement shall be established between the Office of Emergency Medical Services of the Division of Public Health and the State Fire Prevention Commission to foster inclusion and coordination of Basic Life Support Services within the Statewide Trauma System.

(f) The Director of Public Health shall establish a standing Trauma System Committee and ad hoc committees as deemed appropriate to assist in oversight of the Inclusive Statewide Trauma Care System. The standing Trauma System Committee shall convene at least quarterly. Membership on the standing Trauma System Committee will include, but not be limited to, a representative of each of the following constituencies to be selected from the 3 counties within the State:

(1) Trauma rehabilitation professionals

(2) Practicing trauma surgeons

(3) Practicing emergency department physicians

(4) The Association of Delaware Hospitals

(5) Advanced Life Support prehospital providers

(6) Basic Life Support prehospital providers

(7) The State Fire School

(8) Practicing trauma subspecialty physicians

(9) Practicing pediatric surgeons or pediatricians

(10) Practicing registered nurses involved in trauma patient care

(11) Emergency medical dispatchers

(12) Hospital administration

(13) The Delaware state police aviation section

(14) A representative from the State Fire Prevention Commission.

(g) The Trauma System Committee shall be an advisory group to the Director of Public Health on the following issues:

(1) Rules governing the operation of Delaware’s Inclusive Statewide Trauma Care System, which will be based upon national references such as the American College of Surgeons’ Resources for Optimal Care of the Trauma Patient: 1993.

(2) Recommendations for corrective action based on the reviews of the following:

a. Statewide trauma care system operations, including the monitoring for adherence to adopted policies, procedures, protocols and standards, the availability of appropriate resources and the periodic review of trauma hospital participation (designation) criteria.

b. The delivery of emergency medical and hospital services by trauma care service providers to trauma patients.

(3) Recommendation for modifications of the policies, procedures and protocols of trauma care as a result of system-wide review.

(h) Except for those activities and responsibilities for basic life support, which is under the jurisdiction of the State Fire Prevention Commission, the Office of Emergency Medical Services shall have jurisdiction over the development, implementation and maintenance of a statewide stroke system.

(i) A memorandum of agreement shall be established between the Office of Emergency Medical Services of the Division of Public Health and the State Fire Prevention Commission to foster inclusion and coordination of Basic Life Support Services within the Statewide Stroke System.

(j) The Director of Public Health shall establish and appoint a standing Stroke System Committee and ad hoc committees as deemed appropriate to assist in oversight of the inclusive statewide stroke care system. The standing Stroke System Committee shall convene at least quarterly. Membership on the standing Stroke System Committee will include, but not be limited to, a representative of each of the following constituencies to be selected from the 3 counties within the State and with best efforts to achieve a balance in membership from each county:

(1) Stroke rehabilitation professionals, including but not limited to, physical therapists, occupational therapists, and speech language pathologists;

(2) Practicing stroke neurologists;

(3) Practicing Emergency Department physicians;

(4) The Delaware Healthcare Association;

(5) Advanced life support prehospital providers;

(6) Basic life support prehospital providers;

(7) The State Fire School;

(8) Practicing neurosurgeons;

(9) Practicing neurointerventional radiologists;

(10) Practicing registered nurses involved in stroke patient care;

(11) Emergency medical dispatchers;

(12) Hospital administration or a designee from each acute health-care facility which holds or intends to seek stroke center designation under this title;

(13) The Delaware State Police Aviation Section; and

(14) A representative from the State Fire Prevention Commission.

(k) The Stroke System Committee shall be an advisory group to the Director of Public Health on the following issues:

(1) Recommendations based on Delaware stroke data as determined by the Director of Public Health, and after review of Delaware data as analyzed by the Stroke System Committee, and input from the Committee, as to whether outcomes for Delaware patients will be improved by the adoption of a statewide stroke system. Such recommendations shall be made to the Director of Public Health no later than December 30, 2016. The Director of Public Health shall report the basis for the Directors’ decision to the Chairs of the Health and Social Services Committees of the House and Senate.

(2) Rules governing the operation of Delaware’s inclusive statewide stroke care system, which will be based upon national references and data based guidelines, as determined by the Director of Public Health with the advice of the Stroke System Committee.

(3) Recommendations for corrective action based on the reviews of the following:

a. Statewide stroke care system operations, including the monitoring for adherence to adopted policies, procedures, protocols and standards, the availability of appropriate resources and the periodic review of stroke hospital and freestanding emergency department participation (designation) criteria.

b. The delivery of emergency medical and hospital services by stroke care service providers to stroke patients.

(4) Recommendation for modifications of the policies, procedures and protocols of stroke care as a result of system-wide review.

(l) Except for those activities and responsibilities for basic life support, which are under the jurisdiction of the State Fire Prevention Commission, the Office of Emergency Medical Services has jurisdiction over the development, implementation, and maintenance of the overdose system of care created under § 9710 of this title.

(m) A memorandum of agreement must be established between the Office of Emergency Medical Services of the Division of Public Health and the State Fire Prevention Commission to foster inclusion and coordination of Basic Life Support Services within the Statewide overdose system of care created under § 9710 of this title.

63 Del. Laws, c. 383, §  1;  67 Del. Laws, c. 152, §  5;  70 Del. Laws, c. 453, §§  3-6;  80 Del. Laws, c. 404, §  4;  81 Del. Laws, c. 428, § 2; 

(a) Personnel. — It shall be the responsibility of the Office to collect and analyze annually data pertaining to certified emergency medical services personnel in Delaware by levels of training in order to identify possible or potential shortages. Once EMS personnel shortages are identified, the Office shall notify the affected agencies and provide recommended courses of action to alleviate the problem or potential problem. In order to accomplish this task, the following agencies shall be required to provide a listing of the appropriate emergency medical services personnel by organization, level of training and county:

(1) Delaware State Fire Prevention Commission or its duly authorized representative;

(2) Wilmington Medical Center School for Emergency Medical Technicians;

(3) Delaware Committee on Trauma of the American College of Surgeons — advanced trauma life support;

(4) American Heart Association of Delaware — cardiopulmonary resuscitation (CPR) training programs and advanced cardiac life support;

(5) American Red Cross, Delaware Chapter — CPR training and first-aid training;

(6) Delaware Chapter of the American College of Emergency Physicians;

(7) Delaware Chapter of the Emergency Department Nurses Association; and

(8) Any other organization not listed above that provides certified emergency medical training, including CPR.

(b) Training. — All organizations providing emergency medical training programs, as listed under the personnel section, shall provide to the Office copies of course curricula and schedules of the availability of training courses. The Office shall monitor EMS training levels to provide information on the availability of training programs for all levels of EMS personnel. In addition, the EMS Office shall keep abreast of all federal training standards to ensure that EMS training agencies in Delaware are aware of regional and national standards. In accordance with § 6711(a)(3) of this title [repealed], the State Fire Prevention Commission shall adopt regulations setting forth the qualifications required for the certification of ambulance attendants. Since advanced life support ambulance personnel are “physicians’ assistants” as defined in subchapter VI of Chapter 17 of Title 24, they must have been trained in programs approved by the Delaware State Board of Medical Licensure and Discipline.

(c) Communications. — The Office shall:

(1) Through the appropriate county dispatch center directors, monitor and evaluate the effectiveness of the statewide EMS communications system;

(2) Identify resources to improve or augment both the communications system in Delaware and the training of medical dispatchers as needed;

(3) Monitor and evaluate the effectiveness of emergency access numbers in terms of the impact on the EMS system.

(d) Transportation. — In conjunction with appropriate EMS providers in Delaware, the Office shall monitor and evaluate emergency medical transportation services in Delaware to ensure that patients in the EMS system have access to effective and efficient transportation to appropriate treatment facilities. Pursuant to § 6709 of this title, all ambulances in Delaware shall be inspected and certified by the Delaware State Fire Prevention Commission or a duly authorized representative thereof. The Delaware State Fire Prevention Commission or its duly authorized representative shall be required to provide to the Office on an annual basis a listing and location of certified ambulances.

(e) Facilities. — The Office shall monitor the availability of the various levels of care of EMS facilities and services and shall have the authority to categorize all Delaware emergency receiving facilities and services in accordance with criteria established by the Joint Commission on Accreditation of Hospitals (JCAH) for hospital settings and other appropriate national professional organizations for nonhospital settings. This authority shall also include the responsibility of categorizing and designating by level of care, when appropriate, specialty care facilities in accordance with the established criteria of the American Medical Association or other appropriate national professional organizations. In addition, the Office shall periodically reevaluate the categorization or designation of emergency care facilities and specialty care services.

(f) Specialty care units. — The Office shall identify the categorization of the 7 specialty care areas for EMS which are available to all patients (the specialty care areas are: Trauma, burns, spinal cord, poisoning, acute cardiac, high-risk infant and behavioral emergencies). In addition, the Office shall coordinate the activities of the EMS system to ensure that all patients have access, within a reasonable time period depending on the nature of the illness, to specialty care services. In accordance with this activity, the Office shall have the authority to designate or categorize specialty care units by level of care as specified in the section related to facilities.

(g) Public safety agencies. — Based on the data obtained in the section related to personnel, the Office shall monitor and evaluate the activities of public safety agencies to determine the number of trained first responders and to promote their participation, to the maximum level possible consistent with their capabilities, in emergency medical situations.

(h) Consumer participation. — All agencies and organizations involved in the EMS system in Delaware should seek reasonable consumer participation in planning, development and organizational activities.

(i) Access to care. — The Office shall monitor and evaluate activities of all EMS organizations to ensure that no person is denied emergency treatment or transportation services.

(j) Patient transfer. — The EMS system shall provide for transfer of patients to facilities and programs which offer such follow-up care and rehabilitation as is necessary to effect the maximum recovery of the patient. The transfer of emergency patients from the emergency site to the emergency department, specialty care unit and to follow-up care and rehabilitation centers are all within the scope of a total EMS system.

(k) Coordinated patient recordkeeping. — The Office shall collect and analyze available data from all providers of the EMS system. This data will be used by the Office, in conjunction with the appropriate EMS providers, to evaluate the overall effectiveness of the system. It is necessary that the data be collected from each level of care, which includes the initial entry point through final discharge from the health care delivery system. EMS agency certification will be contingent upon agency participation in the Statewide EMS data collection system maintained by the Office.

(l) Public information, prevention and education. — The Office shall provide programs of public information and education designed to inform residents of Delaware and visitors to the State of the availability of, proper use of and access to emergency medical services. The Office shall also support prevention activities designed to address key categories of illness and injury as identified through data collection. The Office will serve as a clearinghouse for illness and injury prevention activity, and will work to coordinate EMS prevention efforts statewide. These programs shall include elements related to citizen involvement in the administration of prehospital care, such as cardiopulmonary resuscitation and first aid, and information concerning the availability of training programs in Delaware. In addition, the Office shall monitor public information and education programs offered by other EMS providers in Delaware. All EMS provider agencies shall provide a report on their prevention and education activities conducted during the previous year to the Office by January 15 of each year. The Office shall publish an annual report outlining the status of prevention and public education activities throughout the State by May 15 of each year.

(m) Review and evaluation. — In conjunction with the health planning agencies and the EMS providers in Delaware, the Office shall conduct and/or coordinate an on-going comprehensive evaluation of the effectiveness of the EMS system, in terms of the impact on the health status of the EMS patients in Delaware.

(n) Disaster planning. — The Office shall: (1) Upon request, participate in disaster planning with all organizations that provide emergency medical services to assist with coordination of disaster activities which impact the EMS system, and (2) review all municipal, county and state disaster plans which utilize the emergency medical services system. All organizations involved in planning disaster exercises which impact the EMS system should advise the Office of scheduled disaster exercises. In addition, the Office shall, upon request, participate in disaster exercises for the purpose of evaluation and improvement of the emergency medical services system and make recommendations as needed to the appropriate provider for the refinement of their disaster plans. All disaster planning activities of the Office shall be coordinated with the Delaware Emergency Management Agency as authorized by Chapter 31 of Title 20, and the Department of Health and Social Services Disaster Coordinator.

(o) Mutual aid agreements. — The Director of the Office in conjunction with the Division Director shall be authorized to develop and implement mutual aid agreements as may be necessary to ensure continuity of care. These agreements shall be coordinated through and approved by the appropriate EMS providers. These agreements may relate to reciprocity of services, and treatment, transfer and triage protocols to coordinate the provision of services, both within Delaware and across state lines as necessary.

(p) Semi-automatic external defibrillators. — (1) The Department of Health and Social Services shall promulgate regulations specific to the use of semi-automatic external defibrillators and shall seek input and review from the Board of Medical Licensure and Discipline, the Delaware EMS Oversight Council and the Delaware State Fire Prevention Commission.

(2) The Office shall coordinate a statewide effort to promote and implement widespread use of semi-automatic external defibrillators and cardio-pulmonary resuscitation to increase the number of publicly available SAEDs to 100 by January 1, 2002, and 200 by January 1, 2004. In addition, the Office shall coordinate a statewide effort to provide, train and maintain a minimum of 5 qualified individuals for each publicly available SAED.

(3) All law-enforcement vehicles on patrol shall be equipped with a semi-automatic external defibrillator by January 1, 2001, subject to appropriations.

(q) Emergency Medical Services for Children. — The Office shall provide a program to address the specific emergency medical care of children. This program shall be known as the Emergency Medical Services for Children (EMSC) program.

(1) The EMSC program shall have the power to:

a. Advise EMS medical direction on the development and implementation of statewide protocols that emphasize pediatric emergency care;

b. Support pediatric emergency medical technician and paramedic education and training programs; which shall include training in the emergency care of infants and children;

c. Develop pediatric emergency care standards and a voluntary program to recognize hospitals able to treat and manage pediatric emergencies;

d. Develop programs for parents and communities which shall identify and reduce barriers to emergency care for children;

e. Provide information relating to child-specific health promotion and injury prevention;

f. Focus on recognition of emergencies;

g. Assist in improving access to appropriate use of the local EMS systems;

h. Develop and maintain a Special Needs Alert Program to educate EMS providers, and, on a voluntary basis, identify for EMS providers children with special health care needs in the community; and

i. Analyze pediatric injury/illness data collected through the Office for the purpose of quality management purposes. All quality management proceedings shall be confidential.

(2) There is established the EMSC Advisory Committee. The Committee shall advise the Office on issues concerning EMS care for children, and shall consist of the following representatives:

a. The State EMS Medical Director;

b. The State EMS Director;

c. The Director of Children with Special Health Care Needs of the Division;

d. The Chair of the Delaware State Fire Prevention Commission or another Commissioner selected by the Chair;

e. The Chair of the State Trauma System Committee or another member selected by the Chair;

f. The Chair of School Health Services in the Department of Education or another member selected by the Chair;

g. Advanced Life Support Agency County EMS Chiefs or Directors in Delaware or another member of the Advanced Life Support Agency selected by the Chief or Director;

h. The Commander of the State Police EMS Aviation Section;

i. The President of the Delaware Chapter of the American College of Emergency Physicians or, at the President’s discretion, a representative of the Chapter;

j. The President of the Delaware Chapter of the American Academy of Pediatrics or, at the President’s discretion, a representative of the Chapter;

k. The President of the Delaware Healthcare Association or, at the President’s discretion, a representative of the Delaware Healthcare Association;

l. The President of the Delaware Emergency Nurses Association or, at the President’s discretion, a representative of the Emergency Nurses Association who is an emergency nurse licensed and practicing in Delaware;

m. The President of the Delaware Volunteer Firefighter’s Association or, at the President’s discretion, a representative of the Delaware Volunteer Firefighter’s Association;

n. The President of the Delaware EMS Association or, at the President’s discretion, a representative of the Delaware EMS Association;

o. The Chair of Safe Kids Delaware or, at the Chair’s discretion, a member of Safe Kids;

p. The Commander of the Health Care Clinic at the Dover Air Force Base or at the Commander’s discretion a medical care representative from the Dover Air Force Base;

q. A Pediatric Emergency Medicine Physician practicing in the State of Delaware; and

r. Three lay parent representatives of children ages 0-19, 1 from each county, appointed by the Director of the Division of Public Health.

63 Del. Laws, c. 383, §  1;  67 Del. Laws, c. 152, §  5;  69 Del. Laws, c. 78, §  1;  70 Del. Laws, c. 186, §  1;  72 Del. Laws, c. 137, §§  22, 24, 25;  75 Del. Laws, c. 141, §  3;  77 Del. Laws, c. 319, §  1;  78 Del. Laws, c. 326, §  2; 

(a) In order to monitor and evaluate the effectiveness of the EMS system, the Office must be notified of any proposed new service or major service modification within the emergency medical services system in Delaware.

(b) Copies of applications for federal, state and county emergency medical service grant funds shall be sent to the Office.

(c) All proposed legislation pertaining to the EMS system in Delaware shall be reviewed by DEMSOC with recommendations from the Office.

(d) The Office shall, with the consent of the Director of the Division of Public Health, be authorized to make news releases pertaining to the emergency medical services system as required in order to inform the public on issues pertinent to the health and well being of the citizens of Delaware.

(e) The Office shall be required to provide routine progress reports identifying the accomplishments and the problem areas within the system to DEMSOC at its regularly scheduled meetings. In addition, an annual summary report shall be sent to the Chairperson of DEMSOC through the Division Director by August 15 of each year.

(f) The Office is authorized and empowered to apply for, accept and disburse grants, gifts and contributions from the government, individuals, foundations, corporations and other organizations, agencies or institutions on behalf of the EMS system in Delaware.

(g) The Director of Public Health shall, except for those activities and responsibilities for basic life support, which is under the jurisdiction of the State Fire Prevention Commission:

(1) Use the Trauma System Committee recommendations as the basis for establishing a plan for the implementation and maintenance of Delaware’s Inclusive Statewide Trauma Care System. The State Trauma System Plan shall address each component of trauma care as outlined in national references such as Model Trauma Care System Plan, HRSA-BHRD, September 1990 and subsequent revisions. These include, but are not limited to:

a. Prehospital care. — Standardized and statewide policies, procedure and protocols to be used by all emergency medical service providers and licensed personnel for the identification, treatment and transport of trauma patients.

b. Prevention. — Efforts to decrease the numbers and severity of injuries, resulting in decreased demand for care.

c. Hospital care. — Standards and criteria for hospital personnel, equipment and designation that identify the necessary resources that hospitals must have in order to be recognized within Delaware’s Inclusive Statewide Trauma Care System as a specified category trauma facility. These standards and criteria shall be consistent with those identified in national trauma system references, such as the American College of Surgeons’ Resources for Optimal Care of the Injured Patient: 1993 and subsequent revisions. All expenses associated with utilizing a nationally recognized accreditation team to verify a hospital’s compliance with hospital designation criteria will be the responsibility of the hospital being surveyed.

d. Rehabilitative care. — Standards for the follow-up care for persons with disabilities resulting from injuries.

e. Trauma continuing education. — The on-going trauma related education for trauma care system personnel/providers to maintain knowledge and skills.

f. Trauma care system evaluation. — Monitor policies and procedures regarding the effectiveness/impact of trauma care systems.

(2) The Director of Public Health shall have the authority to promulgate rules for the management of all components of Delaware’s Inclusive Statewide Trauma Care System, and shall seek input and review from the Trauma System Committee.

(3) Maintain a program of trauma care system evaluation, including a trauma data collection and registry system and a mechanism for evaluating and monitoring system performance throughout the continuum of trauma care.

(h) The Director of Public Health shall have the authority to promulgate rules for EMS provider recognition and compliance with an advance health-care directive that has become effective pursuant to § 2503(c) of this title, or Delaware Medical Orders for Scope of Treatment and those from other states that have become effective pursuant to Chapter 25A of this title, and shall seek input and review from the Board of Medical Licensure and Discipline, the Delaware EMS Oversight Council and the Delaware State Fire Prevention Commission. For purposes of this subsection, “EMS provider” shall mean providers certified by the Delaware State Fire Commission or the Board of Medical Licensure and Discipline. EMS providers acting in accordance with the regulations promulgated hereunder shall be immune from criminal or civil liability pursuant to § 2510 of this title.

(1), (2) [Repealed.]

(i) The Director of Public Health shall, except for those activities and responsibilities for basic life support, which is under the jurisdiction of the State Fire Prevention Commission:

(1) Use the Stroke System Committee recommendations as the basis for establishing a plan for the implementation and maintenance of Delaware’s inclusive statewide stroke care system.

(2) The State Stroke System Plan shall address each component of stroke care as outlined in national references. These include, but are not limited to:

a. Prehospital care. — Standardized and statewide policies, procedure and protocols to be used by all emergency medical service providers and licensed personnel for the identification, treatment and transport of stroke patients.

b. Prevention. — Efforts to decrease the numbers and severity of strokes resulting in decreased demand for care.

c. Hospital care. — Standards and criteria for hospital personnel, equipment and designation that identify the necessary resources that hospitals must have in order to be recognized within Delaware’s inclusive statewide stroke care system as a specified category stroke facility. These standards and criteria shall be consistent with those identified in national stroke system references produced by national accreditation and certification organizations. All expenses associated with utilizing a nationally recognized accreditation team to verify a hospital’s compliance with hospital designation criteria will be the responsibility of the hospital being surveyed.

d. Rehabilitative care. — Standards for the follow-up care for persons with disabilities resulting from injuries.

e. Stroke continuing education. — The ongoing stroke-related education for stroke care system personnel/providers to maintain knowledge and skills.

f. Stroke care system evaluation. — Monitor policies and procedures regarding the effectiveness/impact of stroke care systems.

(3) Have the authority to promulgate rules for the management of all components of Delaware’s inclusive statewide stroke care system, and shall seek input and review from the Stroke System Committee.

(4) Maintain a program of stroke care system evaluation, including a stroke data collection and registry system and a mechanism for evaluating and monitoring system performance throughout the continuum of stroke care.

(j) The Director of the Division of Public Health shall have the authority to promulgate rules, in consultation with the Delaware Emergency Medical Services Advisory Council and the Director of the Division of Professional Regulation, to combine emergency medical services data and emergency department data about nonfatal overdoses with data from the Prescription Monitoring Program database.

63 Del. Laws, c. 383, §  1;  67 Del. Laws, c. 152, §  5;  70 Del. Laws, c. 186, §  1;  70 Del. Laws, c. 453, §  7;  72 Del. Laws, c. 137, §  28;  72 Del. Laws, c. 360, §  1;  75 Del. Laws, c. 194, §  1;  77 Del. Laws, c. 319, §  1;  80 Del. Laws, c. 18, §  3;  80 Del. Laws, c. 404, §  4;  81 Del. Laws, c. 429, § 3; 

(a) Confidentiality of quality review program and participants. — As used in this section, “records” means the recordings of interviews and all oral or written reports, statements, minutes, memoranda, charts, statistics, data and other documentation generated by the Trauma System Committee or its subcommittees for the stated purposes of trauma system medical review or quality care review and audit.

All quality management proceedings shall be confidential. Records of the Trauma System Committee, its quality care review committee and members, attendees and visitors at meetings held for stated purposes of trauma system medical review or quality care review and audit shall be confidential and privileged and shall be protected from direct or indirect means of discovery, subpoena or admission into evidence in any judicial or administrative proceeding. Raw data shall not be available for public inspection nor is it a public record within the meaning of the Delaware Freedom of Information Act [Chapter 100 of Title 29].

(b) Confidentiality of Delaware Emergency Medical Services Oversight Council (DEMSOC) quality review program and participants. — As used in this section, “records” means the recordings of interviews and all oral or written reports, statements, minutes, memoranda, charts, statistics, data and other documentation generated by the Delaware Emergency Medical Services Oversight Council (DEMSOC) or its subcommittees for the stated purposes of the Emergency Medical Services System medical review or quality care review and audit. All quality management proceedings shall be confidential. Records of DEMSOC, its quality care review subcommittees and members, attendees and visitors at meetings held for stated purposes of the Emergency Medical Services Systems medical review or quality care review and audit shall not be available for public inspection nor are they a public record within the meaning of the Delaware Freedom of Information Act, and shall be protected from direct or indirect means of discovery, subpoena or admission into evidence in any judicial or administrative proceeding. Raw data and original records relating to medical care shall not be available for public inspection nor are they a public record within the meaning of the Delaware Freedom of Information Act, except to the extent that such raw data and original records relating to medical care would have been subject to disclosure or discovery pursuant to other statute or court rule.

(c) Confidentiality of Emergency Medical Services for Children Advisory Committee. — Records of the EMSC Advisory Committee, its quality care review committee and members, attendees and visitors at meetings held for stated purposes of pediatric emergency care system medical review or quality care review and audit shall be confidential and privileged and shall be protected from direct or indirect means of discovery, subpoena or admission into evidence in any judicial or administrative proceeding. Raw data shall not be available for public inspection nor is it a public record within the meaning of the Delaware Freedom of Information Act [Chapter 100 of Title 29].

(d) Confidentiality of Stroke Quality Review Program and participants. — As used in this section “records” means the recordings of interviews and all oral or written reports, statements, minutes, memoranda, charts, statistics, data and other documentation generated by the Stroke System Committee or its subcommittees for the stated purposes of stroke system medical review or quality care review and audit. All quality management proceedings shall be confidential. Records of the Stroke System Committee, its Quality Care Review Committee and members, attendees and visitors at meetings held for stated purposes of stroke system medical review or quality care review and audit shall be confidential and privileged and shall be protected from direct or indirect means of discovery, subpoena, or admission into evidence in any judicial or administrative proceeding. Raw data shall not be available for public inspection nor is it a public record within the meaning of the Delaware Freedom of Information Act [Chapter 100 of Title 29].

(e) Immunity. — No person shall be subject to, and shall be immune from, any claim, suit, liability, damages or any other recourse, civil or criminal, arising from any act or proceeding, decision or determination undertaken or performed, or recommendation made while discharging any duty or authority under this chapter, so long as such person acted in good faith without malice, and within the scope of his or her duty or authority under this chapter or any other provisions of the Delaware law, federal law or regulations or duly adopted rules and regulations providing for the administration of this chapter, good faith being presumed until proven otherwise, with malice required to be shown by the complainant.

(f) Confidentiality of overdose system of care review program and participants. — (1) For purposes of this subsection, “records” means recordings of interviews and all oral or written reports, statements, minutes, memoranda, charts, statistics, data, and other documentation generated by the Overdose System of Care Committee or its ad hoc committees for the stated purpose of overdose system medical review or quality care review and audit.

(2) All overdose system medical review or quality management proceedings are confidential.

(3) Records and raw data collected or created by the Overdose System of Care Committee and members, attendees, and visitors at meetings held for the stated purpose of overdose system medical review, quality care review, or audit are confidential and privileged and are be protected from direct or indirect means of discovery, subpoena, or admission into evidence in any judicial or administrative proceeding and are specifically excluded from the definition of public record as set forth at § 10002 of Title 29.

70 Del. Laws, c. 453, §  8;  70 Del. Laws, c. 186, §  1;  73 Del. Laws, c. 52, §  1;  78 Del. Laws, c. 326, §  3;  80 Del. Laws, c. 404, §  4;  81 Del. Laws, c. 428, § 3; 

(a) Public safety personnel who in good faith renders emergency care or rescue assistance at the scene of any emergency or who undertakes to transport any victim thereof to the nearest medical facility is not liable for any civil damages as a result of any act or omission in rendering the emergency care if all of the following apply:

(1) The public safety personnel has any required, relevant, current training or certification.

(2) The public safety personnel did not cause the injuries or death wilfully, wantonly, or recklessly or by gross negligence.

(b) This section may not be construed to require public safety personnel to administer first aid or emergency care to an individual who is ill or injured if such individual objects.

81 Del. Laws, c. 265, § 4; 

(a) The Advanced Life Support Standards Committee is created for the purpose of assisting the Board of Medical Licensure and Discipline in developing standards for advanced life support services. The Standards Committee is composed of the Chairperson and 20 members. The Board of Medical Licensure and Discipline shall appoint the Chairperson. The Board of Medical Licensure and Discipline shall select the other members of the Standards Committee from the names submitted to the Board by resolution of the following organizations:

(1) The American College of Emergency Physicians, 3 members with 1 member representing each county.

(2) The American College of Surgeon’s Committee on Trauma, 1 member.

(3) The Medical Society of Delaware, 1 member.

(4) The Delaware Chapter of the Emergency Department Nurses Association, 1 member.

(5) Sussex County Firefighter’s Association, 1 member who is an active practicing ambulance attendant.

(6) Kent County Firefighter’s Association, 1 member who is an active practicing ambulance attendant.

(7) New Castle County Firefighter’s Association, 1 member who is an active practicing ambulance attendant.

(8) The State of Emergency Medical Services Office, 1 member.

(9) The State Fire Prevention Commission, 1 member.

(10) New Castle County government, 1 member.

(11) Kent County government, 1 member.

(12) Sussex County government, 1 member.

(13) The City of Wilmington, 1 member.

(14) The City of Dover, 1 member.

(15) The Delaware Chapter of the American Heart Association, 1 member.

(16) The Division of Public Health, 1 member.

(17) Delaware State Fire School, 1 member.

(18) The chief or director of each county paramedic service shall submit 1 name of a practicing paramedic, certified and employed in the State for selection to the Board of Medical Licensure and Discipline — from these 3 names, 1 member.

(b) Each member serves at the pleasure of the organization that member represents and each member’s successor shall be chosen in a like manner. The Standards Committee shall meet at the call of the Chairperson of the Standards Committee or the Chairperson of the Board of Medical Licensure and Discipline.

(c) The Standards Committee shall provide technical assistance to the Board of Medical Licensure and Discipline regarding all of the following:

(1) Establishing of minimum standards for advanced life support services.

(2) Reviewing curricula for training programs submitted to the Board of Medical Licensure and Discipline.

(3) Providing recommendations on proposed curricula for training programs.

81 Del. Laws, c. 265, § 5; 

(a) The Secretary shall create an overdose system of care to coordinate the treatment and care provided to individuals who have overdosed or require acute management of substance use disorder, including opioid use disorder.

(b) (1) The Secretary may adopt regulations, policies, and procedures to permit the Director of the Division of Substance Abuse and Mental Health to designate a facility as a stabilization center.

(2) A facility may be designated as a stabilization center if the facility meets federal and State requirements to receive a patient from Emergency Medical Services and can do all of the following:

a. Provide medical care and supervision after an overdose.

b. Provide medical care and supervision for acute management needs for substance use disorder.

c. Initiate medication-assisted treatment.

d. Refer individuals to other services.

(c) (1) The Secretary may adopt regulations, policies, and procedures to designate a facility as an overdose system of care center.

(2) The Secretary must use a guideline and evidence-based process as recommended by the Overdose System of Care Committee to determine designation criteria.

(d) The Secretary may adopt regulations, policies, and procedures to establish other distinct categories of care in the overdose care system as supported by evidence and recommended by nationally recognized guidelines and the Overdose System of Care Committee.

(e) The Secretary may suspend or revoke a designation under this section if a facility fails to meet the standards established under this section.

(f) The Director of the Division of Public Health may include an acute health care facility, hospital, freestanding emergency department, or emergency medical services provider in the overdose system of care if the entity does all of the following:

(1) Participates in the care of patients who have overdosed or require acute management for substance use disorder.

(2) Contributes data required by the Director of the Division of Public Health or the Director of the Division of Substance Abuse and Mental Health.

(3) Participates in overdose system of care quality improvement.

81 Del. Laws, c. 428, § 4; 

(a) The Secretary shall establish an Overdose System of Care Committee to assist in oversight of the overdose system of care.

(1) The Co-Chairs of the Overdose System of Care Committee are as follows:

a. The Director of the Division of Public Health, or a designee appointed by the Director of the Division of Public Health.

b. The Director of the Division of Substance Abuse and Mental Health, or a designee appointed by the Director of the Division of Substance Abuse and Mental Health.

(2) The Overdose System of Care Committee must include all of the following, appointed by the Secretary:

a. One member from the Department of Homeland Security.

b. One member from the Department of Correction.

c. The Director of the Division of Medicaid and Medical Assistance or their designee.

d. One member from the Drug Overdose Fatality Review Commission.

e. One member from the State Fire Prevention Commission.

f. One member who is the Chair of the Behavioral Health Consortium.

g. One member who is an advanced life support prehospital provider.

h. One member who is a basic life support prehospital provider.

i. One member who is an emergency medical dispatcher.

j. One member who is a law-enforcement officer.

k. One member from the Delaware Healthcare Association.

l. One member who is an emergency medicine physician.

m. One member, or a designee appointed by the member, who is a hospital administrator from each acute health-care facility which holds or intends to seek designation as an overdose system of care center under § 9710 of this title.

n. Three members who are addiction treatment professionals, such as a physician, nurse, mental health provider, Nationally Certified Peer Recovery Specialist, or treatment administrator.

(3) The Overdose System of Care Committee shall meet at least quarterly.

(4) The Overdose System of Care Committee may establish ad hoc committees as deemed appropriate.

(b) The Overdose System of Care Committee shall advise the Director of Public Health and the Director of the Division of Substance Abuse and Mental Health on all of the following:

(1) Improving outcomes for Delaware overdose patients that are based on Delaware drug misuse, overdose, and death data.

(2) Rules governing the operation of the overdose system of care facility, under § 9710 this title.

(3) Recommendations to improve or correct problems identified regarding the following:

a. Overdose system of care operations, including the monitoring for adherence to adopted policies, procedures, protocols, and standards.

b. The delivery of services by emergency medical services and health care service providers to overdose patients.

c. The availability of appropriate resources.

d. The periodic review of pre-hospital, hospital, freestanding emergency department, and stabilization center designation criteria.

(4) Recommendation for modifications of the policies, procedures, and protocols of the overdose system of care as a result of system-wide review.

(c) The Overdose System of Care Committee shall function in cooperation with the Behavioral Health Consortium, as well as other state health policy activities.

(d) The Overdose System of Care Committee may not do either of the following:

(1) Direct or interfere with a state agency or a service provider’s internal review process for investigating and evaluating critical incidents and deaths.

(2) Direct Department of Health and Social Services resources, personnel, or activities.

81 Del. Laws, c. 428, § 4;  83 Del. Laws, c. 383, § 2;