table of contents ems policy summaries

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1 table of contents ems policy summaries Policy 9 DESTINATION DETERMINATION BASIC PROCEDURE Policy 9 DESTINATION DETERMINATION 5150/OBSTETRIC Policy 9 DESTINATION DETERMINATION DIALYSIS/ROSC/BURN...91 Policy 10 DECLINING MEDICAL CARE OR TRANSORT (AMA)...92 Policy 13 TRAUMA TRIAGE ACTIVATION CRITERIA...93 Policy 13 TRAUMA TRIAGE DESTINATION CRITERIA Policy 19 DETERMINATION OF DEATH Policy 20 DNR AND POLST ORDERS...97 Policy 23 ABUSE REPORTING RESPONSIBILITIES Policy 30 RESTRAINTS Policy 33c HELICOPTER TRANSPORT CRITERIA Policy 36 HAZARDOUS MATERIALS EXPOSURE MANAGEMENT Policy ACTIVATION FOR NON-EMERGENCY TRANSPORT PROVIDERS Policy Summaries

2 88 Policy Summaries

3 9 SUMMARY DESTINATION DETERMINATION BASIC PROCEDURE Field personnel shall assess a patient to determine if the patient is unstable or stable Patient stability must be considered along with a number of additional factors in making destination and transport code decisions FACTORS TO CONSIDER UNSTABLE PATIENTS STABLE PATIENTS Patient or family s choice of receiving hospital and ETA to that facility Recommendations from a physician familiar with the patient s current condition Patient s regular source of hospitalization or health care Ability of field personnel to provide field stabilization or emergency intervention ETA to the closest basic emergency department Traffic conditions Hospitals with special resources Hospital diversion status Usually transported to the closest appropriate acute care hospital emergency department or specialized care centers if indicated If the patient or family requests, or if other factors exist which indicate that another facility be considered, field personnel are to contact the base hospital and present their findings, including ETAs to both facilities. Base personnel will assess the benefits of each destination and may direct field personnel to a facility other than the closest. Stable patients are transported to appropriate acute care hospitals within reasonable transport times based on patient s/family preference If a patient does not express a preference, the hospital where the patient normally receives health care or the closest ED is to be considered Policy Summaries 89

4 9 SUMMARY PATIENTS ON 5150 HOLDS OBSTETRIC PATIENTS DESTINATION DETERMINATION 5150/OBSTETRIC A patient placed on a 5150 hold in the field shall be assessed for the presence of a medical emergency. Based upon the history and physical examination of the patient, field personnel shall determine whether the patient is stable or unstable. Stable patients on 5150 holds shall be transported to Contra Costa Regional Medical Center. Unstable patients on 5150 holds shall be transported to the closest acute care hospital: A patient with a current history of overdose of medications is to be considered unstable A patient with history of ingestion of alcohol/illicit street drugs is considered unstable if: Significant alteration in mental status (e.g., decreased LOC or extremely agitated); or Significantly abnormal vital signs; or Any other history or physical findings that suggest instability (e.g. chest pain, shortness of breath, hypotension, diaphoresis) A patient is considered Obstetric if pregnancy is estimated to be of 20 weeks duration or more. Obstetric patients should be transported to hospitals with in-patient OB services in the following circumstances: Patients in labor Patients whose chief complaint appears to be related to the pregnancy, or who potentially have complications related to the pregnancy Injured patients who do not meet trauma criteria or guidelines Obstetric patients with impending delivery or unstable conditions where imminent treatment appears necessary to preserve the mother s life should be transported to the nearest basic emergency department Stable obstetric patients should be transported to the emergency department of choice if their complaints are clearly unrelated to pregnancy 90 Policy Summaries

5 9 SUMMARY DIALYSIS PATIENTS CARDIAC ARREST PATIENTS WITH ROSC BURN PATIENT DESTINATION GENERAL DESTINATION PRINCIPLES PATIENT SELECTION FOR INITIAL TRANSPORT TO BURN CENTER PROCEDURE FOR BURN CENTER DESTINATION DESTINATION DETERMINATION DIALYSIS/ROSC/BURN Dialysis patients often require definitive care at a center that provides acute dialysis services. The preferable destination for this type of patient is the hospital at which the patient has received dialysis care (if applicable). Patients in extremis will need transport to the closest ED. Cardiac arrest patients who have return of spontaneous circulation (ROSC) should be transported to the closest STEMI Receiving Center. Burned patients with unmanageable airways should be transported to the closest basic ED Patients with minor burns and moderate burns can be cared for at any acute care hospital Adult and pediatric patients with burns and significant trauma should be transported to the closest appropriate trauma center The following patients may be appropriate for initial transport to a Burn Center: Partial thickness (2nd degree) greater than 20% TBSA Full thickness (3 rd degree) greater than 10% Chemical or high voltage electrical burns Smoke inhalation with external burns Contact Burn Center prior to transport to confirm bed availability Consult base hospital if any questions regarding destination decision Policy Summaries 91

6 10 SUMMARY DECLINING MEDICAL CARE OR TRANSPORT (AMA) All qualified persons are permitted to make decisions affecting care, including the ability to decline care PATIENT Any person encountered by EMS personnel who demonstrates any known or suspected illness or injury OR is involved in an event with significant mechanism that could cause illness or injury OR who requests care or evaluation COMPETENCY The ability to understand and to demonstrate an understanding of the nature of the illness/injury and the consequence of declining medical care QUALIFIED PERSON A competent person making decision for him/herself or another qualified by: An adult patient defined as a person who is at least 18 years old; A minor (under 18 years old) who qualifies based on one of the following conditions: A legally married minor; A minor on active duty with the armed forces; A minor seeking prevention / treatment of pregnancy or treatment related to sexual assault; A minor, 12 years of age or older, seeking treatment of contact with an infectious, contagious or communicable disease or sexually transmitted disease; A self-sufficient minor at least 15 years of age, living apart from parents and managing his/her own financial affairs; An emancipated minor (must show proof); OR The parent of a minor child or a legal representative of the patient (of any age). Spouses or relatives cannot consent to or decline care for the patient unless they are legally designated representatives. BASE CONTACT REQUIREMENTS When, in the field personnel s opinion, patient s decision to decline care poses a threat to his/her well being If the patient s competency status is unclear (neither competent nor clearly incompetent) and treatment or transport is felt to be appropriate Any other situation in which, in the field personnel s opinion, that base contact would be beneficial in resolving treatment or transport issues 92 Policy Summaries

7 13 SUMMARY TRAUMA ACTIVATION CRITERIA (DIRECT TRAUMA CENTER TRANSPORT) The following meet activation criteria and merit direct transport to the trauma center: PHYSIOLOGIC CRITERIA ANATOMIC CRITERIA MECHANISM CRITERIA COMBINED CRITERIA (COMBINED MECHANISM AND PHYSICAL FINDINGS) BP < 90 in adults GCS 13 or below if not pre-existing Penetrating injury to head, neck, torso, groin, pelvis or buttocks Fracture of femur Fracture of long bone(s) resulting from penetrating trauma Traumatic Paralysis Amputation above wrist or ankle Major burns associated with trauma Crushed, mangled, or degloved extremity Motor vehicle crash with: Extrication > 20 minutes Fatalities in the same vehicle Ejection Unrestrained motor vehicle crash with: Head on mechanism > 40 mph Extrication required Fall 15 feet or greater Auto vs. pedestrian/bicyclist thrown, run over, or struck with significant impact (>20 mph) Note: In the absence of significant symptoms or physical findings with these mechanisms, call base hospital for destination determination Motorcycle crash with: Abdominal or chest tenderness, or Suspected loss of consciousness Unrestrained motor vehicle crash with abdominal tenderness Note: Patients with unmanageable airways or traumatic arrest not meeting field determination criteria should be transported to the closest receiving facility. Policy Summaries 93

8 13 SUMMARY BASE CONTACT REQUIRED FOR DESTINATION DETERMINATION MECHANISMS OF INJURY TRAUMA DESTINATION CRITERIA If not meeting activation criteria (direct transport), base contact should be made in the following situations to determine destination: High-energy mechanisms of injury Low-energy mechanisms with risk factor(s) and/or symptoms/physical findings Uncertain mechanism with risk factor(s) and/or symptoms/physical findings EMS Provider Concern High-energy mechanisms include: Motor vehicle crash with one or more of the following: Intrusion of passenger space by one foot or greater Impact estimated 40 mph or greater Person requiring disentanglement Vehicle rollover with unrestrained occupant Person struck by vehicle (less than 20 mph) Person ejected from moving object (motorcycle, horse, etc.) Blunt assault with weapon (e.g. pipe, bat) Lower energy mechanisms of injury include: Ground level or short fall Blunt assault without weapon Lower-speed motor vehicle crash Other blunt trauma (e.g. sports injury) Other: Uncertain trauma mechanism but trauma suspected Patients with trauma remote to time of EMS call (e.g. several hours) 94 Policy Summaries

9 13 SUMMARY RISK FACTORS SYMPTOMS AND PHYSICAL FINDINGS TRAUMA DESTINATION CRITERIA Age 60 and over Patient taking anticoagulants or known bleeding disorder Pregnancy over 20 weeks Communication barrier with patient (e.g. age, language, psychiatric or developmental issues) Significant signs or symptoms of injury, including: Vital Signs: Any concerns due to hypotension, tachycardia, or tachypnea Systolic BP under 110 in patient age 60 or over Pain level greater than 5 related to torso, head or neck injury Head Injury: Loss of consciousness Repetitive questioning Abnormal or combative behavior New onset of confusion Vomiting Headache Torso Injury: Tenderness to palpation of abdomen, chest/ribs or back/flank Suspected hip dislocation or pelvis injury Policy Summaries 95

10 19 SUMMARY OBVIOUS DEATH MEDICAL ARREST TRAUMATIC ARREST DETERMINATION OF DEATH Pulseless, non-breathing patients with any of the following: Decapitation, Total Incineration, Decomposition Total destruction of the heart, lungs, or brain, or separation of these organs from the body Rigor mortis or post-mortem lividity without evidence of hypothermia, drug ingestion, or poisoning. In patients with rigor mortis or post-mortem lividity: Attempt to open airway, assess for breathing for at least 30 seconds; assess pulse for 15 seconds Rigor, if present, should be noted in jaw and/or upper extremities If any doubt exists, place cardiac monitor to document asystole in 2 leads for 1 minute Mass casualty situations Definition: Cardiac arrest with total absence of observers or witness information; or cardiac arrest in which witness information states arrest occurred greater than 15 minutes prior to arrival of prehospital personnel and no resuscitative measures have been done. Procedure: BLS personnel Follow Public Safety defibrillation guideline ALS personnel Do not initiate CPR; Assess for presence of apnea, pulselessness (no heart tones/no carotid or femoral pulses), document asystole in 2 leads for 1 minute Does not apply if hypothermia, drug ingestion or poisoning is suspected Definition: Blunt or penetrating traumatic arrest Procedure: BLS personnel Follow Public Safety defibrillation guideline ALS personnel Do not initiate CPR; Assess for presence of apnea, pulselessness (no heart tones/no carotid or femoral pulses), document asystole or wide-complex pulseless electrical activity (PEA) at rate of 40 or less 96 Policy Summaries

11 20 SUMMARY VALID DNR ORDERS COMPLYING WITH AN HONORED DNR ORDER COMPLYING WITH A POLST ORDER (NOT IN ARREST) NO VALID DNR ORDER PRESENT AND REQUEST MADE FOR NO RESUSCITATION DNR AND POLST ORDERS A California EMSA/CMA Prehospital DNR Form A California/EMSA POLST form in which Section A (Do Not Attempt Resuscitation/DNR) has been chosen An Advanced Health Care Directive (includes living will or Durable Power of Attorney for Health Care) presented by an agent of the patient empowered to make health care decisions for the patient An EMS-approved standard DNR medallion/bracelet e.g. Medi-Alert A DNR order in the medical record of a licensed healthcare facility (e.g. acute care hospital, skilled nursing facility, hospice or intermediate care facility) signed by a physician. Electronic physician orders are considered signed and will be honored. A verbal DNR order given by the patient s physician who is present at the scene Verify identity of patient Perform no life-saving measures Cancel the responding ambulance Verify identity of patient. Review section B. If Full Treatment marked, patient receives full care If Limited Additional Interventions or Comfort Measures Only is marked, no advanced airway should be done Section C does not apply to pre-hospital setting If the patient presents with advanced or terminal disease and incomplete forms or no forms are presented and an immediate family member, agent, or conservator requests no resuscitation, resuscitative measures may be withheld if there is complete agreement of family and providers on scene. Immediate family members include spouse, domestic partner, adult child(ren) or adult sibling(s) of the patient. No base contact is required. If any question of circumstances or disagreement of family or providers, proceed with resuscitation. Policy Summaries 97

12 23 SUMMARY ABUSE REPORTING RESPONSIBILITIES EMS personnel are mandated reporters. Report when there is reason to suspect abuse, which may be of a physical, sexual, or financial nature, or may involve neglect or domestic violence toward a child, elder, or dependent adult. BASIC ACTIONS Notify the appropriate law enforcement agency immediately if the scene is unsafe or it is suspected that a crime has been committed Make reasonable efforts to transport the patient to a receiving hospital for evaluation, and advise the receiving hospital staff of abuse/neglect suspicions Document observations and findings on the patient care report Contact the appropriate reporting agency by telephoning immediately or as soon as reasonably possible to provide a verbal report CHILD ABUSE REPORTING ELDER ABUSE REPORTING (LONG-TERM CARE FACILITY) Call Children & Family Services Screening Unit: (all numbers are 24 hours/day) at Complete a Suspected Child Abuse Report Form within 2 working days (SS 8572) (available online at ) If the alleged abuse has occurred in a long-term care facility: Call Ombudsman Services of Contra Costa (925) to make a verbal report 24-Hour Crisis Line: Complete a Suspected Dependent Adult/Elder Abuse Form within 2 working days (SOC 341). Available at: entres/forms/english/soc341.pdf 98 Policy Summaries

13 23 SUMMARY ELDER ABUSE REPORTING (ALL OTHER SITES) SEXUAL ASSAULT DOMESTIC VIOLENCE ABUSE REPORTING RESPONSIBILITIES (CON'T) If the alleged abuse has occurred anywhere else (not at a long-term care facility): Call Adult Protective Services (925) or to make a verbal report Complete a Suspected Dependent Adult/Elder Abuse Form within 2 working days (SOC 341). Available at: entres/forms/english/soc341.pdf Sexual assault shall be reported as above in situations involving elder, dependent adult, child, or domestic violence. It is recommended to transport patients who have been sexually assaulted to Contra Costa Regional Medical Center for evaluation and evidentiary exam; however, the patient may be transported to the receiving hospital of choice or if medically unstable to the most appropriate facility for medical care Discourage any activity that would compromise evidence collection prior to transport such as bathing, brushing teeth, brushing hair, urinating, defecating or changing clothes Reporting responsibilities are fulfilled by notifying the local law enforcement agency, and by reporting suspicions and patient findings to receiving hospital staff (if transported) Policy Summaries 99

14 30 SUMMARY RESTRAINTS RESTRAINT TYPES Leather or soft restraints may be used during transport Handcuffs may only be used during transport if law enforcement accompanies the patient in the ambulance. Patients may not be handcuffed to the gurney Chemical restraint RESTRAINT ISSUES Patients shall be placed in Fowler s or Semi-Fowler s position Patients shall not be restrained in hogtied or prone position Method of restraint should allow for monitoring of vital signs and respiratory effort and should not restrict the patient or rescuer s ability to protect the airway should vomiting occur Restrained extremities should be monitored for circulation, motor and sensory function every 15 minutes LAW ENFORCEMENT ROLE TRANSPORT ISSUES Law enforcement agencies are responsible for capture and/or restraint of assaultive or potentially assaultive patients Law enforcement agencies retain responsibility for safe transport of patients under arrest or on 5150 holds Patients under arrest or 5150 hold should undergo a weapons search by law enforcement personnel Patients under arrest must be accompanied by law enforcement personnel If an unrestrained patient becomes assaultive during transport, ambulance personnel shall request law enforcement assistance, and make reasonable efforts to calm and reassure the patient If the crew believes their personal safety is at risk, they should not inhibit a patient's attempt to leave the ambulance. Every effort should be made to release the patient into a safe environment. Ambulance personnel are to remain on scene until law enforcement arrives to take control of the situation. 100 Policy Summaries

15 33C SUMMARY HELICOPTER TRANSPORT CRITERIA USE HELICOPTER ONLY WHEN BOTH TIME AND CLINICAL CRITERIA ARE MET TIME CRITERIA Helicopter transport generally should be used only when it provides a time advantage. Helicopter field care and transport time (which includes on-scene time, flight time, and transport from helipad to the emergency department) is optimally minutes in most cases. Also consider: Time to ground transport to a rendezvous site, or a time delay in helicopter arrival Exception: Patients with potential need for advanced airway intervention (GCS 8 or less, trauma to neck or airway, rapidly decreasing mental status) may be appropriate even when time criteria not met CLINICAL CRITERIA Trauma patients who meet activation criteria according to EMS trauma triage policy, except for: Stable patients with isolated extremity trauma Patients with mechanism but no significant physical exam findings Trauma patients who do not meet activation criteria but by evaluation of mechanism and physical exam findings, appear to have potential significant injuries that merit rapid transport Patients with specialized needs available only at a remote facility such as burn victims/critical pediatric Critically ill or injured patients whose conditions may be aggravated or endangered by ground transport (e.g. limited access via ground ambulance or unsafe roadway) USE AND CANCELLATION The decision to use or cancel a helicopter rests with the Incident Commander (IC). If criteria not met, helicopter should be cancelled. Considerations for IC: Patient need Estimated ground transport time versus air response and transport Proximity of a helispot or need for a helicopter/ ambulance rendezvous site ETA of the helicopter Policy Summaries 101

16 36 SUMMARY HAZMAT RECOGNITION WHILE RESPONDING HAZMAT RECOGNITION WHILE ON SCENE HAZARDOUS MATERIALS EXPOSURE MANAGEMENT PRINCIPLES If alerted to a known or suspected hazmat exposure prior to scene arrival: Request from dispatch the location and safe route to staging area or IC If no staging area, determine location and safe route to report to IC Do not enter contaminated areas or approach contaminated patients until cleared to do so by Incident Commander or designee Decontaminate patient Appropriately trained personnel shall perform decontamination in a designated area Obtain clearance from IC prior to transport Obtain MSDS for chemical if available After patient decontamination, provide care as indicated per treatment guidelines Provide early alert to hospital repeat decontamination may be needed If EMS personnel become aware that a patient in their care may have been contaminated by a unknown or suspected hazardous material: EMS personnel should consider themselves contaminated Minimize exposure by evacuating to an uphill/ upwind safe location If in cloud, travel crosswind until out of cloud Notify fire/medical dispatch and IC of exposure Request Hazardous Materials response team through Sheriff s Dispatch Request backup Fire/Transport as needed for affected EMS personnel and patients 102 Policy Summaries

17 36 SUMMARY HAZMAT RECOGNITION WHILE ON SCENE (CONTINUED) HAZMAT RECOGNITION WHILE TRANSPORTING GENERAL GUIDELINES FOR ALL SITUATIONS HAZARDOUS MATERIALS EXPOSURE MANAGEMENT PRINCIPLES Remain in safe area until Incident Commander arrives and provides further instructions Prepare to be decontaminated Decontaminate EMS personnel and patient(s) Appropriately trained personnel shall perform decontamination in a designated area. If EMS personnel become aware while transporting that a patient may have been contaminated by a known or suspected hazardous material: EMS personnel should consider themselves contaminated Determine if safe to drive (e.g. rescuers with or without symptoms) If not safe to drive, immediate decontamination is needed. Stop transport, notify Fire/Medical Dispatch and request CCHS HazMat response. Request Fire/Transport backup as needed. Protect from further exposure and prepare to be decontaminated. If safe to drive (decontamination is not immediately indicated), proceed to hospital decontamination staging area. Alert hospital early of the HazMat situation. Request staging site if not known. Prepare to be decontaminated. Provide prehospital medical care as soon as it is safe All precautions should be taken to prevent contamination of hospital emergency department and personnel Policy Summaries 103

18 POLICY 39 SUMMARY ACTIVATION FOR NON-EMERGENCY TRANSPORT PROVIDERS Criteria for upgrade to advanced life support (ALS) for non-emergency transport providers DEFINITIONS Unstable: A patient who has life- or limb-threatening condition requiring immediate and definitive care. An unstable patient may have respiratory distress, airway compromise, neurological changes from baseline, signs of actual or impending shock or may meet criteria for transport directly to a trauma center. Non-emergency ambulance provider: An ambulance provider holding a valid Contra Costa non-emergency ambulance permit ambulance provider: An ambulance provider holding a valid Contra Costa emergency ambulance permit and/or contracting with the County to provide advanced life support ambulance response to requests Code 3: Responding to a location and/or transporting to a receiving facility using red lights and sirens UNSTABLE PATIENTS A patient, determined to be unstable and/or needing Code 3 transportation to a hospital shall be transported by a provider, whenever possible. Non-emergency ambulance providers may transport an unstable patient to the closest/appropriate facility, if they can do so safely and the time from arrival on scene to arrival at the hospital is less than 10 minutes. In all other cases the nonemergency ambulance crew shall activate the system and request an ALS response. Any non-emergency ambulance provider transporting a patient that becomes unstable during transport should divert to the closest/ appropriate ED per the Patient Destination Determination Policy (Policy #9). Receiving facilities should receive notification as soon as possible of the need for diversion, patient status and the ETA to that facility. All transports by non-emergency ambulance providers of unstable patients, and/or transports requiring Code 3 transportation are considered an unusual occurrence. For each such occurrence an EMS Event report must be completed and submitted to the EMS Agency within 24 hours of the call. 104 Policy Summaries

19 POLICY 39 SUMMARY ON-VIEWS ACTIVATION FOR NON-EMERGENCY TRANSPORT PROVIDERS In the event that a non-emergency ambulance provider arrives on the scene of a collision, illness or injury by coincidence, the crew shall provide appropriate care and immediately activate the system Policy Summaries 105

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