Contra Costa County - San Ramon Valley Fire

Contra Costa County

Emergency Medical Services Policies and Procedures Notice Updates may occur throughout the calendar year. Visit www.cccems.org for updates.

Contra Costa Emergency Medical Services

EMS POLICIES AND PROCEDURES

Contra Costa Emergency Medical Services reviews and updates policies and procedures annually. Contra Costa Emergency Medical Services Agency approves the following policies and procedures for the 2009 Calendar year.

Art Lathrop, EMS Director

Joseph Barger, MD, EMS Medical Director

EMS Policies #1-

EMT-1 Certification

#2-

Paramedic Accreditation

#3-

MICN Authorization And Re-Authorization

#4-

Contra Costa County EMS Fee Structure

#5-

Prehospital Credential Review Process

#6-

Prehospital Continuing Education Provider

#7-

Paramedic Evaluator

#8-

EMS Quality Improvement Program (EQIP)

#9-

Patient Destination Determination

# 10 -

Declining Emergency Medical Care And/Or Transport

# 11 -

Base Hospital Communications/Disrupted Communications

# 12 -

EMS System Medical Direction And Oversight

# 13 -

Triage Of Trauma Patients

# 14 -

Transfers To Trauma Centers

# 15 -

Hospital Guidelines For Interfacility Transfers Via Ambulance

# 16 -

Transfer Of Care In The Field

# 17 -

EMT/Paramedic Or Non-Transport ALS Programs

# 18 -

Public Safety//EMT AED Programs

# 19 -

Determination Of Death In The Prehospital Setting

# 20 -

Do Not Resuscitate (DNR) Orders and Physician Orders for Life-Sustaining Treatment (POLST) in the Prehospital Setting

# 21 -

Physician On Scene

# 22 -

Infectious Disease Precautions And Exposure Management For EMS Personnel

# 23 -

Abuse/Assault Reporting

# 24 -

Hospital CT And Physical Plant Casualty Diversion

# 25 -

STEMI Triage And Destination

# 26 -

EMS STEMI Receiving Center Designation

# 27 -

Prehospital Patient Care Record (PCR)

# 28 -

Paramedic Interfacility Transfer (CCT-P) Program Standards

# 29 -

Base Hospital Designation

# 30 -

Managing Assaultive Behavior/Patient Restraint

# 31 -

Prehospital Management of Pre-Existing Patient Medical Devices/Equipment: Intravenous Lines And Other

# 32 -

EMS Event Reporting

# 33 -

EMS Aircraft Policies And Procedures A – Classification B – Authorization C – Request, Transport Criteria, And Field Operations

# 34 -

Search For Donor Card

CONTRA COSTA COUNTY HEALTH SERVICES DEPARTMENT Emergency Medical Services Agency Policy Updates Date Updated 8/17/09 8/10/09 1/1/09 1/1/09 1/1/09

1/1/09 1/1/09

1/1/09

1/1/09 1/1/09

9/8/08 9/8/08 7/1/08 12/1/07

Policy Number/Name 25 – STEMI Triage and Destination 22 – Infectious Disease Precautions And Exposure Management For EMS Personnel 12 – EMS System Medical Direction and Oversight 18 – Public Safety/EMT AED Programs 20 – Do Not Resuscitate (DNR) Orders and Physician Orders for Life-Sustaining Treatment (POLST) in the Prehospital Setting 29 – Base Hospital Designation 31 – Prehospital Management of Pre-Existing Patient Medical Devices/Equipment: Intravenous Lines and Other 33C – EMS Aircraft – Request, Transport Criteria, and Field Operations 34 – Search for Donor Card 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 15, 16, 17, 19, 20, 21, 22, 24, 27, 28, 30, 32, 33A, 33B 25 - STEMI Triage and Destination 26 – EMS STEMI Receiving Center Designation 23 – Abuse/Assault Reporting 9 – Patient Destination Determination

12/1/07

19 – Determination of Death in the Prehospital Setting

12/1/07

20 – Do Not Resuscitate (DNR) Orders In The Prehospital Setting 24 – Hospital CT and Physical Plant Casualty Diversion

12/1/07

12/1/07

27 – Prehospital Patient Care Record (PCR)

12/1/07

32 – EMS Event Reporting

8/14/2009

Change Added Sutter Delta Medical Center on 8/17/09 as a STEMI Receiving Center Policy enhanced to include H1N1 and nonbloodborne disease exposure information Section on Optional Scope Procedures and Medications added Clarified reporting requirements Changed to incorporate the POLST form

New policy Rewritten for clarity

Incorporates 33C, 33D and 33E into one policy. Revises transport criteria and clarifies cancellation procedures. Updated references to State regulations Reformatted only

New policy New policy Phone numbers and web addresses updated Policy rewritten for clarity. Added Section F regarding hospital diversion (moved from policy 24) – deleted Section VI regarding stable patients and base contact for transports longer than 45 minutes Added assessment information for patients meeting obvious death criteria due to rigor mortis or postmortem lividity Rewritten for clarity Title changed from Emergency Department Diversion And Unusual Event Notification – removed references to ED diversion – moved CT diversion instructions for field personnel to policy 9. Revised to add documentation requirements when medical care is declined. Title changed from Reporting of Unusual Prehospital Occurrences. Defines ‘EMS Events’ and revised process for reporting and reviewing.

POLICY #: Contra Costa Emergency Medical Services

EMT CERTIFICATION I.

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EFFECTIVE: 01/01/09 REVIEWED: 11/01/08

PURPOSE To identify the Emergency Medical Technician (EMT) certification and recertification process in Contra Costa County.

II.

CERTIFICATION A.

The following requirements apply to all applicants who have never been certified as an EMT-I. 1.

Be eighteen (18) years of age or older.

2.

Provide a current photo ID (CA drivers license, CA ID card or passport).

3.

Provide an EMT-I course completion record from an approved EMT-I training program.

4.

Provide documentation of successful completion of the National Registry of Emergency Medical Technicians (NREMT) written exam within the past two (2) years.

5.

Provide a valid and current CPR card.

6.

Apply for certification within two (2) years of the date of course completion.

7.

Complete a Contra Costa County EMT-I, certification application.*

8.

Complete a Department of Justice Criminal Offender Record Information (CORI) background check.*

9.

Pay the established certification application fee.

Upon completion of #1-9 above, and confirmation that the applicant is not precluded from certification for reasons defined in Section 1798.200 of the California Health and Safety Code, an individual shall be certified as an Emergency Medical Technician for a period of two (2) years from the last day of the month in which the certification process was completed. This certification is valid throughout the State of California. B.

The following requirements apply to a current and valid National Registry EMT-Basic, or a current and valid out-of-state or National Registry EMT-Intermediate, or Paramedic certificate. 1.


2.


3.

Provide documentation of current and valid out-of-state or National Registry certification.

4.


5.

Complete a Contra Costa County EMT-I certification application.*

6.


7.


Upon completion of #1-7 above, and confirmation that the applicant is not precluded from certification for reasons defined in Section 1798.200 of the California Health and Safety Code, an individual shall be certified as an Emergency Medical Technician. The expiration date shall be the same date as stated on the out-of-state or National Registry certification. This certification is valid throughout the State of California. C.

The following requirements apply to a current and valid out-of-state EMT-I certificate: 1.


2.



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3.

Provide documentation of current and valid out-of-state EMT-I certificate.

4.


5.


6.


7.


8.


Upon completion of #1- 8 above, and confirmation that the applicant is not precluded from certification for reasons defined in Section 1798.200 of the California Health and Safety Code, an individual shall be certified as an Emergency Medical Technician. The expiration date shall be the same date as stated on the out-of-state. This certification is valid throughout the State of California.

II.

D.

An individual currently licensed in California as a Paramedic or currently certified in California as an EMT-II is deemed to be certified as an EMT-I, except when the paramedic license or EMT-II certification is under suspension.

E.

Certification cards will be mailed to applicants following verification of documentation submitted with application.

MAINTAINING CERTIFICATION A.

To maintain certification, all candidates shall meet the following requirements and provide documentation to the EMS Agency: 1.

Possess a valid and current EMT-I certificate issued in California.

2.


3.

Successfully complete an approved EMT-I twenty four (24) hour refresher course within the two (2) year certification period. -ORProvide documentation verifying completion of a minimum of twenty four (24) hours of approved BLS continuing education within the two (2) year certification period.

4.

Submit a completed skills competency verification form (EMSA-SCV 07/03).*

5.


6.


7.

Complete a Department of Justice Criminal Offender Record Information (CORI) background check, if not already on file with the Contra Costa EMS Agency.*

8.

Pay the established recertification application fee.

Upon completion of #1-8 above, and confirmation that the applicant is not precluded from certification for reasons defined in Section 1798.200 of the California Health and Safety Code, an individual shall be recertified as an Emergency Medical Technician for a maximum of two (2) years from the last day of the month in which the certification requirements were completed. If the recertification requirements were met within six (6) months prior to the expiration date, the effective date of the certification shall be the expiration date of the current certification. B.



III.

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RECERTIFICATION AFTER LAPSE IN CERTIFICATION A.

All candidates for EMT-I recertification whose EMT-I or EMT-II certificate or Paramedic license has lapsed shall meet the following requirements: 1.

For a lapse of less than six (6) months: a)

Provide a copy of the expired certificate or license.

b)

Successfully complete an approved EMT-I twenty four (24) hour refresher course within the prior two (2) year period. -ORProvide documentation verifying completion of a minimum 24 four (24) hours of approved BLS continuing education within the prior two (2) year period.

2.

c)


d)


e)


f)


g)


h)


For a lapse of six (6) months or more, but less than twelve (12) months: a)


b)

Successfully complete an approved EMT-I twenty four (24) hour refresher course with the prior two (2) year period. -ORProvide documentation verifying completion of a minimum of twenty four (24) hours of approved BLS continuing education within the prior two (2) year period.

3.

c)

Provide documentation of an additional twelve (12) hours of continuing education for a total of thirty six (36) hours.

d)


e)


f)


g)


h)


i)


For a lapse of twelve (12) months or more, but less than twenty four (24) months: a)


b)

Successfully complete an approved EMT-I twenty four (24) hour refresher course within the prior two (2) year period.

c)

Provide documentation of an additional twenty four (24) hours of continuing education for a total forty eight (48) hours.


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d)


e)


f)

Submit a completed skills competency verification form (EMSA-SVC 07/03).*

g)


h)


i)


j)


4. For a lapse of twenty four (24) months or more, complete an entire EMT-I basic course. B.

Upon completion #1, 2, 3 or 4 above, and confirmation that the applicant is not precluded from certification for reasons defined in Section 1798.200 of the California Health and Safety Code, an individual shall be recertified as an Emergency Medical Technician for a maximum of two (2) years from the last day of the month in which the certification requirements were completed.

C.


*Available at the Contra Costa County EMS Agency or on the website: cccems.org


PARAMEDIC ACCREDITATION I.

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PURPOSE To identify the process for paramedic accreditation in Contra Costa County.

II.

ACCREDITATION A.

B.

All candidates shall meet the following accreditation requirements: 1)

Possess a current California paramedic license.

2)

Be employed as a paramedic with a designated ALS service provider or the EMS Agency.

3)

Attend a Contra Costa EMS Orientation provided by the provider agency and approved by the EMS Agency or provided by the EMS Agency.

4)

Successfully complete the Contra Costa County EMS Optional Scope Skills Session provided by the provider agency.

5)

Complete an application form, available online or at the provider agency or the EMS Agency.

Documentation that the accreditation requirements have been met must be submitted to the EMS Agency, by the applicant’s employer, with the candidate’s application and accreditation fee. The EMS Agency shall notify individuals applying for accreditation of the decision to accredit within thirty (30) days of application.

III.

MAINTAINING ACCREDITATION A.

B.

Accreditation to practice shall be continuous as long as: 1)

State licensure is maintained,

2)

Employment as a paramedic with a designated Contra Costa ALS service provider or the EMS Agency is maintained,

3)

A current and valid ACLS card, according to the standards of the American Heart Association is maintained,

4)

Verification of skills competency is completed every two years, and

5)

Any other local requirements are met.

Documentation that the above requirements to maintain accreditation have been met must be submitted by the applicant or the applicant’s employer prior to expiration of the paramedic’s license.


MICN AUTHORIZATION AND REAUTHORIZATION I.

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PURPOSE To identify the process for Mobile Intensive Care Nurse (MICN) authorization in Contra Costa County.

II.

AUTHORIZATION All candidates shall meet the following authorization requirements: A.

Prerequisite Criteria (Documentation that these criteria have been met must be submitted with the candidate's application for authorization.) 1.

Provide documentation of valid and current licensure as a Registered Nurse in the State of California.

2.

Provide documentation of a valid, current ACLS card according to the standards of the American Heart Association. (ACLS certification must be renewed at least every two (2) years.)

3.

Provide documentation of a minimum of twelve (12) months critical care experience as a Registered Nurse in an acute care hospital acquired within the past three (3) years, including six (6) months of emergency department experience acquired within the past one (1) year.

4.

Provide evidence of successful completion of a Contra Costa EMS approved Mobile Intensive Care Nurse (MICN) course within the previous twelve (12) months. A waiver of course completion may be obtained if the applicant provides documentation of current or previous (within one year) authorization (or certification) as a Mobile Intensive Care Nurse (or "Authorized Registered Nurse") in another California EMS system. Upon submission of application to EMS, the applicant’s duration of prior experience and nature of base station function will be assessed to determine whether waiver of an approved EMS course is appropriate.

5.

The candidate will complete and provide documentation of a ground-based paramedic staffed emergency response vehicle observation experience in Contra Costa County, consisting of eight (8) hours of observation or direct observation of at least 4 (four) patient contacts in which the patient is assessed.

B.

Complete the County MICN application form and submit it to the County EMS Agency.

C.

Provide proof of current employment: 1.

within the emergency department of a Contra Costa County designated base hospital;

2.

as an instructor in an ALS training program approved by the Contra Costa County EMS Medical Director, or;

3.

by the Contra Costa County EMS Agency.

D.

Satisfactorily complete at least ten (10) proctored ALS radio calls.

E.

Attend an orientation session held by the Contra Costa County EMS Agency.

F.

Upon successful completion of (A) through (E) above, the County EMS Agency shall authorize the candidate as a base hospital MICN for a period of two (2) years from the last day of the month in which the candidate successfully completed the authorization requirements. Such authorization shall be contingent upon the candidate's continued employment as described in section I D. of this policy.


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Candidates failing to successfully complete the authorization process within twelve (12) months from their initial application submission date must repeat the entire authorization process. Any of the above requirements for authorization may be modified or waived by the Contra Costa EMS Medical Director upon his/her discretion. III.

REAUTHORIZATION All reauthorization candidates shall meet the following requirements and provide documentation to the County EMS Agency: A.

Complete the County MICN application form.

B.

Provide documentation of valid and current licensure as a Registered Nurse in the State of California.

C.

Provide documentation of a valid and current ACLS card according to the standards of the American Heart Association (ACLS certification must be renewed at least every two (2) years).

D.

Provide documentation of current employment as outlined in section II D.

E.

Provide documentation of required continuing education within the current two (2) year authorization period as follows: 1.

F.

Obtain a minimum of twelve (12) hours of continuing education as defined below. a.

Didactic: Formal education relating specifically to prehospital care. This may be utilized for up to six (6) hours of the minimum 12-hour continuing education requirement.

b.

Chart review: Participate in formal review of patient care records as part of an approved quality improvement program. One (1) hour of credit will be provided for review of 12 patient care records (PCRs), as arranged for and verified by the base coordinator.

c.

Tape review: Review of eight (8) audio tape contacts that meet "ALS Patient Contact" criteria, as defined in Section 100159(b) of the EMT-P Regulations. One (1) hour care of credit will be given for this activity, and may be utilized for up to two (2) hours of the 12 hour continuing education requirement. This shall be prearranged and verified with the MICN’s base hospital coordinator.

d.

Self-learning modules: Completion of self-learning modules, as approved by and verified by the base coordinator. This may be utilized for up to four (4) hours of the 12-hour continuing education requirement.

e.

Base hospital coordinators are exempt from the requirements found in section III.F.1 of this policy.

Upon fulfillment of (A) through (E) above, the County EMS Agency shall reauthorize the candidate as an MICN for a period of two (2) years from the expiration date on the candidate's current authorization card.

Any of the above requirements for reauthorization may be modified or waived by the EMS Medical Director upon his/her discretion.


CONTRA COSTA COUNTY EMS FEE STRUCTURE I.

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PURPOSE To outline the fee structure for various programs administered by Contra Costa County EMS.

II.

FEES EMT-I Initial Certification/Re-certification Replacement Care

$30 Application Fee* $10 Fee

Paramedic Accreditation/Re-accreditation (Re-accreditation fee applies only if accreditation has lapsed)

$50 Application Fee

Continuing Education (CE) Provider Authorization/Re-authorization

$100 Application Fee**

Non-Emergency Ambulance Service Permit Three-year county-wide permit

$1,500 Fee

Emergency Ambulance Service Permit Three-year permit per Emergency Response Area (ERA)

$1,500 Fee per ERA

EMS Aircraft Classification

$250 Fee

EMS Aircraft Authorization – Two-year county-wide authorization

$1,800 Fee

Non-Emergency Paramedic Transfer Program A. Yearly fee (includes up to 50 transfers) B. Fee per transfer (after first 50 transfers per year)

$3,000 Fee $50 Fee

*Fee waived for persons employed by a fire service agency within Contra Costa County. **Fee may be waived for providers offering courses at no charge to participants, or offering courses to “in-house” employees only. Fees are not refundable and shall be paid by CHECK or MONEY ORDER, payable to CONTRA COSTA COUNTY HEALTH SERVICES/EMS. Cash will NOT be accepted. There will be a $10.00 charge for checks returned due to insufficient funds.


PREHOSPITAL CREDENTIAL REVIEW PROCESS

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Any proceedings by the EMS Agency to deny, suspend or revoke the certification of an EMT-I or MICN, or place any EMT-I or MICN certificate holder on probation pursuant to Section 1798.200 of the Health and Safety Code shall be conducted in accordance with California Code of Regulations, Title 22, Division 9, Chapter 6. I.

EMT-1/MICN Negative action against any prehospital emergency medical certificate/authorization may be instituted by the EMS Medical Director based upon the finding of an imminent threat to the public health and safety as evidenced by the occurrence of any of the items listed in Health and Safety Code, Division 2.5, Chapter 7, Section 1798.200 or California Code of Regulations, Title 13, Division 2, Chapter 5, Article 1, Section 1101. If at any time during the review or investigation, the Medical Director determines that the facts support placing a certificate holder on probation or denying, suspending or revoking a certificate, the Medical Director may convene and investigative review panel (IRP). The IRP will assess all information on the matter in order to establish the facts of the case and make a written report of its findings and recommendations to the Medical Director. Request for discovery, petitions to compel discovery, evidence and affidavits in the IRP shall be followed pursuant to the Administrative Procedures Act (Government Code, Title 2, Chapter 5, Sections 11507.6, 11507.7, 11513, 11514.

II.

EMERGENCY MEDICAL TECHNICIAN – PARAMEDIC (EMT-P) Paramedic licensure actions (e.g., immediate suspension) shall be performed according to the California Health and Safety Code 1798.202.

III.

BASE HOSPITAL OR PROVIDER AGENCY REPORTING OF INCIDENTS Any incident involving EMS personnel, which may constitute a threat to the public health and safety, should be reported to the County EMS Agency. When such incidents come to the attention of base hospital or provider agency administrative personnel, a report to the EMS Agency should be made by the Base Hospital Liaison Physician (or designee) or provider agency administrative personnel, no later than the next business day following the incident or discovery of the incident. If this report is made by telephone, a written report should be submitted within 72 hours. A.

Grounds for reporting include reasonable suspicion of: 1.

Functioning outside the scope of practice of the held certificate/authorization.

2.

Functioning independent of medical control as described in County policies, procedures and field treatment guidelines.

3.

Gross negligence.

4.

Repeated negligent acts.

5.

Incompetence.

6.

The commission of any fraudulent, dishonest, or corrupt act that is substantially related to the qualifications, functions, and duties of prehospital personnel.

7.

Violating or attempting to violate directly or indirectly, any provision of the Health and Safety Code or of State regulations pertaining to prehospital personnel.

8.

Violating or attempting to violate any federal or state statute or regulation that regulates narcotics, dangerous drugs, or controlled substances.

POLICY #: Contra Costa Emergency Medical Services 9.

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Addiction to, the excessive use of, or the misuse of, alcoholic beverages, narcotics, dangerous drugs, or controlled substances.

If, in the judgment of the Base Hospital Liaison Physician, or other physician in charge if the Liaison Physician is unavailable, immediate action must be taken by the EMS Agency after normal business hours to protect the public health and safety, the On-Call Health Officer may be contacted through the Sheriff's Dispatch Center. Call Sheriff's Dispatch at 646-2441 and leave a message for the On-Call Health Officer.


PREHOSPITAL CONTINUING EDUCATION PROVIDER I.

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PURPOSE To outline the process for approval of prehospital continuing education (CE) providers in Contra Costa County. The California Code of Regulations authorize local EMS Agencies to approve ALS and BLS prehospital continuing education (CE) providers. Approved CE providers shall approve individual courses, assign course identification numbers, and specify the category, number of hours, and level of training, for each course authorized.

II.

PROCEDURE FOR APPROVAL AS CE PROVIDER A.

B.

Submit the following to the EMS Agency: 1.

completed Continuing Education Provider Application,

2.

documentation demonstrating Program Director and Clinical Director experience and qualifications in prehospital care/education as outlined in Title 22, Division 9, Chapter 11, Article 6, section100395(g) and (i),

3.

sample course completion certificate, containing information listed in Title 22, Division 9, Chapter 11, Article 6, section 100395 (m) of the California Code of Regulations,

4.

other course information requested by EMS Agency.

Approval shall be good for four (4) years from the last day of the month in which the application is approved. It shall be the responsibility of the CE provider to submit an application for renewal at least sixty (60) days in advance of the expiration date, in order to maintain continuous approval.

CE providers shall ensure that each continuing education activity or course meets the criteria outlined in the California Code of Regulations, Title 22, Division 9, Chapter 11. All records shall be available to the EMS Agency upon request, or during scheduled or unscheduled sit visits by EMS Agency staff. The EMS Agency shall be notified in writing within thirty (30) days, of any change in CE provider name, address, telephone number, program director or clinical director.


PARAMEDIC EVALUATOR I.

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PURPOSE To define the qualifications, selection process and maintenance requirements for a paramedic evaluator in Contra Costa County.

II.

DEFINITIONS A paramedic evaluator is a paramedic currently employed in Contra Costa County to provide supervision and evaluation of California state licensed paramedics in Contra Costa County.

III.

REQUIREMENTS/QUALIFICATIONS A.

IV.

Paramedic Evaluator 1.

Minimum of two (2) years full-time experience as a paramedic for a third service EMS provider or,

2.

Minimum of four (4) years full-time experience as a paramedic in a fire-based ALS service and,

3.

Minimum of six (6) months current field experience in Contra Costa County.

4.

Paramedic licensure/accreditation current and in good standing.

5.

Absence of QI issues.

6.

Demonstrated professional attitude, appearance and manner of dealing with people.

SELECTION PROCESS A.

Application 1.

B.

Complete an application (available from employer) and return it to employer.

Notification of EMS The employer shall send a letter to the EMS Agency, along with the completed application and statements on the qualifications listed in Section III, above, stating whom they have selected to act as paramedic evaluators.

C.

Orientation The paramedic evaluator shall be required to complete the Contra Costa County Paramedic Evaluator Orientation.

V.

MAINTENANCE A.

B.

To maintain Paramedic Evaluator status all evaluators shall: 1.

Maintain current state paramedic licensure and Contra Costa County accreditation in good standing.

2.

Have no patient care/operational issues requiring remediation.

3.

Attend scheduled bi-annual evaluator updates.

The Contra Costa County EMS Medical Director may withdraw approval to function as a paramedic evaluator at any time.


EMS QUALITY IMPROVEMENT PROGRAM (EQIP) I.

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PURPOSE To identify primary responsibilities of all participants in the Contra Costa County EMS Quality Improvement Program (EQIP) and to ensure optimal quality of care for all patients who access the EMS system.

II.

DEFINITION EMS Quality Improvement Program: An integrated, multidisciplinary program that focuses on system improvement. Methods of evaluation are composed of structure, process and outcome measurements.

III.

REQUIREMENTS A.

EQIP includes all Contra Costa County prehospital care providers participating at the level as agreed between the agency and Contra Costa EMS.

B.

EQIP indicators will be compliant with the California Code of Regulations, Title XXII, Division 9, Chapter 12 and modeled after the State of California Emergency Medical Services Authority (EMSA) Publication: Emergency Medical Services System Quality Improvement Program Model Guidelines.

C.

The oversight for the EQIP will be the responsibility of the EMS Medical Director with advice from stakeholders participating on the Prehospital Quality Improvement Committee.

D.

Appropriate QI indicators shall be reviewed at the agency level on a monthly basis and a report of findings shall be made to the Contra Costa EMS Agency at agreed upon intervals. Aggregate data for the EMS System will be maintained by the Contra Costa County EMS Agency.

E.

Each Prehospital provider agency shall submit an annual report of quality improvement activities to the Contra Costa County EMS Agency.

F.

The Contra Costa County EMS Agency shall provide an annual report of quality improvement activities to the California EMS Authority. This information may be incorporated as part of the Contra Costa County Emergency Medical Services Agency Annual Report Report.

G.

All proceedings, documents and discussions of the Prehospital Quality Improvement Committee are confidential pursuant to section 1157.7 of the Evidence Code of the State of California. 1.

Each member of the Prehospital Quality Improvement Committee shall sign a confidentially agreement.

2.

Each agency shall maintain all records in a confidential manner consistent with current patient privacy laws (HIPPAA).


PATIENT DESTINATION DETERMINATION I.

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PURPOSE To determine the appropriate receiving facility for patients transported by ground ambulance.

II.

III.

POLICY A.

A patient, transported as part of an EMS response, shall be taken to the most appropriate acute care hospital staffed and equipped to provide care appropriate to the needs of the patient.

B.

County boundaries are not considerations in determining the appropriate receiving hospital.

C.

Field transport personnel are responsible for making transport code decisions.

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. Additional factors to be considered include: 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 A.

B.

C.

Unstable Patients 1.

An unstable patient is usually transported to the closest appropriate acute care hospital emergency department.

2.

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 weight the benefits of each destination and may direct field personnel to a facility other than the closest.

3.

Trauma patients should be transported in accordance with County trauma protocols.

4.

Unstable patients are usually transported Code 3 unless contraindicated for medical reasons.

Stable Patients 1.

Stable patients are transported to appropriate acute care hospitals within reasonable transport times based on patient’s/family preference.

2.

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.

Patients on 5150 Holds 1.

Police or other designated individuals may place a person who, as a result of a mental disorder is a danger to self, to others, or is gravely disabled on a “5150” involuntary hold. This involuntary hold is an application for detention for up to 72 hours for the purpose of psychiatric evaluation and treatment.


D.

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2.

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.

3.

Medically stable patients on 5150 holds shall be transported to Contra Costa Regional Medical Center.

4.

Medically unstable patients on 5150 holds shall be transported to the closest acute care hospital. a.

A patient with a current history of overdose of medications is to be considered unstable.

b.

A patient with history of ingestion of alcohol or illicit street drugs is considered unstable if there is any of the following: 1)

Significant alteration in mental status (e.g., decreased level of consciousness or extremely agitated),

2)

Significantly abnormal vital signs

3)

Any other history or physical findings that suggest instability (e.g. chest pain, shortness of breath, hypotension, diaphoresis).

Obstetrical Patients 1.

A patient is considered “Obstetric” if pregnancy is estimated to be of 20 weeks duration or more.

2.

Obstetric patients should be transported to acute care hospitals with in-patient obstetrical services in the following circumstances:

3.

a.

Patients in labor;

b.

Patients whose chief complaint appears to be related to the pregnancy, or who potentially have complications related to the pregnancy;

c.

Injured patients who do not meet trauma criteria or guidelines.

In-patient obstetrical services are provided by all acute care hospitals in Contra Costa County with the exception of Doctor’s Medical Center in San Pablo, Kaiser Medical Center in Richmond and John Muir Health – Concord Campus. Other nearby Approved Ambulance Receiving Facilities in western Contra Costa include: Alta Bates in Berkeley, Kaiser Medical Center in Oakland, Sutter Solano Medical Center in Vallejo and Kaiser Medical Center in Vallejo.

E.

4.

Obstetric patients meeting trauma criteria are to be transported to adult trauma enters.

5.

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.

6.

Stable obstetric patients should be transported to the emergency department of choice if their complaints are clearly unrelated to pregnancy.

7.

The base hospital is available to provide guidance in situations in which the appropriate choice of receiving facility is unclear to transport personnel.

Patients With Burns 1.

Hospital Selection a.

Burned patients with unmanageable airways should be transported to the closest basic ED.

b.

Patients with minor burns and moderate burns can be cared for at any acute care hospital.


2.

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c.

Adult and pediatric patients with burns and significant trauma should be transported to the closest appropriate trauma centers.

d.

Patients with more extensive or complex burns may be appropriate for transport directly to a Burn Center including: 1)

Partial thickness (2nd degree)>20% TBSA

2)

Full thickness (3rd degree)> 10%

3)

Significant burns to the face, hands, fee, genitalia, perineum, or circumferential burns of the torso or extremities

4)

Chemical or high voltage electrical burns

5)

Smoke inhalation with external burns

Procedure for Burn Center destination a.

Contact Burn Center prior to transport to confirm bed availability.

b.

Consult base hospital for any questions regarding destination decision.

c.

If air transport to UC David Medical Center or Santa Clara Valley Medical Center is not available, patient should be transported by ground to the closest available burn center.

d.

The closest available Burn Centers are: Hospital

Services

Phone

Santa Clara Valley Medical Center 751 S. Bascom Avenue San Jose, California

Adult and Pediatric

408-885-6666

UC Davis Medical Center – Regional Burn Center 2315 Stockton Blvd. Sacramento, California

Adult and Pediatric

916-734-3636

St. Francis Burn Center 900 Hyde Street San Francisco, California

Adult and Pediatric

415-353-6255

F.

Hospital Diversion 1.

CT Diversion a.

b.

A hospital goes on CT Diversion when it does not have an operation CT scanner. The following patients should not be transported to a facility on “CT scan diversion,” but should be transported to the next closest appropriate ED with a functioning CT scan. 1)

Suspected stoke – duration of signs and symptoms two hours or less. Symptoms might include sudden onset of weakness, paralysis, confusion, speech disturbances, visual field deficit and may be associated with a headache.

2)

New onset of altered level of consciousness for traumatic or medical reasons.

Most patients meeting the above criteria should be transported to the next closest appropriate ED with a functioning CT scan.

POLICY #: Contra Costa Emergency Medical Services c.

2.

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CT Diversion Exceptions 1)

Patients with unstable airways, uncontrolled bleeding, or in cardiac arrest should be transported to the nearest ED regardless of CT diversion status.

2)

Patients requesting transport to a hospital on CT diversion have the right to be transported to that hospital. These patients should be told: a)

That the hospital of choice has an inoperative CT scanner and has requested that patients that may need this service be transported to another facility to assure availability of the necessary level of care.

b)

That transport to a hospital with an inoperative CT scanner might result in a delay of care and/or a transfer to another facility.

Physical Plan Casualty (PPC) Diversion If notified that a hospital is on PPC diversion, transport units should determine the appropriate destination for the patient as identified in this policy while eliminating the hospital on diversion from consideration.


DECLINING EMERGENCY MEDICAL CARE AND/OR TRANSPORT I.

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PURPOSE To provide guidance to prehospital personnel in situations where the patient, or his/her legal representative, declines medical care or transport when care is recommended and felt to be necessary by the prehospital personnel attending that patient. All qualified persons are permitted to make decisions affecting his/her care, including the ability to decline care.

II.

DEFINITIONS A.

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.

B.

Competency: The ability to understand and to demonstrate an understanding of the nature of the illness/injury and the consequence of declining medical care.

C.

Qualified Person: A competent person making a decision for him/herself or another who is qualified by one of the following: 1.

An adult patient defined as a person who is at least 18 years old;

2.

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 or 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,

3.

III.

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.

PATIENT EVALUATION A.

All potential patients at the scene of an EMS system call must be offered medical care/transport.

B.

Patients should be evaluated as much as capable and allowed.

C.

Qualified persons defined above have the legal right to decline EMS care or transportation.

D.

Qualified persons may limit the scope of their consent (e.g. may consent to transportation but not treatment, or consent only to certain treatments).

E.

Every reasonable attempt should be made to convince a patient or legal representative of the need for further medical evaluation and treatment, and he/she should be informed clearly of the risks and consequences of declining care. Resources to aid in the effort include family members and friends, law enforcement, and base hospital personnel.

F.

Prehospital personnel should not put themselves in danger by attempting to treat or transport patients who do not meet qualifications to decline care (not competent to decline care or not


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qualified to decline). Assistance from support agencies in appropriate circumstances should be utilized. IV.

BASE CONTACT REQUIREMENTS A.

Base contact is required: 1.

When, in the field personnel’s opinion, the patient’s decision to decline care poses a threat to his/her well being.

2. If the patient’s competency status is unclear (neither competent nor clearly incompetent) and treatment or transport is felt to be appropriate. 3. Any other situation in which, in the field personnel’s opinion, that base contact would be beneficial in resolving treatment or transport issues. B.

V.

Patients in law enforcement custody or under 5150 hold do not require consent for transportation and base contact is not required in these circumstances. Patients in custody or under a 5150 hold may decline treatment.

DOCUMENTATION Documentation requirements are outlined in Policy 27 – “Patient Care Record.”


BASE HOSPITAL COMMUNICATIONS/ DISRUPTED COMMUNICATIONS I.

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PURPOSE The purpose of this policy is to outline criteria for base hospital contact by EMS personnel, and procedures in case of disrupted communications.

II.

POLICY A.

Basic Life Support Personnel: At the scene of an emergency call, base contact may be necessary for destination decision or management of certain DNR situations. The base hospital may be utilized for consultation if Basic Life Support personnel encounter situations in which base input would be helpful.

B.

Paramedic Personnel: Paramedics function under the EMS Medical Director and Base Hospital supervision. Paramedics shall only accept medical direction from nurses or physicians who are authorized base personnel (except written or in-person DNR orders from physicians). Paramedics are encouraged to contact the base hospital if they have any questions regarding treatment or disposition.

C.

Disrupted Communication: When a paramedic reasonably determines that a delay in treatment may jeopardize the patient but is unable to establish or maintain base contact, the paramedic may initiate indicated ALS care as specified in the Field Treatment Guidelines until base contact can be established or until the patient is delivered to the closest appropriate receiving facility. The paramedic shall transport the patient as soon as possible while providing necessary treatment en route. If ALS procedures are performed under disrupted communications the paramedic shall: 1.

Immediately following delivery of the patient to the receiving hospital: a.

Complete the PCR documenting the ALS skills performed;

b.

Notify, or request that the agency dispatcher notifies Sheriff’s Dispatch of the communication problem, if the paramedic suspects that any radio problem was due to a situation other than location.

2. Within 24 hours, send a copy of the completed PCR and a written report explaining the reason(s) or suspected reason(s) for communication failure to the Paramedic provider agency QI coordinator. 3. The paramedic provider agency QI coordinator shall evaluate paramedic reports and submit reports on a quarterly basis to the Emergency Medical Services Agency. The paramedic shall be prepared to demonstrate that the treatment delivered was appropriate.


EMS SYSTEM MEDICAL DIRECTION AND OVERSIGHT I.

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PURPOSE Emergency medical services rendered by Contra Costa County EMS system provider agencies are accomplished under the medical direction of the EMS Medical Director. This policy defines the scope of medical direction and oversight provided in the EMS system.

II.

SCOPE OF OVERSIGHT AND DIRECTION Medical direction applies to all events involving emergency medical care for patients from the outset of 911 system activation to the delivery of patients to receiving facilities. Dispatch, first response, transport provider care, and base hospital direction fall under the auspices of the EMS Medical Director or his/her designee. In addition to emergency responses, medical direction also applies to paramedic (and in some situations to EMT-I) interfacility transports. Medical direction is provided prospectively through written policies and procedures, approved by the EMS Medical Director, and immediately through on-line communications with the base hospital. Oversight is also provided retrospectively through quality improvement activities and continuing education of providers. Medical direction also includes oversight of EMS personnel credentialed by the county. These include EMT-Is, paramedics, and base station MICNs.

III.

PROSPECTIVE, IMMEDIATE, AND RETROSPECTIVE MEDICAL DIRECTION AND OVERSIGHT Below is a listing of examples that describe individual facets of prospective, immediate, and retrospective medical direction and oversight. This list is not all-inclusive. Prospective medical direction and oversight: Credentialing of EMT-I, paramedic and MICN personnel; Designation of continuing education and prehospital training program providers; Designation of base hospitals and trauma center; Review and approval of medical dispatch protocols, including pre-arrival and post-dispatch instructions; Provision of the Prehospital Care Manual, which guides EMT-Is, paramedics, and MICNs in the care provided in the field; Continuing education activities; Provision of the Multicasualty and Multi-Victim Incident Plans; EMS Agency policies. Immediate (concurrent) medical direction and oversight: Provision for guidance by MICNs following treatment guidelines from the Prehospital Care Manual; Provision for guidance by base hospital physicians (including situations defined in the Prehospital Care Manual); Provision for guidance by base MICNs and physicians concerning interfacility transfers with regard to scope issues for EMT-I and paramedic personnel. Retrospective medical direction and oversight: Quality assurance and improvement activities, coordinated at the EMS Agency level; Specific incident review and action by base station and EMS Agency personnel; Continuing education prompted by QI data review.


IV.

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INPUT AND MODIFICATION OF MEDICAL DIRECTION System participants, including provider agencies and personnel, participate in regular meetings of the Medical Advisory Committee (MAC). This committee is open to the public for input. Requests for changes in treatment guidelines or policy and procedure changes that impact medical care are discussed and recommendations are made. The recommendations of MAC are advisory to the EMS Medical Director and the EMS Director. Formal requests for changes are to be made in writing to the EMS Medical Director. Proposals for utilization of paramedic personnel in settings other than 911 ground response (e.g. bicycle-based units, aircraft-based paramedics) must be submitted to the EMS Medical Director and EMS Director for review and authorization. Any approval must include policies and procedures that maintain prospective, immediate, and retrospective medical direction and oversight of paramedic personnel.

V.

OPTIONAL SCOPE PROCEDURES AND MEDICATIONS Most procedures or medications outside of the basic scope of practice require additional authorization from the EMS Medical Director and Emergency Medical Services Authority. Proposals for optional procedures, medications or trial studies shall be submitted to the EMS Medical Director for consideration as part of the treatment guidelines, policy and procedure update process. The EMS Medical Director is responsible for submission of requests for optional scope procedures and medications and for trial studies to the Emergency Medical Services Authority.


TRIAGE OF TRAUMA PATIENTS I.

POLICY #:

13

PAGE:

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PURPOSE Trauma triage directs trauma patients to appropriate medical facilities for definitive care. The goal of triage is to identify critically injured patients who need rapid surgical intervention or the specialized services of the trauma center. Those who do not need trauma center services can be transported to the closest appropriate facility or the patients’ hospital(s) of choice.

II.

DEFINITIONS Base Hospital: John Muir Medical Center – Walnut Creek Campus is the designated base hospital for Contra Costa County. Trauma Center: The appropriate trauma center for adults is John Muir Medical Center – Walnut Creek Campus. The most appropriate trauma center for pediatric patients (0-14 years) is Children’s Hospital, Oakland if transport can be made in less than 30 minutes. High-Risk Criteria: Symptoms and mechanisms that correlate with a high risk of critical trauma injuries and merit direct transport to a trauma center after an early notification call. Early Notification Call: For patients meeting criteria for direct transport to the trauma center (high-risk), notification in a brief manner at an early stage to allow the trauma center to prepare resources pending the patient’s arrival. The call should be made as early as possible, preferably before leaving the scene. Call-In Criteria: For patients who do not have high-risk criteria, but have trauma mechanisms that could potentially cause severe trauma. These patients require a destination determination call to the base hospital. Destination Determination: For patients meeting call-in criteria, the base hospital physician will determine which patients warrant trauma center destination based on the report of the paramedic. 5-minute Update: Notification from the field to the trauma center that the patient will be arriving in five minutes. This call initiates hospital activation of a trauma team. Patients with Unmanageable Airway: Patients whose airways are unable to be adequately maintained with BLS or ALS maneuvers. Patients requiring needle cricothyrotomy should be considered to have an unmanageable airway.

POLICY #:

13

PAGE:

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Contra Costa Emergency Medical Services III.

TRAUMA TRIAGE ALGORITHM Π Π

Unmanageable airway Trauma arrest (not meeting field determination)

High-Risk Criteria

YES

Closest Facility

NO

Π Π

PHYSIOLOGIC CRITERIA BP 20 minutes - Fatalities in the same vehicle - Ejection from vehicle Unrestrained MVC with: - Head-on mechanism > 40 mph - Extrication required Fall 15 feet or greater

YES

Early notification, Trauma Center Transport

**In the absence of significant symptoms or physical findings despite mechanism, call for destination decision instead of early notification.

NO

Π Π

COMBINED CRITERIA Motorcycle crash with: - Abdominal or chest tenderness - Observed loss of consciousness Unrestrained motor vehicle crash with: - Abdominal tenderness

YES

Early notification, Trauma Center Transport

YES

Call for Destination Decision

NO

MEETS CALL-IN CRITERIA?


IV.

13

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CALL-IN CRITERIA FOR BASE HOSPITAL DESTINATION DECISION A.

Most trauma mechanisms are quire variable in terms of risk for significant injury. In order to maintain the highest accuracy in trauma triage, base hospital destination decision is required prior to transport of the following patients (who do not meet high-risk criteria otherwise): 1.

V.

POLICY #:

Evidence of high-energy dissipation or rapid deceleration which may include: a.

vehicle rollover with unrestrained occupant,

b.

intrusion of passenger space by 1 foot or greater,

c.

impact of 40 mph or greater (restrained),

d.

persons requiring disentanglement from a vehicle,

2.

Adult hit by vehicle traveling faster than 15 mph.

3.

Child less than 14 years hit by a vehicle.

4.

Persons ejected from a moving object (motorcycle, horse, etc.)

5.

Significant blunt force to the head, neck, thorax (chest/back), abdomen or pelvis.

6.

Penetrating injury to extremities (above knee or elbow) without apparent fracture.

B.

If no significant symptoms or physical findings noted despite above mechanism(s), call-in not required and patient may be transported to hospital of choice or to closest facility.

C.

Base contact should be made if a patient meets call-in criteria and it is believed trauma center services may be needed, even in the event that the trauma has occurred several hours prior to EMS response.

D.

Patients 65 years of age and older may sustain significant injuries with less forceful mechanisms, and may merit call-in for less significant mechanisms (e.g. ground level fall with new alteration of mental status).

TRIAGE AND REPORTING PROCEDURES A.

Determine whether the patient meets high-risk criteria for direct transport or meets call-in criteria.

B.

Contact the Base Hospital as soon as possible for either early notification or destination decision as indicated in the Trauma Triage Algorithm. 1.

2.

Early Notification Report: This report should be brief (approximately 1 minute) a.

Agency name and unit number

b.

Advise as Early Notification Report

c.

ETA at trauma center

d.

Patient age and sex

e.

Brief description of mechanism of injury and scene

f.

Brief description of known significant abnormalities in primary and secondary surveys

Destination Decision Report: This report needs to contain sufficient detail to aid in decision making by base physician. a.

Agency name and unit number

b.

Advise as Destination Decision Report

c.

ETA to trauma center

d.

Patient age and sex

e.

Mechanism of injury (brief description)

f.

Basic scene information (e.g. protective gear, extrication, estimated MPH)

POLICY #:

13

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VI.

g.

Primary Survey (can be reported as ABCD normal except…)

h.

Secondary Survey (report abnormal findings only)

i.

Prehospital treatments and response

j.

Paramedic concerns

C.

The five-minute update call should be made when five minutes from the trauma center and should include expanded patient information, including significant changes in vital signs, mental status, physical findings or symptoms en route.

D.

Receiving hospitals shall be contacted by field personnel prior to arrival.

E.

On Trauma Center arrival, use MIVT format at transfer of patient care. (30-second report) 1.

Report should be made to Trauma physician or ED physician

2.

MIVT format a.

Mechanism of injury

b.

Injuries Sustained and Level of Consciousness (AVPU format)

c.

Vital signs – include ECG rhythm if abnormal, pulse oximetry if known

d.

Treatment and patient’s response to treatment

e.

More detailed information can be provided when requested

SPECIAL CIRCUMSTANCES A.

All patients with unmanageable airway should be transported to the closest Basic ED.

B.

Patients who do not qualify for field pronouncement of death but have or develop cardiopulmonary arrest should be transported to the closest Basic ED.

C.

Contra Costa County Trauma Center Bypass:

D.

E.

1.

Transport patients with high-risk criteria or patients directed to a trauma center by base hospital destination decision via ground or air transport, as indicated, to the closest appropriate and available designated out-of-county trauma center.

2.

If an out-of-county trauma center is not available: a.

Transport via ground to the nearest Basic ED, which may include John Muir Medical Center – Walnut Creek Campus.

b.

If helicopter transport is utilized, transport to John Muir Medical Center – Walnut Creek Campus.

Out-of-County Destinations: 1.

Aside from trauma center bypass situations, an out-of-county destination may be the appropriate destination if there is significant time saving.

2.

The base shall be contacted to assist with destination determination of patients who require transport to out-of-county destinations, including pediatric patients with prolonged transport times (>30 minutes) and patients redirected because of trauma center bypass.

3.

The base will be responsible for notification of other trauma centers to alert them of the patient’s pending arrival.

Disrupted Communications with Base: 1.

Patients who normally require base hospital destination determination should be transported to the most appropriate and available receiving facility per the paramedic’s judgment.

2.

Alternate mechanisms of communication (e.g., via dispatch) should be used to determine trauma center availability if out-of-county destinations are being considered.


TRANSFERS TO TRAUMA CENTERS I.

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PURPOSE To outline the criteria and process for transfer of patients needing trauma center care from nontrauma centers to appropriate trauma centers.

II.

POLICY Under field trauma triage protocols, most critical trauma patients will be triaged directly to a Trauma Center from the field. Trauma patients, who present at other facilities via EMS or other arrival mode, should be considered for transfer to trauma centers for definitive care when medically appropriate.

III.

PATIENT SELECTION A.

Patients appropriate for trauma center transfer may include: 1.

2.

B.

IV.

Patients who, as a result of trauma, have need for: a.

Timely surgical or diagnostic imaging intervention to prevent mortality or morbidity; or

b.

Evaluation by trauma surgeon or advanced diagnostic modality to address potential critical injuries; or

c.

Monitoring of a traumatic injury that may require intervention or complex care not readily available otherwise.

Patients who have sustained injuries with mechanisms likely to need trauma center evaluation or intervention, including: a.

Penetrating injury to head, neck, torso, groin, pelvis or buttocks; or

b.

Penetrating injury to extremity with fracture (excluding hands/feet) or with compromised circulation;

c.

Other traumatic mechanisms that have resulted in symptoms, signs, or diagnostic evidence of serious injury.

Patients in need of emergent intervention are of the highest priority, and should be transferred in a timely fashion by the fastest available and appropriate transport method. These patients include: 1.

Patients with need for immediate neurosurgical intervention;

2.

Patients with penetrating gunshot wounds to head or torso;

3.

Patients with penetrating wounds by any mechanism who present with or develop shock;

4.

Patients with blunt injury and shock;

5.

Patients with vascular injuries that cannot be stabilized and are at risk of hemorrhagic shock or loss of limb acutely (excluding fingers/toes).

TRAUMA CENTERS A.

John Muir Medical Center – Walnut Creek (JMMC-WC) is the designated trauma center for adults (patients 15 years of age and older) in Contra Costa County.

B.

Children’s Hospital in Oakland is the closest designated trauma center for pediatric patients (patients 14 years of age and younger).

C.

When JMMC-WC is on trauma bypass status, it is unable to accept patients with emergent need for transfer or field triages because critical hospital resources (surgeons, operating rooms) are


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not available. Location and helipad availability are items to consider in choice of other trauma. Other local adult trauma centers include:

V.

VI.

1.

Oakland – Alameda County Medical Center (formerly Highland) (no helipad on site);

2.

Castro Valley – Sutter Eden Medical Center (helipad on site);

3.

Sacramento – UC Davis Medical Center (helipad on site);

4.

San Jose – Santa Clara Valley Medical Center (helipad on site);

5.

San Francisco General Hospital (no helipad on site).

D.

When not on trauma bypass status, JMCC-WC may also be impacted by bed availability issues and may not be able to accept non-emergent transfers.

E.

Alternate pediatric trauma centers include UC Davis Medical Center and Santa Clara Valley Medical Center in San Jose.

PROCESS A.

Contact the trauma center to discuss patient status and request transfer. See attachment 1 for list of hospitals and phone numbers.

B.

If transfer is accepted, arrange for transport, appropriate to patient condition or potential.

TRANSPORT OPTIONS Timeliness of availability and level of care needed should be considered in all transports. Emergency Ambulance Availability

Skill

Within 10 minutes in most cases

911 Paramedic Ambulance Scope of Practice (Includes Basic scope)

Critical Care Transport Paramedic (CCT-P) Variable (service not designed for emergency response)

Interfacility Transfer Paramedic Scope of Practice (CCT-P)

Critical Care Nurse (CCT-RN) Air Ambulance: Within 30-45 minutes in most cases Ground Ambulance: Variable (service not designed for emergency response)

Critical Care Nurse Scope of Practice (CCT-RN)

Monitoring

Continuous ECG monitoring Chest tube monitoring Pulse oximetry End-tidal CO2 monitoring IV line monitoring, (no arterial lines)

Same as 911 paramedic ambulance

Paramedic scope plus Arterial line monitoring

Invasive procedures

Needle thoracostomy Needle cricothyrotomy

Same as 911 paramedic ambulance

Surgical cricothyrotomy

Morphine

Morphine

Wide range of medications, wider array of narcotic/sedative agents.

Midazolam for seizures

Midazolam for seizures or sedation while intubated

Paralytic agents

Blood transfusions

Blood transfusions

Medications

C.

Ambulance transport capability can also be potentially enhanced with utilization of hospitalbased RN or physician staff to address scope issues if necessary in order to facilitate the fastest transports with highest levels of care.


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ATTACHMENT 1 LOCAL TRAUMA CENTER CONTACT PERSONS/PHONE NUMBERS

Adult Trauma Centers

Contact Person

Phone Number

*Alameda County Med Center– Oakland (Highland)

On-Call Trauma Surgeon

(510) 437-4800

*San Francisco General Hospital

Attending Physician

(415) 206-8111

John Muir Medical Center – Walnut Creek

Nursing Administrative Coordinator

(925) 941-5005

Santa Clara Valley Medical Center – San Jose

ED Physician

(408) 885-6912

Sutter Eden Medical Center – Castro Valley

On-Call Trauma Surgeon

(510) 784-9287

UC Davis Medical Center – Sacramento

ED Physician

(916) 734-3624

Stanford University

ED Physician

(650) 723-7337

* Indicates no helipad on site Pediatric Trauma Centers

Contact Person

Phone Number

Children’s Hospital Oakland

ED Physician

(510) 428-3240

UC Davis Medical Center – Sacramento

ED Physician

(916) 734-3624

Santa Clara Valley Medical Center – San Jose

ED Physician

(408) 885-6912

Note: This list is subject to change. Last update 07/01/2007.


HOSPITAL GUIDELINES FOR INTERFACILITY TRANSFERS VIA AMBULANCE I.

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PURPOSE To assure that all ambulance transfers between acute care hospitals and other facilities as approved by the EMS Medical Director are arranged in a manner that maximizes patient safety. A.

II.

Requests for ambulance service from all other facilities, e.g., physician's offices, urgent care centers, clinics (except for those approved by the EMS Medical Director), nursing homes, convalescent hospitals, or other facilities not equipped or licensed to provide acute inpatient care are considered either “emergency” or “routine transport” calls rather than interfacility transfers. 1.

The 911 system should be activated by these other (non-acute care) facilities for patients requiring emergency transport and care.

2.

Private ambulance service providers should be contacted for routine transport needs.

RESPONSIBILITY The sending facility is responsible for assuring safe interfacility patient transfer. This means that the sending facility is responsible for selecting the appropriately staffed ambulance for each patient.

III.

AMBULANCE PERSONNEL Four transport options are available for transfers of patients between acute care facilities: EMT-1 Interfacility Transfer Paramedic (CCT-P) Emergency Paramedic Critical Care (includes RN or Physician staff) The scopes of practice of EMT-Is, CCT-Paramedics and Emergency Paramedics are limited and regulated by state regulation and local EMS guidelines. Please refer to page 5 of this policy for a comprehensive listing of scope of practice.

IV.

TRANSFER TYPES A.

EMT-1 Ambulance For transfer of a stable patient requiring en route care within the EMT-I scope of practice, or for the transfer of any patient when accompanied by hospital personnel and equipment to provide care beyond the EMT-I scope of practice. 1.

Ambulance staffed with two (2) EMT-Is

2.

Care provided includes patient observation and basic life support skills.

3.

If patient may require care beyond EMT-I scope of practice, transferring facility must send appropriate personnel supplied with necessary equipment/medications for transfer.

4.

Procedure for Obtaining: Contact private ambulance provider to arrange for transfer.

5.

Medical Oversight: Transferring physician is responsible.

6.

Several private ambulance services offer EMT-I staffed ambulances for patient transfers. These ambulance services are not provided under the auspices of the County Emergency Medical Services Agency.


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Note: EMT-Is are generally utilized for routine (scheduled or unscheduled) transfers. In some cases, EMT-I ambulance may represent the only promptly available level of care based on 911system activity. B.

Interfacility Transfer Paramedics (CCT-Ps)

For transfer of any patient for whom sending physician/hospital determines CCT-P level of care is appropriate. This level of service is appropriate for stable patients requiring cardiac monitoring, advanced life support (ALS) care, or care within the CCT-Paramedic expanded scope of practice. Sending physician should keep in mind that the minimum staffing level of a CCT-P unit is one paramedic and one EMT-I driver. This level of transport may not be appropriate for patients with complex monitoring or treatment requirements.

C.

1.

Staffing levels and standards are regulated and overseen by the local EMS Agency.

2.

Procedure for Obtaining: Contact private ambulance provider offering CCT-P level service to arrange for transfer.

3.

Medical Oversight: CCT-Paramedics function under standing orders written by sending facility physicians. Transferring physician is responsible for specifying orders within parameters of the CCT-P scope of practice.

4.

Some private ambulance services may offer CCT-P ambulances for transfer.

Emergency Paramedic Ambulance Transfer For IMMEDIATE transfer of a patient requiring emergency care not available at sending facility, 1.

May be requested when patient requires care not available at the sending facility, and time to definitive care is critical.

2.

A nearby paramedic ambulance can usually be sent, but due to increased demands on the EMS system, a paramedic ambulance may not always be available. If requested in those situations, the closest available EMT-I unit can be sent.

3.

The patient generally will be transported to the nearest appropriate emergency medical facility. The nearest appropriate facility may not be the closest basic emergency department. Ambulance personnel should consider arrangements that have been made by the sending facility/physician for the timely care of the patient at a hospital that, although not the closest, is equipped, staffed, and prepared to administer care to the patient being transferred.

4.

Procedure for Obtaining: a.

Telephone county-designated emergency ambulance provider dispatch center directly and request an immediate response paramedic ambulance for an emergency transfer.

b.

Prepare to send appropriate personnel and equipment if patient care required enroute is beyond the scope of practice of ambulance personnel who respond.

c.

Prepare copies of medical records, x-rays, etc., for transfer.

d.

An emergency paramedic ambulance should not be expected to wait at the hospital for more than 10 minutes while a patient is being prepared for transport, and after 10 minutes, the crew may contact their dispatch and return to 911 EMS service. (Patient records not available within the 10-minute time frame may be faxed to the receiving hospital.


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Medical Oversight: Paramedics function under EMS Field Treatment Guidelines, and will contact their base hospital if necessary to obtain additional patient orders. By law, paramedics may not accept advanced life support medical direction from physicians or RNs assisting with transfers.

D.

Critical Care Ambulance (CCT) with RN or MD Staffing For transfer of any patient for whom the sending physician/hospital determines CCT level of care is appropriate. RN/Physician-staffed CCT units are the appropriate mode for unstable patients requiring advanced life support level care.

E. V.

1.

Equipped/staffed to transfer critically ill patients.

2.

Staffing levels, standards, quality activities are NOT regulated or overseen by the county.

3.

Procedure for Obtaining: Contact private ambulance provider offering CCT level service to arrange for transfer.

4.

Medical Oversight: Transferring physician is responsible.

5.

Some private ambulance services provide CCT ambulances for transfer. These services are not provided under the auspices of the County Emergency Medical Services Agency.

Interfacility Transfer Matrix (attached) outlines the various types and capabilities of ambulances that may be available for patient transfer.

DOCUMENTATION AND REVIEW A.

ALL interfacility transfers involving paramedics are subject to EMS system quality improvement review.

B.

The base hospital will also review any emergency paramedic interfacility transfers for which there was base hospital contact.

Contra Costa Health Services

Emergency Medical Services Agency Patient Name: ________________________________________________ Date: ____________ Time: __________ Cardiac monitoring standard unless indicated. Vital Signs:

No Cardiac Monitor required

Every 15 minutes, more frequently by treatment guideline or MD order:

_____ Oxygen: Rate: _____ L/min _____ IV:

_______

______ NC

______ Mask

q __________ min.

_______ ETT

_______ Trach Collar

Solution: _______________________________ Rate: _____________ Saline Lock only

________

_____ IV with KCl: (if >20 mEq/L or < or = 40 mEq/L must run on pump—max rate: 10 mEq/hr) Solution: ____________________________________ Rate: _____________ KCl: ___________ mEq/L _____ Morphine: Dose ______ mg IV, Frequency: _______ (Maximum 20 mg) _____ IV NTG: Concentration: ml/hr)

_____ Half-strength (25 mg/250 ml)

Starting rate ______

ml/hr (max 30

_____ Full-strength (50 mg/250 ml)

Starting rate ______

ml/hr (max 15

ml/hr) Note: NTG sublingual should not be co-administered with IV NTG _____ Sublingual NTG: Dose 0.4 mg Frequency ______________ Note: Sublingual NTG should not be co-administered with IV NTG

Maximum 6 doses

_____ IV Heparin: Concentration 100 units/ml (25,000 units/250 ml or 50,000 units/500 ml) Rate: ______ units/hour

________ ml/hour (maximum rate 1600 units/hr or 16 ml/hour)

_____ IV Lidocaine infusion ________ mg/minute (maximum rate 4 mg/minute) Rate: _______________ _____ IV Dopamine infusion ________ mcg/kg/minute Concentration: _______ mg/ml _____ Nebulized Albuterol: Dose: _______ 2.5 mg/3 ml _______ 5 mg/6 ml Note: maximum standing order dose 10 mg for children age 14 and under _____ NG or Gastric Tube: ______ _____ Suction @ _____ Chest Tube: ______ Water Seal ______ _____ Other indwelling devices _______ Foley

Gravity Drainage

Rate:

ml/hour ml/hour

Frequency ___________

_____ Clamped_________________

Suction @ ____________ ______ Other: ______________________________________

_____ Other (within CCT-P scope): _______________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ STANDING ORDERS: Cardiopulmonary arrest or impending arrest: Follows County EMS Treatment Guidelines Other medical issues (e.g. anaphylaxis, seizure): Follows County EMS Treatment Guidelines MD Signature:

______________________________________________

Date: __________________

Paramedic Signature: ______________________________________________

Date: __________________

Ambulance Service:

Unit: __________________

______________________________________________

INTERFACILITY TRANSFER MATRIX (4/29/02) SKILL LIFE SUPPORT

AIRWAY MANAGEMENT

EMT-I SCOPE OF PRACTICE

CPR Oropharyngeal airway Nasopharyngeal airway Suction devices Oxygen delivery via nasal cannula or simple mask only Bag-valve-mask May monitor peripheral lines containing plain isotonic or glucose solutions with no medications added.. EMT-I’s are restricted to monitoring, maintaining present rate, or turning off flow of IV fluid

EMERGENCY AMBULANCE PARAMEDIC SCOPE OF PRACTICE (Includes EMT-I scope)

CPR plus ACLS within scope

Endotracheal intubation Esophageal/tracheal airway Airway visualization with laryngoscope and foreign body removal with forceps

INTERFACILITY TRANSFER PARAMEDIC SCOPE OF PRACTICE

CPR plus ACLS within scope

Same as emergency ambulance paramedic

Administer and adjust rate of glucose or isotonic balanced saline solutions. May monitor and adjust IV solutions containing potassium (20 mEq/L or less).

Administer and adjust rate of glucose or isotonic balanced saline solutions May monitor and adjust IV solutions containing potassium, heparin, and/or NTG May use an infusion pump to administer the above

MONITORING

Cannot provide cardiac monitoring. May monitor NG and gastrostomy tubes, saline or heparin locks, foley catheters or established tracheostomy tubes. Central venous access lines may be present but no infusions except if via patient-controlled device. Cannot transport patients with arterial lines or chest tubes

Continuous ECG monitoring Chest tube monitoring Pulse oximetry IV line monitoring, not including arterial lines

Continuous ECG monitoring Chest tube monitoring Pulse oximetry IV line monitoring, not including arterial lines Tubes monitoring including foleys, suprapubic catheters, and other indwelling GI tubes

BASIC PROCEDURES

First aid CPR Obtain vital signs, pupillary status, assess level of consciousness Use stretchers and immobilization devices May assist patient in use of patient-operated, physician prescribed devices

Defibrillation Synchronized cardioversion Valsalva maneuver Cardiac pacing Venous blood sample draws Blood glucose monitoring


INVASIVE PROCEDURES

None

Needle thoracostomy Needle cricothyrotomy


Glucose paste only

Activated Charcoal Adenosine Albuterol Atropine Calcium Chloride Dextrose (25% or 50%) Diphenhydramine Dopamine Epinephrine

IV FLUIDS AND MANAGEMENT

MEDICATIONS

PAGE: 5 of 6

Furosemide Glucagon Glucose paste Lidocaine Midazolam Morphine sulfate Naloxone Nitroglycerin (sublingual) Sodium Bicarbonate

Same as emergency ambulance paramedic, plus: IV heparin IV NTG IV KCl

INTERFACILITY TRANSFER MATRIX (4/29/02)

EMERGENCY PARAMEDIC AMBULANCE*

INTERFACILITY TRANSFER PARAMEDICS (CCT-P)*

RN - CRITICAL CARE AMBULANCE

TRANSFER TYPE

EMT-I AMBULANCE*

REASON FOR TRANSFER

Scheduled or routine transfer for med/surg admission or diagnostic procedure. In some instances, may be only available ambulance in emergent situation.

Time sensitive transfer to nearest appropriate higher level of care.

Transfer of patient requiring advanced life support (ALS). Staffed and equipped to transfer stable patients.

Transfer of patients requiring advanced life support; in particular, unstable patients.

Stable med/surg admits from ED and in-pt. transfers. In some instances, may transfer in emergent situation.

Examples: critical trauma, neurosurgical, pediatric, or time sensitive cardiac cath patients.

Examples: cardiac cath patients, stable patients requiring cardiac monitoring and or receiving heparin, KCl and NTG.

Unstable

TYPES OF PATIENTS

Sending MD

Base hospital

Sending physician specifies orders; EMS Medical Director provides oversight.

Sending MD

Call local emergency ambulance provider dispatch center (NOT 911) directly at:

Call:

Call:

MEDICAL CONTROL

HOW OBTAINED/ Call: PHONE NUMBERS (Individual hospital to complete)

Request paramedic ambulance for immediate transfer to nearest higher level of care.

Children’s Transport Team: Available 24 hrs/day. All staff and equipment provided. Call Children's Hospital at: 1-800-428-5437

* EMT-I’s, emergency paramedics and CCT-paramedics may only perform those treatments/skills identified in their Scopes of Practice.

PAGE: 6 of 6

POLICY #:

16

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TRANSFER OF CARE IN THE FIELD I.

II.


PURPOSE A.

To provide guidelines for the transfer of care from non-transport to transport personnel.

B.

To provide guidelines for the transfer of care from an on-scene paramedic to an EMT-I staffed transport ambulance.

SCOPE OF DIRECTION AND OVERSIGHT A.

B.

Patient Care Authority 1.

The most medically qualified pre-hospital personnel first on-scene at a medical emergency shall have patient care management authority.

2.

The individual with patient care authority is responsible for the patient until care is turned over to another appropriate prehospital care provider or responsible receiving facility staff.

Turn Over of Patient Care Authority 1.

BLS First Responders a.

2.

First Responder Paramedics a.

3.

First Responder paramedics, when first on-scene, should transfer patient care authority and provide a verbal report to the transport paramedics as soon as feasible. In those cases where the first responder paramedic believes continuity of his/her care will be in the patient's best interest, he/she should maintain patient care authority and accompany the patient during transport.

Paramedic to EMT-I Transport Crew a.

b.

C.

BLS first responders initiating patient care shall transfer care upon the arrival of either an EMT-I or paramedic transport crew. BLS first responder personnel shall maintain patient care authority and accompany a BLS transport unit when an AED has been used and the BLS transport personnel do not have an AED.

A paramedic may transfer patient care authority to a BLS ambulance crew for transport, when all of the following circumstances exist: 1)

The BLS unit is available within a reasonable time, and

2)

ALS care has not been initiated, and

3)

It does not appear that ALS care is likely to be required during transport.

A paramedic shall maintain patient care authority and shall accompany the patient in a BLS transport ambulance to the appropriate receiving facility if either of the following circumstances exist: 1)

ALS care has been started, or

2)

A reasonable likelihood exists that the patient may require ALS care enroute.

Responsibility for Patients who Decline Care 1.

First responders who determine that patients are declining care or transport are responsible for appropriate documentation of those situations.

2.

If patient care has been transferred and a patient subsequently declines further treatment or transport, the transport crew is responsible for appropriate documentation.

Contra Costa Emergency Medical Services D.

16

PAGE:

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Documentation 1.

E.

POLICY #:

Documentation of transfer of care shall be made by both transferring and receiving crews, e.g., “Patient care transferred to AMR paramedic 56 at 0900,” and “Patient care accepted from CCC Fire paramedic 115 at 0900.”

Turn-over Procedures Those emergency medical response agencies providing enhanced levels of care are responsible for creating and implementing internal operational procedures regarding transfer of patient care. These procedures shall be consistent with the EMS Agency's policies, and shall interface with the procedures of other emergency medical response agencies which might be represented at the scene of an emergency.


EMT/PARAMEDIC OR NON-TRANSPORT

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ALS PROGRAMS I.

PURPOSE To define criteria for units staffed with one EMT and one Paramedic or non-transport paramedic units.

II.

STAFFING A.

Paramedic Non-Transport Units Paramedic non-transport units are fully equipped advanced life support vehicles, staffed with a minimum of one (1) paramedic, and dispatched simultaneously with an emergency (ALS) transport unit. Paramedics assigned to such units must have the training and experience necessary to function safely as the sole care providers until the fire first responder and transport units arrive. Paramedics assigned to paramedic non-transport units shall be approved by their employers and shall meet the following minimum qualifications for staffing such units:

B.

1.

Current accreditation in Contra Costa County

2.

At least two (2) years full-time field experience as a paramedic in the last three (3) years

3.

No actions against State paramedic license within the past two (2) years

Paramedic/EMT-I Units Paramedic/EMT-I Units are fully equipped fire engines or ambulances staffed with a minimum of one (1) paramedic and one (1) EMT-I. Paramedic personnel assigned to these units must have the experience necessary to function safely as the single advanced life support provider. Personnel assigned to paramedic/EMT-I units shall be approved by their employer and meet the following minimum qualifications for staffing such units: 1.

Current accreditation/certification in Contra Costa County

2.

Experience requirements: a.

Paramedic: at least one (1) year full-time field experience as a paramedic in the last two (2) years, or three (3) years field experience as a paramedic.

b.

EMT: at least one (1) year full-time field experience as an EMT-I in the last two (2) years, or three (3) years field experience as an EMT-I.

If unable to meet this criteria, personnel must participate in and successfully complete a provisional assignment approved by the EMS Agency. 3.

No actions against State paramedic licensure/EMT-I certification within the past two (2) years.

Individuals functioning under a current Performance Improvement Plan (PIP) may be precluded from working on either of these units. Permission to function as a paramedic or an EMT on either of these type of units may be rescinded at any time by the Contra Costa County EMS Medical Director. III.

FIELD TREATMENT Personnel assigned to a paramedic/EMT unit or a non-transporting ALS unit work under the existing medical control system and follow Contra Costa County EMS field treatment guidelines, policies and procedures, including base hospital contact requirements. A.

Paramedic/EMT Units 1.

The paramedic assigned to the unit is ultimately responsible for all patient assessment and care.


IV.

2 of 2

The EMT may accompany the patient in the patient compartment of the ambulance, if: a.

B.

PAGE:

17

in the paramedic’s best judgment, the patient does not currently require ALS care and there is no reasonable possibility of the patient requiring ALS care throughout the transport.

Non-transport ALS Units 1.

The non-transport paramedic shall provide a verbal report of patient assessment and treatment provided, to the transporting ambulance personnel.

2.

A written county patient care report (PCR) shall be completed and sent with the patient if time permits. If the PCR cannot be completed prior to patient transport, the non-transport paramedic shall complete the PCR and fax it to the Emergency Department of the receiving facility as soon as possible.

QUALITY IMPROVEMENT A.

Each agency having a paramedic/EMT or non-transport ALS unit program shall have processes identified in their quality improvement plan for review of all calls.

B.

Personnel assigned to a paramedic/EMT or non-transport ALS unit shall be required to complete orientation and training programs which have been developed by the provider agency and approved by the EMS Agency. These requirements may be waived at the discretion of the EMS Medical Director.


PUBLIC SAFETY/EMT AED PROGRAMS I.

PAGE:

18 1 of 2


PURPOSE

Defibrillation, utilizing a semi-automatic/automatic automated external defibrillator (AED) according to policies and procedures established by the EMS Agency, is included in the EMT-1 scope of practice and has been approved as an optional skill for use by personnel trained to Public Safety Standards. The Public Safety/EMT AED program is intended to guide the treatment of only non-perfusing ventricular rhythms (ventricular tachycardia and ventricular fibrillation) by personnel approved by and employed with an approved AED service provider. II.

AED SERVICE PROVIDER An AED service provider is an agency or organization that employees individuals as Public Safety or EMT personnel and who obtains AEDs for the purpose of providing AED services to the general public. A.

An AED service provider shall be approved by the EMS Agency. In order to receive and maintain AED service provider approval, an AED service provider shall comply with the requirements of this policy and/or applicable state regulations.

B.

AED service provider approval may be revoked or suspended for failure to maintain the requirements of this policy and/or applicable state regulations.

C.

An AED service provider shall be approved if it meets and provides the following: 1.

Complete an application available from the EMS Agency

2.

Provide orientation of AED authorized personnel to the AED

3.

Ensure maintenance of the AED equipment

4.

Ensure initial training and continued competency of AED authorized personnel

5.

Notification to the EMS Agency when an AED has been utilized on a patient

6.

Collect and report to the EMS Agency quarterly, data that includes:

7. D. III.

a.

Number of patients with sudden cardiac arrest receiving CPR prior to arrival of AED service provider personnel;

b.

Total number of patients the AED was attached;

c.

Total number of patients on whom defibrillatory shocks were administered;

d.

Total number of patients on whom defibrillatory shocks were administered, who suffered a witnessed cardiac arrest.

Authorize personnel and maintain a listing of all authorized personnel and provide the list to the EMS Agency annually or upon request.

An approved AED service provider and its authorized personnel shall be recognized statewide.

PUBLIC SAFETY AED SERVICE PROVIDER TRAINING PROGRAM REQUIREMENTS A.

A public safety agency wishing to implement an AED program must submit a training program for approval by the EMS Agency. This program shall include: 1.

A minimum of four (4) hours of initial instruction and testing.

2.

A course outline which includes the topics and skills listed in the current Public Safety regulations, for the optional skill of AED.


IV.

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18 2 of 2

A final written and practical evaluation.

B.

The public safety agency shall implement a quality improvement program as outlined in the quality improvement plan established by the EMS Agency.

C.

The public safety agency shall follow the policies and procedures issued by the EMS Agency Medical Director.

D.

The defibrillator and defibrillator trainer shall be maintained in accordance with manufacturer’s recommendations.

PUBLIC SAFETY AED INSTRUCTOR REQUIREMENTS To be authorized to instruct public safety personnel in the use of an AED, an AED instructor shall either: A.

Complete an American Red Cross or American Heart Association recognized instructor course (or equivalent) including instruction and training in the use of an AED, or;

B.

Be approved by the EMS Agency Medical Director and meet the following requirements: 1.

Be AED accredited or able to show competency in the proper utilization of an AED, and

2.

Be able to demonstrate competency in adult teaching methodologies.


DETERMINATION OF DEATH

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IN THE PREHOSPIAL SETTING I.

PURPOSE To provide criteria to aid prehospital personnel in determining death in the field.

II.

III.

POLICY A.

Prehospital personnel do not pronounce death but may determine death in certain situations.

B.

Prehospital personnel need not initiate CPR or may direct the discontinuation of CPR when death has been determined using the criteria outlined in this policy, or when an approved Do Not Resuscitate order has been produced.

C.

If any doubt exists as to the presence of vital signs, or if hypothermia, drug overdose, or poisoning is suspected, begin CPR and follow the appropriate field treatment guidelines.

D.

The body of a patient who has been determined to be dead from any of the reasons identified in the Coroner section of this policy shall not be disturbed or moved from the position or place of death without permission of the coroner or the coroner's appointed deputy.

E.

Base hospital direction may be utilized in situations other than those outlined in this policy in which field personnel believe cessation of efforts are warranted, or if questions exist about application of the policy.

OBVIOUS DEATH Pulseless, non-breathing patients with any of the following: A.

Decapitation

B.

Total incineration

C.

Decomposition

D.

Total destruction of the heart, lungs, or brain, or separation of these organs from the body.

E.

Rigor mortis or post-mortem lividity without evidence of hypothermia, drug ingestion, or poisoning

F.

Mass casualty situations

G.

Procedure: 1.

Do not initiate CPR

2.

In patients with rigor mortis or post-mortem lividity: a.

Attempt to open airway

b.

Assess for breathing for at least 30 seconds; assess pulse for 15 seconds

c.

Rigor, if present, should be noted in jaw and/or upper extremities

d.

If any doubt exists, place cardiac monitor to document asystole in two leads for one minute

3.

Notify County Coroner and any other appropriate investigative agencies (if not already done)

4.

Complete Prehospital Care Report

POLICY #: Contra Costa Emergency Medical Services IV.

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19 2 of 3

PROBABLE DEATH Does not apply if hypothermia, drug ingestion, or poisoning is suspected. A.

B.

V.

Medical Arrest 1.

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.

2.

Procedure: a.

BLS personnel – Follow Public Safety defibrillation treatment guideline.

b.

ALS personnel 1)

Do not initiate CPR

2)

Assess for presence of apnea, pulselessness (no heart tones/no carotid or femoral pulses)

3)

Document asystole in two leads for one minute

Traumatic Arrest 1.

Definition: Blunt or penetrating traumatic arrest

2.

Procedure: a.

BLS personnel – Follow Public Safety defibrillation treatment guideline.

b.

ALS personnel 1)

Do not initiate CPR

2)

Assess for presence of apnea, pulselessness (no heart tones/no carotid or femoral pulses)

3)

Document asystole or agonal rhythm (wide, bizarre rhythm, 20/minute or less) for 1 minute.

C.

Following determination of death, notify coroner and any other appropriate investigative agency (if not already done).

D.

Complete Prehospital Care Report including approximate time death was determined.

DISCONTINUING ADULT CPR Does not apply if hypothermia, drug ingestion, or poisoning is suspected. A.

Prehospital personnel may discontinue adult CPR if an approved Do Not Resuscitate order is produced for the patient after initiation of resuscitative efforts. No base hospital contact is necessary.

B.

Prehospital personnel may discontinue adult CPR without base hospital contact, in patients in whom resuscitative efforts are unsuccessful (asystole or agonal rhythm despite interventions of adequate ventilation, defibrillation, and two rounds of cardiotonic drugs).

C.

Prehospital personnel should attempt resuscitation and should transport patients with multiple rhythms, intermittent perfusing rhythms such as bradycardia or ventricular tachycardia, or in whom scene conditions warrant transport (safety issues, some public settings).

D.

CPR may not be discontinued during patient transport.

E.

Procedure: 1.

Document asystole or agonal rhythm (wide bizarre rhythm less than 20 per minute) in 2 leads for 1 minute.

2.

Notify coroner and any other appropriate investigative agency (if not already done).

3.

Complete Prehospital Care Report including approximate time death was determined.

POLICY #: Contra Costa Emergency Medical Services VI.

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EMERGENCY MEDICAL DISPATCH A.

Obvious Death Emergency Medical Dispatchers (EMDs) provide prearrival instructions for administering CPR unless they have been provided information indicating that the patient meets one of the following obvious death criteria:

B.

1.

Decapitation

2.

Total incineration

3.

Decomposition that prevents resuscitation

4.

Total destruction of the heart, lungs, or brain, or separation of these organs from the body

5.

Rigor mortis that prevents resuscitation

“Do Not Resuscitate” (DNR) The EMD shall pre-arrival instructions for administering CPR even if he/she is advised that the patient has DNR paperwork. If the caller refuses, the EMD shall advise them to have the DNR paperwork available for the responding personnel and shall notify the enroute unit(s) of the existence of DNR paperwork.

VII.

MULTICASUALTY/MULTIVICTIM INCIDENTS CPR will be initiated pursuant to the procedures outlined in the Multicasualty Plan. Field personnel should initiate CPR when there are sufficient numbers of rescuers to adequately manage the total number of, and types of, casualties on the scene.

VIII. CORONER INVESTIGATION The Coroner is responsible for investigating all deaths listed in California Government Code Section 27491 including, but not limited to the following and therefore should not be disturbed or moved from the position or place of death without permission of the coroner or the coroner's appointed deputy. A.

Violent, sudden, or unusual deaths;

B.

Unattended deaths;

C.

Deaths where a physician has not attended to the deceased in the 20 days before death;

D.

Known or suspected homicide, suicide, or accidental poisoning;

E.

Deaths known or suspected as resulting in whole or in part from or related to accident or injury either old or recent;

F.

Deaths due to drowning, fire, hanging, gunshot, stabbing, cutting, exposure, starvation, acute alcoholism, drug addiction, strangulation, aspiration, or where the suspected cause of death is sudden infant death syndrome;

G.

Death in whole or in part occasioned by criminal means;

H.

Deaths known or suspected as due to contagious diseases and constituting a public hazard;

I.

Deaths from occupational diseases or occupational hazards.

POLICY #:

20

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DO NOT RESUSCITATE (DNR) ORDERS AND PHYSICIAN ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST) IN THE PREHOSPITAL SETTING I.


PURPOSE This policy identifies those orders for withholding resuscitative measures and the treatment of patients with an advanced airway that can be honored in the prehospital setting.

II.

III.

DEFINITIONS A.

A Do-Not-Resuscitate (DNR) order is an order written by a physician, in consultation with the patient or surrogate to withhold life saving measures should the patient succumb to a cardiac arrest.

B.

A Physician Orders for Life-Sustaining Treatment (POLST) is an order sheet defining the care of a patient based on the person’s current medical condition and wishes.

C.

A surrogate is a patient’s legal representative, e.g. a Durable Power of Attorney for Health Care agent, a court-appointed conservator, spouse or other family member.

DNR ORDERS HONORED BY PREHOSPITAL PERSONNEL The following types of DNR orders may be honored by prehospital personnel:

IV.

A.

A California EMSA/CMA Prehospital DNR form.

B.

A California EMSA POLST form where Section A – Do Not Attempt Resuscitation/DNR has been chosen.

C.

A DNR order in the medical record of a licensed healthcare facility (e.g., acute care hospital, skilled nursing facilities, hospices, intermediate care facilities) signed by a physician.

D.

A verbal DNR order given by the patient’s physician who is present at the scene. (EMS personnel may not accept a verbal order by telephone without base hospital physician approval.)

E.

A MedicAlert medallion/bracelet that says “Do Not Resuscitate – EMS.”

PROCEDURE FOR COMPLYING WITH AN HONORED DNR ORDER DNR orders only apply to patients in cardiac arrest. A patient with a DNR order that is not in cardiac arrest should be provided with treatment as appropriate for their complaint unless a Physician Orders for Life-Sustaining Treatment (POLST) is in place that directs care differently. (see POLST procedure below) A patient (or patient’s surrogate) may verbally rescind the DNR order at any time. If a DNR order is available: A.

Review the DNR order to verify that it is appropriately completed (patient or surrogate’s signature and physician’s signature) and that it does not appear to have been altered or amended.

B.

Verify the identity of the patient as being the person for whom the DNR order is intended.

C.

Perform no life saving measures.

D.

Cancel the responding ambulance if not needed and not yet on scene.

POLICY #:

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V.

PROCEDURE FOR COMPLYING WITH A POLST FORM A.

Review the POLST form to verify that it is appropriately completed (patient or surrogate’s signature and physician’s signature) and that it does not appear to have been altered or amended.

B.

Verify the identity of the patient as being the person for whom the POLST form is intended.

C.

Section A – Person has no pulse and is not breathing 1.

If “Attempt Resuscitation/CPR” is marked – patient receives full care.

2.

If “Do Not Attempt Resuscitation/DNR” is marked – no life saving measures should be done.

Section B – Person has pulse and/or breathing 1.

If “Full Treatment” is marked – patient receives full care.

2.

If “Limited Additional Interventions” or “Comfort Measures Only” is marked – No Advanced Airway should be done – all other medications or treatment will be done.

Section C – does not apply to Prehospital Setting

VI.

D.

If DNR, no life saving measures should be done – cancel responding ambulance.

E.

Other patients should be transported. If not transported, follow EMS Policy for patients declining emergency medical care and transport.

SPECIAL CONSIDERATIONS A.

A DNR order or POLST form is presented, but on-scene relatives object to the order or the validity of the form is in question: 1.

Provide all appropriate care/resuscitation measures for the patient. Although a patient’s instructions should remain paramount, resuscitation is to done until the situation is clarified.

2.

EMS personnel shall make base hospital contact. Base hospital physicians retain responsibility and authority for determining appropriateness and extent of prehospital resuscitation decisions.

B. If CPR is initiated prior to the presentation of an approved DNR order, CPR may be discontinued without base hospital contact. C. If both a DNR and POLST form are presented follow the order with the most current date. NOTE: EMS personnel shall document all relevant information on a PCR for all patients. DNR orders/POLST forms shall be attached to PCRs if a patient is not transported.


PHYSICIAN ON SCENE I.

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PURPOSE To provide direction for field personnel and physicians on prehospital emergency medical responses.

II.

POLICY Paramedics function by law under physician contact, however, most physicians are unfamiliar with the paramedic scope of practice, skills, drugs, equipment, and EMS protocols. Most physicians do not have the time to accompany paramedics and their patients to a Receiving Hospital. For this reason, Base Hospital physicians assume medical control through input into EMS protocols and through voice contact. If a physician at the scene wishes to direct paramedic care, s/he should be shown the card issued by the State of California entitled Note to Physician on Involvement with EMT-IIs & EMT-Ps (paramedic). The Endorsed Alternatives for Physician Involvement printed on the back of the card are: "After identifying yourself by name as a physician licensed in the State of California, and, if requested, showing proof of identity, you may choose to do one of the following: A.

Offer your assistance with another pair of eyes, hands, or suggestions, but let the life support team remain under base hospital control; or,

B.

Request to talk to the base station physician and directly offer your medical advice and assistance; or,

C.

Take responsibility for the care given by the life support team and physically accompany the patient until the patient arrives at a hospital and responsibility is assumed by the receiving physician. In addition, you must sign for all instructions given in accordance with local policy and procedure. (Whenever possible, remain in contact with the base station physician.)”

Even if a physician chooses option #3 listed on the card, in Contra Costa County, the paramedic must still maintain Base Hospital control through the voice contact.

POLICY #:

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INFECTIOUS DISEASE PRECAUTIONS AND EXPOSURE MANAGEMENT FOR EMS PERSONNEL I.


AUTHORITY Division 2.5, California Health and Safety Code, Sections 1797.186, 1797.188. 1797.189. www.leginfo.ca.gov Bloodborne pathogens - 1910.1030, U.S. Department of Labor. www.osha.gov/SLTC/bloodbornepathogens/

II.

PURPOSE To provide guidelines and procedures for EMS prehospital personnel, to reduce risk of infectious disease exposure to themselves and patients, and to evaluate and report suspected exposures to communicable diseases.

III.

A.

Although the presence of disease causing agents may or may not be known, these agents may be present in body fluids and substances. Even apparently healthy persons may carry and be capable of transmitting disease.

B.

Precautions identified in this policy are intended to provide prehospital personnel with information to safely care for all patients, regardless of disease status.

EXPOSURE RISK REDUCTION A.

B.

C.

IV.

Prehospital Personnel. Prehospital personnel shall: 1.

Follow employer’s policies/procedures for infection control to protect both patients and themselves.

2.

Use universal precautions in all patient contacts. Additional barrier precautions are to be used based on the potential for exposure to body fluids and substances.

3.

Wash hands, prior to and following patient contact at a minimum regardless of the use of gloves or other barrier precautions. Thorough hand washing with soap and water is the most effective infection control activity for prehospital personnel. Waterless hand sanitizers are an option if soap and water are not available.

Provider Agency. Each provider agency shall: 1.

Comply with all federal, state, and local regulations regarding infectious disease precautions.

2.

Establish and maintain a written exposure control plan designed to eliminate or minimize employee exposure. This plan shall include a procedure to be used if an employee is possibly exposed to a communicable disease and this plan shall be made easily accessible.

3.

Designate an infection control officer to evaluate and respond to possible infectious disease exposure of provider agency’s prehospital personnel.

4.

Make available equipment, supplies and training necessary for prehospital personnel to reasonably protect themselves and their patients against infectious disease exposure.

Receiving Facility. Receiving hospitals should have staff procedures for: 1.

Assisting possibly exposed prehospital personnel in assessing the significance of the exposure, and the need for and provision of prophylaxis.

2.

Obtaining the appropriate testing to determine whether or not the source patient is infected with a communicable disease.

EXPOSURE DEFINITION A significant communicable disease exposure is defined by criteria set by the Centers for Disease Control (CDC) and the Local Public Health Department and may include:


POLICY #:

22

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A.

Contact with patient's blood, bodily tissue, or other body fluids containing visible blood on non-intact skin (e.g. open wound; exposed skin that is chapped, abraded, affected with a rash) and/or mucous membranes (e.g., eye, mouth)

B.

Contaminated (used) needle stick injury

C.

Unprotected mouth-to-mouth resuscitation

D.

Face-to-face contact in areas with restricted ventilation with patients who have airborne communicable diseases (e.g. H1N1, Avian flu, tuberculosis or meningitis)

E.

If extent of exposure is in question contact Contra Costa Health Service’s Public Health Department for additional guidance.

V.

CENTER FOR DISEASE CONTROL RECOMMENDATIONS CDC recommendations should be used for HIV prophylaxis following significant exposures. Provider agencies, designated officers, occupational injury treatment centers, and emergency department staffs are expected to coordinate efforts to ensure prompt treatment for affected prehospital personnel.

VI.

RESPONSIBILITIES IN A CASE OF SUSPECTED EXPOSURE A.

Individual that may have been exposed shall: 1. Contact his or her employer’s Infection Control Officer/Designated Officer as soon as possible to determine the extent of the exposure and if follow-up recommendations including prophylaxis are required. 2. Refer to employer’s internal notification requirements and internal policy for direction and advice on reporting, evaluation and treatment. 3. Complete a Contra Costa Health Services “Notification of Possible Communicable Disease Exposure” Form (EMS6). Submit form to appropriate parties according to instructions on the form.

B.

a.

This form will provide the hospital and Public Health with source patient information as well as contact information for the possibly exposed individual.

b.

If the possibly exposed individual does not respond to the hospital that received the patient, the individual should follow his/her provider agency procedures for form distribution.

Employer of the individual that may have been exposed should: 1.

Assess the potential exposure to determine that exposure meets the definition as defined above.

2.

Assure individuals with suspected exposures are instructed to report immediately to emergency departments, or nother health treatment facilities for risk assessments and determination of need for prophylactic treatment.

3.

Assure that exposed individual has completed a Contra Costa Health Services-Public Health “Notification of Possible Communicable Disease Exposure” form (EMS-6) available at www.cccems.org. Fax completed form to Public Heath at 925-313-6465. a.

In situations where the exposed individual does not report to the hospital that received the source patient, the form should be faxed to the Emergency Department Charge Nurse in the source patient receiving hospital.

b.

The exposed individual or his/her provider agency is responsible for confirming that the faxed form was received according to provider agency policy.

NOTE: On significant exposures, the Public Health Division’s Communicable Disease Program should be notified by phone, in addition to completing and faxing the notification form (EMS-6). VII.

RECEIVING HOSPITAL RESPONSILITIES – SOURCE PATIENT A.

Evaluate source patient for any history, signs or symptoms of a communicable disease.

B.

Obtain consent to, and collect appropriate specimens (e.g. blood, sputum) from the source patient necessary to determine potential risk to the exposed person.


POLICY #:

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C.

Expedite the testing process (select the tests with rapid turn around in mind), to the extent possible, in consideration of the exposed individual’s concerns and the need for continued prophylactic care.

D.

Promptly report any reportable communicable diseases found in the source patient to the Public Health Division's Communicable Disease Program at 925-313-6740, Monday through Friday, 0800 - 1700. After hours, weekends and holidays page at 925-975-6508 as well as on the CMR form as required by law.

VIII. RECEIVING HOSPITAL RESPONSIBILITIES – EXPOSED INDIVIDUAL A.

Receiving hospitals must assist prehospital personnel who have had significant exposures.

B.

Receiving hospital emergency department staff shall:

C.

1.

Actively assist exposed prehospital personnel in evaluating risk and recommending and/or providing appropriate prophylactic care when indicated.

2.

Obtain blood and necessary tests from the exposed prehospital person necessary to determine base line status.

Emergency departments are expected to follow CDC guidelines when managing prehospital exposure to potentially infectious substances. The CDC websites listed below are current as of the effective date of this policy, however, check the EMS Agency website at www.cccems.org to assure the latest information. HIV: www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm H1N1: www.cdc.gov/h1n1flu/ Hepatitis B virus (HBV) or hepatitis C virus (HCV): www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm Meningococcal disease: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5631a3.htm Tuberculosis MMWR, December 16, 2005:www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a1.htm Additional exposure management resources: National Clinicians’ Post-exposure Prophylaxis Hotline (PEPline) run by University of California-San Francisco: Phone: 888-448-4911; www.ucsf.edu/hivcntrVII

IX.

HEALTH SERVICES PUBLIC HEALTH DIVISION RESPONSIBILITIES Upon notification, the Health Services Public Health Division will: A.

Verify the exposure is significant and contact the receiving hospital(s) and the prehospital employer’s designated officer for infection control.

B.

Notify the exposed person of any recommended disease prevention/prophylaxis needed and provide a written opinion and evaluation of the exposure, as well as identify any medical condition(s) resulting from the exposure that may require further evaluation or treatment.

If exposed individuals have immediate concerns about possible exposures, or if the exposures are significant, they should contact the Public Health Division’s Communicable Disease Program at: Monday through Friday, 0800 – 1700 at 925-313-6740 After hours, weekends and holidays, page at 925-975-6508


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ABUSE/ASSAULT REPORTING I.

23

PURPOSE To describe reporting requirements for prehospital personnel when child or elder abuse, sexual assault, or domestic violence is observed or is reasonably suspected.

II.

CHILD ABUSE, ELDER/DEPENDENT ADULT ABUSE, AND DOMESTIC VIOLENCE EMS personnel faced with a situation where s/he has reason to suspect child abuse, elder/dependent adult abuse (physical/sexual/financial) or neglect, or domestic violence shall:

III.

A.

Notify the appropriate law enforcement agency immediately if the scene is unsafe or it is suspected that a crime has been committed.

B.

Make reasonable efforts to transport the patient to a receiving hospital for evaluation, and provide the receiving hospital staff of abuse/neglect suspicions.

C.

Document observations and findings on the patient care report.

D.

Contact the appropriate reporting agency by telephoning immediately or as soon as reasonably possible to provide a verbal report.

E.

File a written report with the appropriate reporting agency within two (2) working days.

REPORTING A.

To Report Child Abuse:

Call Children & Family Services Screening Unit: (all numbers are 24 hours/day) West County (510) 374-3324 Central County (925) 646-1680 East County (925) 427-8811

B.

Complete a Suspected Child Abuse Report Form (SS 8572) (available online at http://www.ag.ca.gov/childabuse/pdf/ss_8572.pdf ) within 2 working days and submit to: Employment & Human Services Department Children & Family Services Screening Unit 2530 Arnold Drive, Suite 200 Martinez CA 94553

To Report Elder Abuse: If the alleged abuse has occurred in a long-term care facility

Call Ombudsman Services of Contra Costa (925) 685-2070 to make a verbal report

Complete a Suspected Dependent Adult/Elder Abuse Form (SOC 341) (available online at http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/SOC341.pdf ) within 2 working days and submit to: Ombudsman Services of Contra Costa 1601 Sutter Street, Suite A Concord, CA 94520

If the alleged abuse has occurred anywhere else

Call Adult Protective Services (925) 646-2854 or 1-877-839-4347 to make a verbal report

Complete a Suspected Dependent Adult/Elder Abuse Form (SOC) (available online at http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/SOC341.pdf ) within 2 working days and submit to: Employment & Human Services Department Adult Protective Services 2530 Arnold Drive, Suite 300 Martinez CA 94553

POLICY #: Contra Costa Emergency Medical Services C.

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To Report Domestic Violence: Reporting responsibilities are fulfilled by notifying the local law enforcement agency, and by reporting suspicions and patient findings to receiving hospital staff (if transported).

IV.

SEXUAL ASSAULT A.

Sexual assault shall be reported as above in situations involving elder, dependent adult, child, or domestic violence.

B.

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.

C.

Discourage any activity that would compromise evidence collection prior to transport such as bathing, brushing teeth, brushing hair, urinating, defecating or changing clothes.


HOSPITAL CT

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AND PHYSICAL PLANT CASUALTY DIVERSION I.

PURPOSE To see that emergency patients are transported to the most accessible medical facility that is staffed, equipped, and prepared to administer emergency care appropriate to the needs of the patient.

II.

TYPES OF DIVERSION Inoperable CT scanner (CT Divert) Physical plant casualty (PPC Divert)

III.

HOSPITAL ELIGIBILITY FOR DIVERSION A.

B.

IV.

V.

CT scanner inoperative (CT divert). If a hospital’s CT scanner is inoperative, diversion of specific ambulance patients may be considered. These patients may include those with: 1.

Suspected stroke – duration of signs and symptoms two hours or less.

2.

New onset of altered consciousness for traumatic or medical reasons.

Physical Plant Casualty. A hospital is eligible for physical plant casualty divert whenever an internal disaster has occurred that has rendered emergency department services unavailable to the public, e.g., Bomb threat, fire or explosion.

PROCEDURE FOR REQUESTING, IMPLEMENTING AND CANCELLING DIVERT STATUS A.

Obtain authorization from hospital administration according to hospital’s internal procedures.

B.

Update hospital status on ReddiNet following ReddiNet procedure below.

C.

Physical Plant Casualty only: When the circumstances of the internal disaster preclude the above steps, notify Sheriff’s dispatch (925-646-2441) of the nature of the emergency and request dispatch to notify all ambulance providers, the On-Call Health Officer, and the EMS Duty Officer.

D.

To re-establish normal ambulance traffic, update hospital status on ReddiNet or, if ReddiNet is unavailable, request Sheriff’s dispatch to notify all ambulance providers, the On-Call Health Officer, and the EMS Agency.

REDDINET NOTIFICATION OF DIVERSION STATUS ReddiNet is the only accepted method for reporting CT or PPC diversion. Once a hospital’s status has been changed on ReddiNet, ambulance dispatch centers automatically receive the notification and then notify their ambulances of the diversion status. The ReddiNet “memo” feature will not reliably result in ambulance diversion and should not be used.


STEMI TRIAGE AND DESTINATION I.

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PURPOSE Utilizing prehospital 12-lead electrocardiograms (P12ECG), patients presenting with ST-segment elevation myocardial infarction (STEMI) shall be triaged and transported, with patient consent, directly to STEMI centers for rapid intervention. This policy outlines the process of triage and transport of STEMI patients.

II.

DEFINITIONS Prehospital 12-lead ECG (P12ECG): A 12-lead electrocardiogram obtained by EMS crews or in rare circumstances by a medical facility or office other than a hospital. ST-Segment Elevation Myocardial Infarction (STEMI): A specific finding on P12ECG showing STsegment elevation of 1 mm or greater in anatomically contiguous leads, indicating this specific type of myocardial infarction. Computer Interpretation of STEMI: With printout of P12ECG done, a patient with a STEMI is identified distinctly with ***Acute MI*** or ***Acute MI Suspected*** by a computerized algorithm present in the monitor-defibrillator unit (wording varies by manufacturer). Other abnormalities of P12ECG do not signify STEMI. STEMI Receiving Center (SRC): Hospitals designated by Contra Costa EMS as those to which patients with identified STEMI on P12ECG will be transported based on the center’s prompt availability of invasive cardiac care. STEMI Alert: Report from prehospital personnel that notifies a STEMI Receiving Center as early as possible that a patient has a computer-interpreted P12ECG indicating a STEMI. The alert allows the SRC to prepare equipment and personnel for arrival of the patient in order to provide intervention in the most rapid fashion possible.

III.

TRIAGE A.

Patients with chest pain or other symptoms suggestive of Acute Coronary Syndrome (ACS) should have a P12ECG performed. 1.

Exceptions include patients who are not cooperative with the procedure, or patients in whom the need for critical resuscitative measures preclude performance of the P12ECG.

2.

Paramedic personnel should review the P12ECG tracing in all instances to assure that little or no artifact exists (steady baseline, lack of other electrical interference, complete complexes present in all 12 leads). Repeat P12ECG may be necessary to obtain an accurate tracing.

B. If computerized interpretation of accurately performed P12ECG indicates either ***Acute MI*** or ***Acute MI Suspected***, the patient qualifies as a candidate for transport to an SRC. Patients without these findings should be transported per the EMS “Patient Destination Determination” policy (Policy #9). IV.

DESTINATION A.

Patients with an identified STEMI shall be transported to a STEMI Receiving Center (SRC). 1.

Patients shall be transported to the closest SRC unless they request another facility.

2.

An SRC that is not the closest SRC facility is an acceptable destination if estimated additional transport time does not exceed 15 minutes.


V.

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B.

Patients with cardiac arrest who have a STEMI identified by 12-lead ECG before or after arrest shall be transported to the closest SRC.

C.

Patients with unmanageable airway en route shall be transported to the closest basic emergency department.

STEMI ALERT/PATIENT REPORT A.

In patients with identified STEMI, desired destination shall be promptly determined after the P12 ECG is completed and read, and that hospital shall be contracted as soon as possible after destination determined.

B.

The STEMI Alert should contain the following essential information: 1.

Situation: a.

Identify the call as a “STEMI Alert”

b.

Give estimated time of arrival (ETA) in minutes

c.

Patient age and gender

d.

State ECG findings and any urgent concerns

e. 2.

3.

4.

C.

1)

P12ECG shows ***Acute MI*** (ZOLL) or

2)

P12ECG shows ***Acute MI Suspected*** (LP12)

If patient elects to go to a facility that is not STEMI designated inform receiving facility

Background: a.

Presenting/chief complaint and symptoms

b.

Pertinent past cardiac history

c.

Pacemaker placement

Assessment: a.

General impression

b.

Pertinent vital signs and physical exam

c.

Pain level

Rx-Recap: a.

Prehospital treatments given

b.

Patient response to prehospital treatments

Emergency Room Patient handoff report should repeat STEMI Alert information and include: 1.

Patient identification

2.

Presenting complaint

3.

Additional background information:

4.

a.

Past medical history

b.

Advanced directives if known

Allergy and medication history including high-risk medications a.

Anticoagulants

b.

Insulin

c.

Digoxin

d.

Erectile Dysfunction Drugs (ERDs)


VI.

VII.

PAGE:

5.

Previous history of Coronary Artery Surgery or thrombolytic (clot busting) therapy

6.

Cardiologist if known

25 3 of 3

DOCUMENTATION A.

A copy of the P12ECG (multiple if performed) shall be delivered to the nurse caring for the patient at arrival in the Emergency Department.

B.

A copy of the P12ECG (multiple if performed) shall be generated for inclusion in the prehospital Patient Care Record or incorporated via electronic means into the record. The finding of STEMI on P12ECG and confirmation of the STEMI Alert shall also be recorded in the Patient Care Record.

LIST OF STEMI CENTERS IN-COUNTY STEMI CENTERS

OUT-OF-COUNTY STEMI CENTERS

Doctors Medical Center San Pablo

ValleyCare - Pleasanton

John Muir Medical Center – Concord Campus

Oakland Summit Medical Center

John Muir Medical Center – Walnut Creek Campus Kaiser Permanente Medical Center– Walnut Creek San Ramon Regional Medical Center – San Ramon Sutter Delta Medical Center - Antioch


EMS STEMI RECEIVING CENTER DESIGNATION I.

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PURPOSE To define requirements for designation as a Contra Costa County STEMI Receiving Center (SRC) for patients transported via the 911 system with ST-elevation myocardial infarction (STEMI) who may benefit by rapid assessment and percutaneous coronary intervention (PCI).

II.

APPLICATION PROCESS To apply for designation as an EMS STEMI Receiving Center (SRC) for Contra Costa County, and interested hospital shall:

III.

A.

Submit a Contra Costa EMS designation application to the Contra Costa EMS Agency.

B.

Pay applicable initial application fee and annual designation fee to cover initial and ongoing County costs to support the STEMI program.

DESIGNATION CRITERIA A.

Current California licensure as an acute care facility providing Basic Emergency Medical Services.

B.

Ability to enter into a written agreement with Contra Costa County identifying SRC and County roles and responsibilities.

C.

Meets STEMI Receiving Center Designation Criteria as defined in the STEMI Designation Application. The criteria include: 1.

Hospital Services a.

Special permit for cardiac catheterization laboratory.

b.

Intra-aortic balloon pump capability.

c.

Special permit for cardiovascular surgery service.

d.

1)

The Contra Costa EMS Medical Director may waive this requirement for patient or system needs.

2)

Conformance with the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Intervention (ACC/AHA/SCAI) guidelines for centers without backup cardiovascular surgery will be evaluated in consideration of the waiver.

Continuous availability of PCI resources (24-hours/7-days a week).

2.

Hospital Personnel a. STEMI Receiving Center Medical Director b. STEMI Receiving Center Program Manager c. Cardiac Catheterization Lab Manager/Coordinator d. Intra-aortic balloon pump technician(s) e. Appropriate Cardiac catheterization nursing and support personnel f. Physician Consultants 1) Cardiology interventionalist 2) CV Surgeon

3.

Clinical Capabilities a.

ACC/AHA/SCAI guidelines for activity levels of facilities and practitioners for both primary PCI and total PCI events are optimal benchmarks.

POLICY #: Contra Costa Emergency Medical Services b. D.

E.

V.

Performance (timeliness) and outcome measures will be assessed initially in the survey process, and will be monitored closely on an ongoing basis.

1.

Cardiac interventionalist activation

2.

Cardiac catheterization lab team activation

3.

STEMI contingency plans for personnel and equipment

4.

Coronary angiography

5.

PCI and use of fibrinolytic

6.

Interfacility transfer STEMI policies/protocols

Performance Improvement Program Participation in Contra Costa EMS SRC QI Committee Core Membership a.

EMS Medical Director

b.

EMS Quality Improvement Coordinator

c.

Designated cardiologist from each SRC

d.

Designated quality improvement representative from each SRC

2.

Meetings to be held on a quarterly basis initially. Meeting frequency to be reviewed following the first year.

3.

Written internal quality improvement plan/program description for STEMI patients shall include appropriate evidence of an internal review process that includes:

4.

IV.

2 of 2

Appropriate internal (hospital) policies including:

1.

F.

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a.

Death rate (within 30 days, related to procedure regardless of mechanism)

b.

Emergency CABG rate (result of procedure failure or complication)

c.

Vascular complications (access site, transfusion, or operative intervention required)

d.

Cerebrovascular accident rate (peri-procedure)

e.

Post-procedure nephrotoxicity (increase in serum creatinine of >0.5)

f.

Sentinel event, system and organization issue review and resolution processes

Participation in Prehospital STEMI related educational activities.

Data Collection, Submission and Analysis 1.

Participation in National Cardiac Data Registry (NCDR)

2.

Participation in Contra Costa County EMS data collection as defined by Data Requirements for STEMI Centers document available at the Contra Costa EMS Agency.

DESIGNATION A.

SRC designation will be awarded to a hospital following satisfactory review of written documentation and an initial site survey by Contra Costa EMS staff.

B.

SRC designation period will coincide with the period covered in the written agreement between the SRC and the County.

BASIS FOR LOSS OF DESIGNATION A.

Inability to meet and maintain STEMI Receiving Center Designation Criteria

B.

Failure to provide required data

C.

Failure to participate in STEMI system QI activities

D.

Other criteria as defined and reviewed by the SRC QI Committee


PREHOSPITAL PATIENT CARE RECORD (PCR) I.

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PURPOSE The purpose of this policy is to define requirements for patient care documentation and the procedure for completion, distribution and retention of the patient care record (PCR) applicable to EMS transport providers, ALS first responders, and Enhanced EMT first responders.

II.

AUTHORITY The use of EMS approved paper or electronic PCRs and their associated data collection and

III.

reporting capabilities is established by the Contra Costa County EMS Agency, in accordance with the California Health and Safety Code and the California Code of Regulations. DEFINITION Completed PCR: a patient care record which documents required information as defined in Section VI.D of this policy.

IV.

V.

POLICY A.

EMS personnel shall complete patient care records (PCR) on all EMS patient responses regardless of patient outcome. This includes calls where a unit responded and there was no patient contact, as well as calls where the response is cancelled before arrival on scene.

B.

Emergency department staff shall have early access to information describing all patient care provided by EMS personnel so that a continuity of care can be maintained.

C.

All available and relevant information shall be accurately documented on the PCR.

D.

Intentional failure to complete a PCR when required or fraudulent or false documentation on a PCR may result in formal investigative action under the California Health and Safety Code, 1798.200, and Contra Costa County EMS Policy.

E.

Patient care documentation management is to be compliant with HIPAA and medical record retention requirements.

PCR AVAILABILITY A completed PCR delivered to the receiving facility is a high priority and must be left for each patient prior to clearing the receiving hospital, or within 2 hours of providing patient care.

VI.

A.

A partially completed or preliminary PCR, marked as such, shall be left with the patient if a PCR cannot be completed prior to clearing the receiving facility.

B.

Non-transporting agencies that have turned over care to the transporting personnel may send a partially completed or preliminary PCR, marked as such, with the patient.

C.

All PCRs must be fully completed and delivered (fax or hard copy) to the receiving facility within 24 hours of patient contact.

PCR PROCEDURES A.

Personnel providing patient care are responsible for accurately documenting all available and relevant patient information on the PCR.

B.

Care given prior to arrival, by bystanders or first responder personnel, shall be documented on a PCR.

C.

Use of usual and customary abbreviations is permitted in the narrative section of the record or as defined in automated PCR pre-designated pick lists.

POLICY #: Contra Costa Emergency Medical Services D.

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The PCR shall contain the following Basic Data Elements, when available: 1.

2.

VII.

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27

Initial Response Information a.

EMS unit number

b.

Date and estimated time of incident

c.

Time of receipt of call

d.

Time of dispatch to the scene

e.

Time of arrival at the scene

f.

Incident location

Patient Information a.

Name

b.

Age and date of birth

c.

Gender

d.

Weight, if necessary for treatment

e.

Address

f.

Chief complaint

g.

Patient history

h.

Vital signs

i.

Appropriate physical assessment

j.

Emergency care rendered, and patient’s response to such treatment

k.

Patient disposition

l.

Time of departure from scene (if transported)

m.

Time of arrival at receiving facility (if transported)

n.

Name of receiving facility (if transported)

o.

Name and unique identifier number(s) of EMS personnel on the call

p.

Signature of EMS personnel on the call

E.

The PCR shall be completed and distributed in accordance with this policy.

F.

A completed PCR shall not be altered or changed except by the individual who completed the PCR. Exceptions are permitted to add or change billing information, or add a name or other pertinent demographics unknown at the time of the call.

G.

If a paper PCR is used, or a change is made on a hard copy of an automated PCR, documentation errors shall be lined through (e.g. Like this), and the correction shall have the patient attendant’s initials beside it.

H.

Any changes made to an electronic PCR shall have documentation of those changes retained in the computer database.

DOCUMENTATION WHEN MEDICAL CARE OR TRANSPORT IS DECLINED A.

In situations where the patient, or their legal representative, declines medical care or transport when care is recommended and felt to be necessary by the prehospital personnel attending that patient, documentation should include all available basic data elements, plus: 1.

Mental status and patient competency to decline care without impairment due to drugs, alcohol or organic causes (medical or mental illness).

2.

Patient informed of nature of condition and planned treatment/transportation offered.


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3.

Specific risks and consequences discussed – patient acknowledged understanding.

4.

Specific comments made by patient (with quote marks) in declining care/transport.

5.

Base contact/physician name, if done.

6.

Advisory for patient to contact 911 or seek further care if s/he should change mind.

7.

Disposition – released to self, custody of parent/guardian, law enforcement or other person.

8.

Signature of patient/responsible party or documentation of refusal to sign.

9.

Name/signature of witness, if available, plus permanent identifier.

10.

Name of interpreter if used.

11.

Any other information appropriate to document situation or event.

B.

If a first responder agency has patient contact, the call results in no transport, and the transport agency has no patient contact, first responder agency personnel are responsible for completion of appropriate documentation.

C.

If patient care has been transferred from first responders and a patient subsequently declines further treatment or transport, the transport crew is responsible for appropriate documentation.

VIII. HOSPITAL RESPONSIBILITIES Hospitals should implement mechanisms to assure that prehospital documentation arriving with the patient is readily available to ED staffs and is incorporated into the hospital medical record system. IX.

X.

ELECTRONIC SYSTEM FAILURE A.

Back-up systems to provide for paper PCR documentation must be in place for use should an electronic documentation system fail. Electronic documentation system failure is NOT an exception for providing the required PCR documentation.

B.

The EMS Agency shall be notified of downtime or transmission difficulties lasting more than 24 hours.

MULTI-CASUALTY INCIDENTS A.

Electronic or paper PCRs shall be completed for all patients in multi-casualty incidents unless requirements have been shifted to documentation on triage tags per MCI plan directives.

B.

In incidents with large numbers of persons refusing treatment or transport, efforts should be made to document as much information as possible.


PARAMEDICS INTERFACILITY TRANSFER (CCT-P) PROGRAM STANDARDS I.

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PURPOSE The CCT-P Program has been developed to provide an alternative means of transferring stable patients who require, or who may require, care within the CCT-Paramedic Scope of Practice during transfer. CCT-P units may be used to transfer patients from acute care facilities, or other medical facilities approved by the EMS Medical Director, to other acute care facilities. Contra Costa EMS authorizes and contracts with interested ambulance companies that meet the training, staffing, equipment and oversight requirements for providing this level of service and that agree to comply with program standards. Program authorization may be denied or withdrawn for failure to comply with program standards or failure to submit required fees.

II.

STAFFING A CCT-P unit is a fully equipped advanced life support ambulance, staffed with a minimum of two (2) qualified staff that includes at least one (1) paramedic. A.

B.

Paramedic Personnel: Paramedics assigned to CCT-P units shall meet the following minimum qualifications: 1.

Current and valid California Paramedic License,

2.

Current accreditation in Contra Costa County,

3.

At least two (2) years full-time field experience as a paramedic in an ALS system,

4.

Current and continuously renewed provider status in BCLS, ACLS, PALS, PEPP, and PHTLS or BTLS,

5.

Successful completion of EMS Agency approved provider training and orientation programs specific to skills used on interfacility transfers.

EMT-I Personnel EMTs assigned to CCT-P units shall meet the following minimum qualifications:

III.

1.

Current and valid EMT-I certification in California,

2.

Current provider status in BCLS,

3.

Successful completion of EMS Agency approved training program specific to skills used to assist paramedics with patient care during ALS interfacility transfers, and

C.

Employer shall provide the EMS Agency with a list of all staff working on a CCT-P unit and shall see that this list is updated whenever there is a change in personnel.

D.

Employer shall retain on file, at all times, copies of current and valid credentials for all personnel performing services under this program.

MEDICAL DIRECTION Personnel assigned to a CCT-P unit work under the existing medical control system and follow Contra Costa County EMS policies and procedures, as approved by the EMS Medical Director. A.

CCT-Paramedic Scope of Practice The County CCT-P Scope of Practice includes the County Basic and Optional Scopes of Practice for paramedics listed in the Contra Costa Prehospital Care Manual. In addition, CCT-Ps have an expanded scope that includes the administration of intravenous (IV) nitroglycerin (NTG), potassium chloride (KCI) and heparin by IV pump.

B.

Transferring Physician Orders


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The transferring physician specifies standing orders for a patient based on skills and medications included in the County CCT-P scope of practice using a County-approved form. C.

Patient Care Outside of the Paramedic Scope of Practice 1.

2. D.

When a patient’s treatment/care is beyond the CCT-P paramedic scope of practice, that patient may be transported by a CCT-P unit only when: a.

A licensed medical professional (e.g. RN, Nurse Practitioner, Nurse-midwife, PA or MD) is in attendance and assumes control and responsibility for providing patient care outside the Paramedic Scope of Practice; AND,

b.

Medication or equipment needed by the patient that is not stocked on the ambulance unit are provided by the sending facility.

Accompanying licensed medical personnel providing care function under their own written standing orders and document any care provided.

Exceptional Situations 1.

2.

Critical patients and “on views”: If the CCT-P unit either responds to a private request for a transport and finds a patient that requires immediate ALS care, or “on views” an emergency scene, the CCT personnel shall: a.

Activate the 9-1-1 system.

b.

Provide appropriate patient care, which may include any indicated ALS interventions following Contra Costa County field treatment guidelines.

c.

Initiate transport if emergency transport unit is not on-scene and ETA to closest appropriate receiving facility is shorter than ETA of the emergency transport unit.

Patient deterioration during transport: If the CCT-P unit responds to a private request for transport and the patient begins to deteriorate after transport has begun, personnel shall: a.

Provide appropriate patient care that may include any indicated ALS interventions following Contra Costa County EMS Field Treatment Guidelines.

b.

Make base hospital contact if required by EMS protocol.

c.

Divert to a closer facility if necessary and appropriate, based on patient condition and base hospital direction.

CCT-P personnel shall submit a written report fully explaining the circumstances of any exceptional situations including those described above together with a copy of the patient care report and related dispatch records to the EMS Agency within 24 hours of the incident. IV.

DOCUMENTATION A.

Patient Care Report A written patient care report (PCR), format of which has been approved by the EMS Agency, shall be accurately completed on each patient. 1.

The PCR shall contain available information regarding call demographics, patient assessment, care rendered, and patient response to care.

2.

A copy of the PCR shall be given to the receiving facility prior to the transfer unit department the facility.

3.

If the patient is turned over to an emergency transport unit, a copy of the PCR shall be sent with the patient if time permits. If the PCR cannot be completed prior to patient transport, the CCT-P paramedic shall complete the PCR and fax it to the Emergency Department of the receiving facility as soon as possible.


V.

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28 3 of 5

A copy of each PCR shall be sent by the first business day following the transfer to: a.

The EMS Agency

b.

The base hospital if involved in the transfer

CCT-P STAFF PREPARATION AND COURSE APPROVAL PROCESS A.

Submit a Paramedic Interfacility Transfer Program Application, completed checklist, and supporting documentation to the EMS Agency for approval at least 2 weeks prior to the course start date.

B.

Paramedic interfacility didactic and clinical training requirements 1.

Education – didactic a.

Minimum number of hours for course = 80 didactic hours.

b.

Describe the method of assessing successful course achievement/evaluation.

c.

Principle instructor of paramedic training must be a registered nurse or physician knowledgeable in the subject matter. Principle instructor of EMT-I training may be a paramedic, registered nurse or physician.

d.

Provide course content and objectives.

e.

Course content to include: 1)

EMTALA

2)

Review of County paramedic and expanded paramedic scopes of practice

3)

Recognition of patients who require a higher level of care

4)

What to do if the patient deteriorates: a)

Diversion

b)

Implement Contra Costa County Policies

c)

Base contact is not required unless the patient deteriorates and requires care not covered by the transferring physician orders, or unless specifically mandated by EMS treatment protocol.

5)

Obtaining and receiving reports from sending/receiving facilities

6)

Notification to receiving hospital while enroute (cell phone) a)

7)

Breathing and Airway Management a) b) c)

8)

Patient status and ETA Anatomy, physiology, pathophysiology, signs and symptoms, assessment Tracheostomies Endotracheal intubation and Needle Cricothyrotomy (review of procedure)

d)

Pharmacologic agents

e)

Chest tubes (operation, troubleshooting, assessment)

f)

Pleural Decompression (review of procedure)

g)

Portable ventilators

Laboratory Values a)

Review of common blood analyses including arterial blood gas, urinalysis Normal/abnormal findings and implications


PAGE:

28 4 of 5

Practical application of values to patient presentations 9)

Pharmacology a)

Review of common medications, including sedatives, analgesics, paralytics, antihypertensives, vasopressors, volume expanders, bronchodilators, antiarrhythics, atianginals, thrombolytics, anticoagulants.

b)

Drug calculations (bolus and infusions, by volume and rate).

c)

Detailed instruction (drug actions, indications, dosages, calculation, adverse reactions, contraindications and precautions) on the following: Intravenous NTG Intravenous heparin KCI infusion Lidocaine Dopamine.

d)

10)

11)

Review of other agents not in CCT-P scope (magnesium sulfate, mannitol, oxytocin, procainamide, use of blood products – including transfusion reaction recognition and management).

Infusion Pumps a)

Operation and troubleshooting

b)

Review of variety of available equipment

c)

Practical application (setting drip rates, troubleshooting)

Hemodynamic Monitoring a)

Non-invasive monitoring NIBP, pulse oximetry, capnography, auscultation

b)

Invasive monitoring (review only, not in scope of CCT-P) Arterial lines, Swan-Ganz

c)

Existing vascular access devices (e.g., Hickman, Broviak, Porta-Cath, PIC and others) Evaluation, troubleshooting, potential complications

d) 12)

ECG Interpretation a)

13)

Mechanism, complications and patient management

Cardiac Pacemakers a)

15)

Arrhythmia, coronary ischemia

Implanted Defibrillators a)

14)

Wound care at site of devices

Implanted devices, transvenous (not in CCT-P scope), transcutaneous

Indwelling Tubes a)

Urinary: Foley and suprapubic catheters

b)

Nasogastric, PEG, Dobhoff tubes

16)

Shock and multi-organ failure

17)

Special populations

POLICY #: Contra Costa Emergency Medical Services a) 18)

19) 2.

C.

PAGE:

28 5 of 5

Including renal and peritoneal dialysis patients, pediatric, obstetric, neurologic, and trauma patients

Isolation issues a)

VRE, MRSA

b)

Procedures

Documentation

Education – clinical 40 hours (total) a.

Minimum number of hours with Respiratory Therapist = 4 hours

b.

Minimum observational time spent on IFT ride-along = 8 hours (must include at least 2 separate transports)

EMT-I interfacility didactic and clinical training requirements

Minimum four (4) hours didactic and clinical instruction specific to the skills needed to assist a single paramedic in-patient care delivery during CCT-P calls. Completion of the Contra Costa “Partners” course meets this requirement. VI.

CONTINUOUS QUALITY IMPROVEMENT (CQI) PLAN A.

A CCT-P program shall have a written CQI Plan approved by the EMS Agency.

B.

A Registered Nurse or Physician shall have clinical oversight of the CCT-P CQI Plan.

C.

Provider’s CQI staff shall evaluate all CCT-P transfers for medical appropriateness. 1.

2. D.

Specific review for use of intravenous NTG, heparin and KCI will include: a.

Review of transferring physician’s orders and evidence of compliance with orders.

b.

Documentation of vital signs, including frequency.

c.

Documentation of any side effects/complications including hypotension, bradycardia, increasing chest pain, arrhythmia, altered mental status, and interventions with these events.

d.

Documentation of any unanticipated discontinuation or rate adjustments of infusions along with rationale and outcome.

e.

Review of any base contact or transferring physician for orders during transport.

Significant complications shall be communicated to the EMS Agency by the next business day.

EMS Agency will receive quarterly reports summarizing CQI activity, identified trends, and resolutions.


BASE HOSPITAL DESIGNATION I.

PAGE:

29 1 of 3


PURPOSE To define the criteria, which shall be met by acute care hospitals in Contra Costa County for Base Hospital designation.

II.

AUTHORITY Health and Safety Code, Division 2.5, Sections 1798, 1798.101, 1798.105, 1798.2 and California Code of Regulations, Title 22, Section 100175.

III.

DEFINITION AND FUNCTION A Base Hospital is a hospital designated by the Local EMS Agency as responsible for directing the advanced life support system and prehospital care system assigned to it by the local EMS agency. The Base Hospital functions within the Local EMS system to facilitate and expedite safe, high-quality, patient-centered care providing destination and prehospital on-line decision making support without interruption, 24 hours per day, 7 days a week. The base hospital works in partnership with local EMS stakeholders in accordance with California EMSA and Local EMS Agency requirements.

IV.

V.

DESIGNATION PROCESS A.

Contra Costa Emergency Medical Services designates Base Hospitals.

B.

Application and agreement process is defined by the Contra Costa Emergency Medical Services Agency in compliance with California Emergency Medical Services Authority (EMSA) requirements.

C.

The designation period will coincide with the period covered in a written agreement between the Base Hospital and the Contra Costa Emergency Medical Services (EMS) Agency.

DESIGNATION CRITERIA A.

Current California Licensure as an acute care facility providing Basic Emergency Medical Services and Joint Commission Accreditation.

B.

Ability to enter into a written agreement as Base Hospital with the Contra Costa EMS Agency.

C.

Continuous availability of Base Hospital service without interruption (24-hours/7-days a week).

D.

Ability to provide immediate response to each and every request by prehospital personnel for medical consultation or trauma destination.

E.

Commitment to collaborate with Contra Costa EMS Agency to provide and maintain function of communication equipment for the purposes of communicating with prehospital personnel without interruption.

F.

Ability to promptly notify receiving hospital of every patient for whom there is Base Hospital direction.

G.

Ability to provide audio and written documentation of radio and telephone consultations with Prehospital personnel including trauma destination determinations.

H.

Commitment to assist the county in implementing new policies and procedures issued by the county.

I.

Designate appropriate personnel to support and oversee Base Hospital functions including: 1.

Base Hospital Liaison Physician Physician responsible for providing oversight and leadership to the Base Hospital EMS QI program.


2.

3.

2 of 3

a)

Licensed physician on the hospital staff experienced in emergency medicine and regularly assigned to the Emergency Department.

b)

Experienced in base hospital radio operations and Contra Costa EMS Agency policies and procedures.

c)

Maintains Base Hospital Physician requirements.

d)

Participates on Medical Advisory Committee, Pre-Trauma Audit Committee (PreTAC) and other appropriate prehospital committees or advisory groups.

Base Hospital Nurse Coordinator responsible for providing overall support for base station operations and assists the Base Hospital Liaison Physician in the medical supervision of prehospital and hospital personnel within the Base Hospital’s area of responsibility. a)

MICN authorized California Licensed Registered Nurse experienced in emergency nursing.

b)

Experienced in base hospital radio operations and Contra Costa EMS Agency policies and procedures.

c)

Participates on Medical Advisory Committee and other appropriate prehospital committees or advisory groups.

d)

Acts as liaison between receiving facilities and Contra Costa EMS Agency supporting identification and resolution of Base Hospital issues.

e)

Coordinates the Base Hospital data collection and quality improvement program.

Base Hospital Physicians knowledgeable and capable of issuing advice and instructions to MICNs and prehospital personnel consistent with the standards established by State of California EMSA and Contra Costa EMS Agency. a)

Maintain current certification in ACLS. This requirement may be waived if the physician is Board certified in Emergency Medicine.

b)

Board certified or eligible in Emergency Medicine.

c)

Completes radio communications preparation and base hospital orientation to EMS prior to acting as EMS Base Hospital Physician including:

d) 4.

PAGE:

29

(1)

State legislation and regulations governing EMS and prehospital providers.

(2)

Base physician role and responsibilities.

(3)

County Field Treatment guidelines and patient care report forms.

(4)

Policies and procedures pertinent to Base Hospital function and medical control, e.g., interfacility transfers, disrupted communications.

Acts as a resource in quality improvement activities to Base Hospital Coordinator and Base Hospital Liaison Physician.

MICNs knowledgeable and capable of issuing advice and instructions in consultation with Base Physician to prehospital personnel consistent with the standards established by the State of California and Contra Costa EMS. a)

Maintain current certification in ACLS.

b)

Maintain MICN Authorization in compliance with Contra Costa EMS Policies and Procedures.

c)

Completes radio communications preparation and base hospital orientation to EMS prior to acting as a MICN including: (1)

State legislation and regulations governing EMS and Prehospital providers.

(2)

MICN role and responsibilities.


d) VI.

VII.

PAGE:

29 3 of 3

(3)

County Field Treatment guidelines and patient care report forms.

(4)

Policies and procedures pertinent to Base Hospital function and medical control, e.g., interfacility transfers, disrupted communications.

Acts as a resource in quality improvement activities to Base Hospital Coordinator and Base Hospital Liaison Physician.

PERFORMANCE IMPROVEMENT A.

Base Hospital Staff maintains a written Base Hospital Quality Improvement Policy or Plan.

B.

Assures quality improvement plan shall interface with the Contra Costa EMS Agency Quality Improvement Program.

C.

Participates in Contra Costa EMS Agency Quality Improvement Program.

D.

Participates in Contra Costa EMS Agency event reporting.

E.

Provides in a timely manner data and statistical reports as may reasonably be required by the Contra Costa County EMS Agency and as allowed under HIPPAA.

F.

Maintains and oversees Base Physician and MICN authorization and continuing education tracking system.

BASIS FOR LOSS OF DESIGNATION Base hospital designation may be denied, suspended or revoked by the Contra Costa EMS Agency Medical Director for failure to comply with state and Contra Costa EMS Agency policies, procedures or regulations.


MANAGING ASSAULTIVE BEHAVIOR/

PAGE:

30 1 of 2


PATIENT RESTRAINT I.

PURPOSE To provide guidance on the approach to patients with assaultive behavior and to outline appropriate use of patient restraints.

II.

POLICY A.

Safety of responding personnel, community, and the patient is of paramount concern.

B.

Restraints should only be utilized when necessary, in situations in which the patient is exhibiting behavior that presents a danger to themselves or others.

C.

Restraint types

D.

E.

III.

1.

Leather or cloth restraints may be utilized for patient restraint during transport.

2.

Handcuffs for initial restraint may only be applied by law enforcement personnel and should be replaced with another method of restraint prior to transport. Handcuffs may only be used for restraint during transport when law enforcement personnel accompany the patient in the ambulance. A patient in handcuffs may not be handcuffed to the gurney.

Law enforcement responsibilities 1.

Law enforcement personnel are responsible for the capture and/or restraint or assaultive or potentially assaultive patients. Field personnel should obtain assistance from law enforcement to prepare patients for ambulance transport.

2.

Law enforcement agencies retain primary responsibility for safe transport of patients under arrest or 5150 hold.

3.

Patients under arrest or on 5150 hold shall be searched thoroughly by law enforcement for weapons prior to placement in the ambulance.

4.

Patients under arrest must always be accompanied by law enforcement personnel.

5.

Ambulance and law enforcement personnel should mutually agree on need for law enforcement assistance during transport of patients on 5150 hold.

A competent patient may not be transported against his or her will unless under arrest or on 5150 hold. Patients with medical conditions that appear to compromise their ability to consent for care may be restrained (when indicated) and transported without law enforcement authority in situations in which a life-threatening emergency exists or potentially exists.

PROCEDURE A.

General approach 1.

Assaultive behavior may be a manifestation of a medical condition such as head injury, drug or alcohol intoxication, metabolic disorders, hypoxia, or post-ictal state. Field personnel should consider these conditions along with psychiatric disorders in the approach to assaultive patients. Field personnel should obtain a detailed history from family members, bystanders, and law enforcement personnel, and make particular note of patient surroundings for clues to the cause of the behavior (e.g. drug paraphernalia, medication bottles).

2.

Field personnel should attempt to de-escalate verbally aggressive behavior with a calm and reassuring approach and manner.

POLICY #: Contra Costa Emergency Medical Services B.

C.

PAGE:

30 2 of 2

Restraint issues 1.

Restrained patients shall be placed in a supine position, in Fowler's or semi-Fowler's position (gurney angled 30-90 degrees). Patients shall not be transported in a prone or "hog-tied" position.

2.

The method of restraint must allow for adequate monitoring of pulse and respiration, and should not restrict the patient or rescuer’s ability to protect the airway should vomiting occur.

3.

Restrained extremities should be monitored for circulation, motor function, and sensory function every 15 minutes.

4.

Prehospital documentation should include behavior reason for restraint, other pertinent clinical information, and documentation of monitoring of restrained extremities.

Transport issues 1.

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.

2.

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.


PREHOSPITAL MANAGEMENT OF PRE-EXISTING PATIENT MEDICAL DEVICES/EQUIPMENT: INTRAVENOUS LINES AND OTHER I.

II.

PAGE:

31 1 of 2


PURPOSE To provide guidance for pre-hospital management of patients with pre-existing medical devices & equipment during routine, emergency or inter-facility transport; including intravenous lines and devices, home ventilators, and other patient care equipment. PROCEDURE A. Peripheral IV Lines 1. EMT-Is may: a. Monitor IV lines delivering glucose solutions or isotonic balanced salt solutions including Ringer’s Lactate for volume replacement. b. Monitor, maintain and adjust if necessary in order to maintain a preset rate of flow and turn off the flow of IV fluid. c. They may not monitor an IV if any medication has been added to the solution. 2. Paramedics may: a. Administer intravenous glucose solutions or isotonic balanced salt solutions including Ringer’s lactate solution. b. Monitor and adjust IV flow rates of existing IV(s) with solutions containing potassium chloride (KCl) equal to or less than 20 mEq/L. c. Monitor, maintain and adjust approved IV solutions with medications that are allowed as part of the local paramedic scope of practice. B. Special Populations For dialysis patients whose peripheral access site (shunt or fistula) has already been accessed, the existing IV line may be used by a paramedic for administration of fluids or medications. C. Central Lines/Central Venous Access Device/Infusion Devices 1. EMT-Is may transport patients with existing central lines or central venous access devices, e.g. Heparin or saline locked central lines, but may not transport patients if any fluid or medications are being administered through these devices. Exception: In the case where a patient has a physician-prescribed infusion device that is being controlled/monitored by either the patient or a family member, e.g. patient controlled analgesia (PCA) pump. If any question exists, base contact should be made for further clarification. 2. Paramedics may transport a patient that has fluid or medication running through a central line or other central venous access device as long as the medications are within the paramedic scope of practice. Exceptions:


D.

E.

F.

G.

PAGE:

31 2 of 2

o In the case where a patient has a physician-prescribed infusion device that is being controlled/monitored by either the patient or a family member. o In the event of cardiopulmonary arrest or extremis due to circulatory shock, and a peripheral IV or IO cannot be obtained, an indwelling central line(s) can be used by the paramedic to deliver fluids and medications within their scope. If any question exists, base contact should be made for further clarification. 3. Central venous access devices that would require the penetration of skin by the paramedic, such as internal subcutaneous infusion ports or fistulas, may not be used. 4. When handling a central line paramedics should: a. Use strict aseptic technique, b. Not remove injection caps from catheters, o Not allow IV fluids to run dry, o Always expel air from preloads/syringes prior to medication administration, o In the event of damage to the central line immediately clamp the external catheter between the site of the catheter damage and the patient. Thorascostomy Tubes Paramedics may monitor thorascotomy tubes. EMT-Is are not permitted to transport patients with thoracostomy tubes. Foley Catheters, Nasogastric Tubes, Gastrostomy Tubes, Tracheostomy Tubes EMT-I and paramedic personnel may transport these patients, however, these devices are not to be manipulated, removed, or discontinued. If any question exists, base contact should be made for further clarification. Home Ventilators EMT-Is may transport patients with home ventilators but these patients should ideally be transported via ALS-level ambulance. In an emergency situation requiring immediate transport (cardiac arrest, respiratory distress or extremis due to shock), patients may be transported to the closest facility via EMT-I ambulance and ventilation should be supported via bag-valve-mask device. Other Devices If other equipment is encountered by EMT-I or paramedic personnel, a patient may be transported with the equipment provided that the prehospital providers are not required to discontinue or alter the functioning of the equipment. If the patient cannot be moved without disrupting the function of the equipment, base consultation should be obtained.


EMS EVENT REPORTING I.

POLICY #:

32

PAGE:

1 of 3


PURPOSE To establish a clear system of patient safety and EMS response-related reporting for the purposes of review, data analysis, patient safety and EMS system performance. To define reporting requirements for events that have the potential to cause community concern or represent a threat to public health and safety. To define the reporting and monitoring responsibilities of all EMS system participants. To recognize exemplary prehospital care in the EMS system.

II.

AUTHORITY California Health and Safety Code; California Code of Regulations, Title 22 and California Health and Safety Code section 1798.200.

III.

POLICY EMS events shall be appropriately reported, reviewed and tracked to monitor, maintain and improve safety. Exemplary care may also be identified, tracked and acknowledged through this process. Reporting is encouraged from any individual who encounters or recognizes a situation in which a safety related or exemplary event occurred while a patient was being cared for. Definitions of EMS Events

IV.

A.

Any event that has resulted in or has the potential to lead to an adverse patient outcome. These events may be related to systems, operations, devices, equipment, medications or any aspect of patient care.

B.

Great Catches: Events that are recognized and prevented before they actually occur. A “great catch” includes recognition of provider action that contributes to the prevention of negative or adverse patient outcomes. Near miss events are included in this category.

C.

Community events that may cause public concern, (either positive or negative): Examples of potential community concerns could include: bomb threats, toxic exposures, multi casualty incidents, infectious outbreaks or exposures, and EMS system operational issues.

D.

Exemplary care in the field deserving of recognition or commendation.

E.

Events that represent a threat to public health and safety as defined by 1798.200, as listed on the back of the EMS event report form.

REVIEW PROCESS A.

The involved agency(ies) will review and take any indicated follow-up actions on all reported EMS events. 1.

The on-duty officer or supervisor shall verbally notify EMS Agency promptly of events that may cause public concern.

2.

Involved agencies should review, and if appropriate, report EMS events to the EMS Agency using the instructions and forms on the Contra Costa County EMS website at www.cccems.org. a.

Contra Costa County EMS Event Report Form

b.

Contra Costa County EMS Event-QI Review Paper or Electronic Form

Contra Costa Emergency Medical Services B.

POLICY #:

32

PAGE:

2 of 3

Interagency EMS Events To allow for prompt review and follow-up, communication of events should occur between the involved agencies. Each agency is responsible for its own internal review and follow-up. EMS Agency staff is available to assist all participants in seeking solutions to patient safety events that affect the EMS system.

C.

V.

EMS events that require review include: 1.

Any threat to public safety as defined by the Health and Safety Code 1798.200

2.

Medication related: incorrect drug choice, dosage, or route

3.

Equipment related: equipment problems, adverse events or failures related to patient care or EMS response

4.

Treatment or Procedure related such as: a.

Difficulties, problems and unexpected events associated with procedures (e.g. known esophageal intubation)

b.

Events related to patient assessment or application of treatment guidelines (e.g. multiple attempts at interventions outside the number recommended by treatment guidelines

c.

Events related to interventions or procedures done that are not consistent with paramedic primary impression

5.

Scope related: situations in which an EMT or Paramedic scope of practice was not property followed.

6.

Patient Interaction related: Verbal or physical event identified which resulted or had the potential for harm, insult, neglect or abuse of the patient.

RESPONSIBILITIES A.

B.

Prehospital personnel 1.

Assure patient safety by immediately notifying the hospital staff at the receiving facility and the base hospital (if involved), when an event impacts or has a potential to impact the patient.

2.

Immediately report event of concern to an on-duty officer or supervisor using the appropriate chain of command.

3.

Complete the EMS event form. Include verification of verbal reports on the form.

4.

Recommendations for corrective actions from the individuals involved are encouraged.

Provider Agency Each agency shall have a process of fact-finding, follow-up and tracking of EMS events. All reported events regardless of significance should be reviewed and tracked as part of the provider’s quality improvement program. 1.

Assure patient safety first. Assure medical providers involved in the patient’s care at the receiving hospital and base station (if involved) have been informed of events that have the potential to impact patient care.

2.

Evaluate the event and notify the EMS Agency promptly regarding issues of public concern or that require urgent investigation.

3.

Provide the EMS Agency with additional written or verbal reports if requested.

4.

Take action to remediate the situation. Develop remediation programs (e.g., individual performance improvement plans) that offer appropriate and timely feedback, skills review and competency training.

POLICY #:

32

PAGE:

3 of 3

Contra Costa Emergency Medical Services 5. C.

Patient safety reporting data may be requested by the EMS Agency at regular intervals in order to assist the EMS Agency in evaluating system and operations issues.

Base Hospital Base hospital should notify the Base Coordinator or designee of any identified EMS events. The Base Coordinator will: 1.

Assure patient safety

2.

Evaluate the event

3.

Complete the EMS event form and forward to involved agency(s) for review

4.

Notify EMS Agency if event meets prompt notification criteria

5.

Take action to remediate the situation

Patient safety reporting data may be requested by the EMS Agency at regular intervals in order to assist the EMS Agency in evaluating system and operations issues. D.

Receiving Hospitals Receiving hospitals should report any identified EMS events to the involved agency supervisor(s) if possible. Hospitals may fax EMS events to the EMS Agency to be distributed to the appropriate agency.

E.

Other Reporting Any other system participants or individuals, including receiving hospital personnel, are encouraged to report EMS events to the EMS Agency.

F.

Anonymous Reporting EMS events may be reported anonymously to a provider agency representative or to the EMS Agency directly. Anonymous reporting should never be discouraged.


EMS AIRCRAFT - CLASSIFICATION I.

POLICY #:

33A

PAGE:

1 of 2


PURPOSE To specify the classification requirements for EMS aircraft providers that base their operations within Contra Costa County.

II.

AUTHORITY Division 2.5 California Health and Safety Code; Title 22 California Code of Regulations.

III.

CLASSIFICATION The local EMS Agency is responsible for classifying EMS aircraft based within its jurisdiction, except that the California EMS Authority is responsible for classifying aircraft of the California Highway Patrol, California Department of Forestry, and California National Guard. A.

Classification Categories An EMS aircraft will be classified as either an air ambulance or a rescue aircraft. Rescue aircraft will be further classified as advanced life support, basic life support or auxiliary based on level of medical flight crew credentials. 1.

2.

B.

Air Ambulance: Any aircraft that is a.

constructed, modified, equipped, and used to respond to emergency requests and to transport critically ill or injured patients, and

b.

staffed with a minimum of two attendants credentialed in advanced life support.

Rescue Aircraft: An aircraft whose usual function is not prehospital emergency patient transport but which may be used, in compliance with EMS policy, for prehospital emergency patient transport when use of an air or ground ambulance is unsuitable or unavailable. a.

Advanced Life Support Rescue Aircraft: A rescue aircraft whose medical flight crew has a minimum of one attendant credentialed in advanced life support.

b.

Basic Life Support Rescue Aircraft: A rescue aircraft whose medical flight crew has at a minimum one attendant certified as an EMT-A. An EMT-NA with the additional training and experience specified in Title 22, Section 100283 may be used to meet the BLS rescue aircraft medical staffing requirement.

c.

Auxiliary Rescue Aircraft: A rescue aircraft which does not have a medical flight crew, or whose medical flight crew does not meet minimum requirements established for Basic Life Support Rescue Aircraft.

Medical Helicopter The term “medical helicopter” shall mean a rotary wing aircraft that has been classified as an “air ambulance.”

IV.

CLASSIFICATION PROCEDURE A.

B.

To become classified in Contra Costa County, and EMS aircraft provider is required to: 1.

Submit a completed Contra Costa County EMS Aircraft Classification form,

2.

Submit all required attachments, and

3.

Pay the current EMS Aircraft Classification Fee.

Prior to classification, EMS Agency staff may visually inspect the aircraft, equipment and radios.

Contra Costa Emergency Medical Services C.

D.

POLICY #:

33A

PAGE:

2 of 2

An EMS aircraft provider shall apply for re-classification whenever there is a: 1.

Transfer of ownership, or

2.

Change in any factor that applies to or affects its classification category.

No person or organization shall provide or hold itself out as providing prehospital air ambulance or air rescue services unless that person or organization has been classified by a local EMS agency, or in the case of the California Highway Patrol, California Department of Forestry, and California National Guard, the EMS Authority.


EMS AIRCRAFT - AUTHORIZATION I.

POLICY #:

33B

PAGE:

1 of 3


PURPOSE To specify authorization requirements for EMS aircraft providers with operations based in Contra Costa County.

II.

AUTHORITY Division 2.5, California and Safety Code; Title 22. Division 9 and Chapter 8, California Code of Regulations.

III.

AUTHORIZATION The local EMS Agency is responsible for authorizing EMS aircraft used for EMS response within its jurisdiction. Normally, only EMS aircraft that meet the “air ambulance” classification standard shall be authorized by the EMS Agency to respond in Contra Costa County. However, any request by a public safety agency dispatch center shall constitute “authorization” to respond to that request only.

IV.

AUTHORIZATION PROCESS To become authorized in Contra Costa County, and EMS aircraft provider is required to:

V.

A.

Submit a completed EMS Aircraft authorization form,

B.

Enter into a written contract with the County, and

C.

Pay the current EMS Aircraft Authorization Fee.

PERFORMANCE STANDARDS A.

B.

Services 1.

Only an “Air ambulance” may be dispatched in response to an emergency medical aircraft request.

2.

Aircraft may respond to emergency requests when and only when requested by a local public safety dispatch center.

3.

A seamless “one contact number system,” approved by the EMS Agency, is to be used by local public safety dispatch centers when requesting EMS aircraft assistance.

4.

An authorized provider shall assure that its dispatch center provides an accurate “estimated time of arrival” (ETA) in minutes and clock hours to the requester of each air ambulance request.

5.

An authorized provider shall comply with all applicable Federal, State and local laws and regulations, and County EMS policies, procedures and protocols.

Dispatch and Communications 1.

EMS aircraft dispatch centers shall be staffed an equipped to receive and process requests for EMS aircraft.

2.

Dispatchers shall be adequately trained and prepared to process emergency medical requests.

3.

Aircraft shall be equipped with County’s MEDARS radio system for communications with Sheriff’s Dispatch, on-scene ambulances, public safety agencies, and local base and receiving hospitals.

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33B

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Contra Costa Emergency Medical Services C.

D.

E.

F.

Staffing 1.

Air ambulance staffing shall include a medical flight crew consisting of a minimum of two (2) attendants licensed in advanced life support, at least one (1) of which is a registered nurse or physician.

2.

Air medical flight crewmembers and pilots shall maintain all required professional licensure.

Training and Orientation 1.

Medical flight crewmembers shall be trained in aeromedical transportation as specified in Section 100302, California Code of Regulations, and maintain current professional licenses.

2.

Medical flight crews and pilots shall be oriented and familiar with the local EMS system prior to responding to local emergency medical requests. Orientation shall include the following topics: a.

Terrain and weather considerations specific to the geographic area of the County.

b.

Local EMS and public safety agencies.

c.

Locations of and special operational information related to local hospitals and medical specialty centers, helipads, airports and pre-determined emergency landing sites.

d.

Comprehensive communications inventory including frequency numbers, agency names and identifiers, PL codes, and any special communications procedures.

e.

(Medical crew) Local medical control policies and procedures.

Medical Control 1.

Local Medical Control Agreements shall be in place for paramedic crewmembers.

2.

Providers shall assure compliance with local policies and procedures for medical control.

3.

Registered Nurse crewmembers function within the Nurse Practice Act and shall be trained/qualified to provide advanced life support care within the local paramedic scope of practice at a minimum.

Documentation and Reporting 1.

Patients transported from within Contra Costa County: Patient care reports (PCRs) shall be completed for all patient transports despite location of receiving facility. PCRs include the required patient care data elements, requesting party/agency, and times necessary to determine aircraft response time from initial notification, on-scene time, and hospital transport time. Copies of PCRs are left with the patient at the receiving hospital. a.

2.

G.

PCRs for all patients shall be sent to the EMS Agency within ten working days.

Patients transported into Contra Costa County from another county: Patient name, age, transport date/time, assessment, CRAMS/GCS, mechanism of injury and destination shall be sent to EMS within ten calendar days of the end of that month.

Quality Improvement 1.

Medical treatment guidelines for medical flight crew shall be in place and shall have been approved by the County EMS Medical Director.

2.

A comprehensive continuous quality improvement (CQI) program approved by the EMS Medical Director shall be in place and shall be overseen by a physician or a Registered Nurse.

3.

Quality improvement information shall be supplied to the County upon request.


H.

VI.

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33B

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4.

County shall be notified of any events that could impact the credentials of air medical crewmembers.

5.

Provider shall participate in County-related CQI activities.

Equipment and Supplies 1.

EMS aircraft shall meet configuration and restraint standards for “air ambulance” according to Section 100306, California Code of Regulations.

2.

Aircraft shall be stocked with full drug and solution inventories, and with basic, advanced life support and related specialty medical equipment and supplies at all times.

MAINTENANCE OF AUTHORIZATION 1.

County may inspect aircraft, facilities, equipment, policies and records relating to aircraft maintenance, dispatch, patient care, and personnel qualifications as pertain to local operations.

2.

Provider shall adhere to all applicable FARs including FAR Part 91 and 135 (or their equivalent).

3.

County may deny, suspend, or revoke an air ambulance authorization for failure to comply with applicable policies, procedures and regulations.


EMS AIRCRAFT – REQUEST,

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33 C

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TRANSPORT CRITERIA, AND FIELD OPERATIONS I.

PURPOSE To identify procedures for use by public safety agencies when requesting a medical helicopter or rescue aircraft for an EMS system response. To specify criteria for patient transport by air ambulance (medical helicopter) and to outline coordination of field operations at incidents involving air ambulance response. To assure the most appropriate, safest, and most cost effective method of transport based on the needs of the patient.

II.

AUTHORITY Division 2.5, California Health and Safety Code; Title 22. Division 9 and Chapter 8, California Code of Regulations.

III.

IV.

REQUEST FOR MEDICAL HELICOPTER OR RESCUE AIRCRAFT A.

The Incident Commander (IC) or designee is responsible for initiating a medical helicopter or rescue aircraft response through his or her fire/medical dispatch center if these resources are thought to be necessary and are in the best interest of the patient. Requests may occur prior to or after IC arrival at scene.

B.

Requests should include the current weather conditions, and if known: 1.

Number of patients potentially requiring helicopter transport,

2.

Current weather conditions, and

3.

Haz-Mat information if pertinent.

EMS AIRCRAFT UTILIZATION CRITERIA Helicopter transport involves increased costs and more potential risk in transport. The benefits of transport should outweigh risks. For these reasons, helicopter transport should only be used when both time and clinical criteria are met. A.

Time Criteria. Helicopter transport generally should be used only when it provides an advantage in terms of timely delivery of the patient from the scene to the emergency department.

B.

1.

Helicopter field care and transport time (which includes on-scene time, flight time, and transport from helipad to the emergency department) is optimally 20-25 minutes in most cases.

2.

Time to ground transport a patient to a helicopter rendezvous site, or a time delay in helicopter arrival are additional factors to be considered when determining whether or not a helicopter is the most rapid method of transport overall.

3.

Trauma patients with potential need for advanced airway intervention (GCS 8 or less, trauma to neck or airway, rapidly decreasing mental status) may be appropriate for helicopter transport even when time criteria is not met.

Clinical Criteria 1.

Patients who meet the following criteria may benefit from helicopter transport. a.

Trauma patients who meet high-risk criteria according to EMS trauma triage policy except for:

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V.

VII.

Stable patients with isolated extremity trauma (who may meet high-risk criteria on that basis).

2)

Patients with mechanism but no significant physical exam findings.

b.

Trauma patients who do not meet high-risk criteria but by evaluation of mechanism and physical exam findings, appear to have potential significant injuries that merit rapid transport.

c.

Patients with specialized needs available only at a remote facility such as burn victims or critical pediatric patients.

d.

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) may be appropriate for helicopter transport.

HELICOPTER UTILIZATION AND CANCELLATION DECISION A.

The decision to use a helicopter rests with the Incident Commander (IC).

B.

The IC is responsible for cancellation of the helicopter response when helicopter transport criteria are not met. The following information is important for the IC to consider in making the best possible decision regarding mode of transport:

C.

VI.

1)

1.

Patient need. The paramedic with primary patient care responsibility will have the best information regarding the patient meeting clinical criteria.

2.

Estimated ground transport time versus air response and transport. The ground transport crew will be the best resource for determining whether or not there will be a transport time savings based on the travel time considering current traffic/weather conditions particularly when timesavings by helicopter is minimal.

3.

Proximity of a helispot or need for a helicopter/ambulance rendezvous site. A significant amount of time may be added to overall transport time if a helicopter is unable to land in proximity to the patient.

4.

ETA of the helicopter. If the patient is packaged and ready for transport, ground transport may be the fastest mode of transport overall if a helicopter has not arrived on scene.

The ground ambulance responding to, or at the scene, should not be canceled until: 1.

The helicopter has left the scene with the patient aboard, or

2.

The senior medical personnel with primary patient care responsibility on-scene have determined that no patient transport is required.

COMMUNICATIONS A.

Under normal circumstances, CALCORD is utilized for air-to-ground communication. The IC or designee, in conjunction with the fire/medical dispatch will designate an alternate frequency if necessary.

B.

The IC or designee may cancel a helicopter response at any time prior to patient transport through the fire/medical dispatch center or by direct communication to the responding helicopter.

GROUND AMBULANCE RESPONSIBILITIES A.

Ground ambulance units shall make trauma base contact as soon as possible to provide early notification of patient arrival.

B.

A ground unit paramedic, who accompanies a patient in a rescue aircraft must assure the presence of appropriate medical equipment and must obtain orientation to the aircraft and to medical air transport procedures prior to transport.


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33 C

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VIII. HELICOPTER RENDEZVOUS

IX.

A.

If a helicopter rendezvous is deemed appropriate even considering added transport time, a helispot (rendezvous site) as close as possible to the scene should be established.

B.

A first-responder paramedic may elect to maintain primary patient care responsibility by accompanying the patient in transport to the helispot in order to facilitate communication with the treating helicopter crew.

MULTICASUALTY INCIDENT (MCI) RESPONSES Detailed roles and responsibilities for EMS helicopter providers during multicasualty incidents are specified in the Count MCI Plan. Helicopters:

X.

A.

Respond to an incident only when requested.

B.

Prepare to stage at closest airport or location designed by the Incident Commander.

INCIDENT REVIEW AND QUALITY IMPROVEMENT A.

Helicopter providers shall participate in EMS Agency quality improvement activities.

B.

Contra Costa EMS maintains oversight of helicopter utilization and works with helicopter provider agencies in assuring appropriate use of helicopter resources.


SEARCH FOR DONOR CARD I.

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34 1 of 1


PURPOSE Section 7150.55 of the Health and Safety Code requires emergency medical personnel to make a reasonable search for a document of anatomical gift, or other information identifying the patient as a donor or an individual who has refused to make an anatomical gift, “upon providing emergency medical services to an individual, when it appears that the death of that individual may be imminent. This requirement shall be secondary to the requirement that ambulance or emergency medical personnel provide emergency medical services to the patient.” No search is to be made by emergency medical personnel after the patient has expired.

II.

DEFINITIONS “Imminent Death”: A condition wherein illness or injuries are of such severity that in the professional opinion of emergency medical personnel, death will probably occur before the patient arrives at the receiving hospital. This definition does not include any conscious patient regardless of the severity of illness or injury. “Reasonable Search”: A brief attempt by emergency medical personnel to locate documentation that may identify a patient as a potential organ donor, or one who has refused to make an anatomical gift. This search shall be limited to a wallet or purse that is on or near the individual, to locate a driver’s license or other identification card with this information. If a purse or wallet is searched by emergency medical personnel, the search must be done in the presence of a witness. A reasonable search shall not take precedence over, interfere with, or delay the provision of emergency medical care.

III.

PROCEDURE Emergency medical treatment and transport of the patient remains the highest priority for field personnel. This search shall not interfere with patient care or transport. A.

If a document of anatomical gift or evidence of refusal to make an anatomical gift is located by emergency medical personnel, and the individual is taken to a hospital, the hospital shall be provided with the documentation. In situations where the investigating law enforcement officer has requested the card, hospital notification of documentation found will meet this requirement.

B.

If emergency medical personnel are unable to perform a search due to overriding medical care priorities or sensitivity concerns at the scene and/or during the transport, the hospital shall be notified that the search has not been performed along with surrounding circumstances.

C.

Details of any search, including witnesses, what was found and who was notified, shall be documented on the Prehospital Care Report completed for that patient.