FOUNDATIONS OF PATIENT CARE. October 1, Canyon County EMS System Standing Written Orders (SWOs)

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1 G-1 FOUNDATIONS OF PATIENT CARE October 1, 2013 FOUNDATIONS OF PATIENT CARE Canyon County EMS System Standing Written Orders (SWOs) # Foundation % These SWOs are the result of the combination of nationally recognized guidelines, local medical practice, and input from the medical director. Sources include but are not limited to: # Basic Life Support (CPR), Advanced Cardiac Life Support (ACLS and ACLS-EP) and associated branch courses # Pediatric Advanced Life Support (PALS) # Emergency Pediatric Care (EPC) # Neonatal Resuscitation Program (NRP, NALS) # Advanced Medical Life Support (AMLS) # Basic Trauma Life Support (BTLS), Pre-Hospital Trauma Life Support (PHTLS) and associated branch courses, and # Advanced Burn Life Support (ABLS) # Geriatric Education for Emergency Medical Services (GEMS) # Idaho Emergency Medical Services Bureau # Ada County (Idaho) Emergency Medical Services Standing Written Orders % Special Emergency Response Team (SERT) providers face unusual situations often outside the depth of these guidelines, or require procedures beyond the scope of normal EMS providers. These special situations may be covered in separate protocols and policies, which will supplement this document. # While this document cannot cover every possible variation of disease or injury encountered in the field, it should provide a foundation for the acute care of the majority of patients seen. # Each and every protocol should be considered to have, as its first directive, a mandate to maintain universal blood and body fluid precautions/isolation. # of practice is assumed to include lower levels. For example, a paramedic level guideline is assumed to include the EMT scope as well.

2 G-1 # Trauma, Cardiac and Stroke patients: All patients shall be stabilized and transported as rapidly and efficiently as possible. When treating patients who may benefit from specific interventional therapy (surgery, thrombolytic, catheterization lab) a goal of less than ten minutes on-scene time is desirable (within the bounds of providing quality patient care). # EARLY NOTIFICATION OF RECEIVING FACILITY IS ESSENTIAL IN SIGNIFICANT CASES # General treatment: All patients shall receive the following general supportive care as appropriate within the scope of practice and sound clinical judgment of the provider: # Airway Control % Positioning/Suctioning % Oral or nasopharyngeal airways % LMA % Endotracheal intubation % Cricothyrotomy (needle, surgical and similar devices) % Use of pharmacological agents to facilitate airway control % Use of difficult airway devices such as endotracheal tube introducer (Bougie) to facilitate airway control # Ventilation Support % Supplemental oxygen by appropriate means with goal of oxygen saturations >94% % Bag-valve mask or bag-valve ETT % Monitoring of pulse oximetry and end-tidal CO 2 (ETCO 2 ) % CPAP and BiPAP devices when available % Deep tracheal suctioning # Circulatory Support % CPR and components of CPR % Basic bleeding control, up to and including use of tourniquets FOUNDATIONS OF PATIENT CARE

3 G-1 FOUNDATIONS OF PATIENT CARE # Vital Signs % A complete sit of vital signs (BP, HR, RR, O2 sat) is to be documented for any patient who receives an assessment. Pain level is also considered a vital sign in the appropriate clinical situation. % A complete set of vital signs must be evaluated prior to any medication administration. # When any components of the vital signs were obtained using functions of the cardiac monitor, the data should be exported to the patient care report electronically. If obtained values are inconsistent with manually obtained values, values imported from the cardiac monitor may/should be appropriately edited to reflect the manually obtained values. % must be evaluated and documented in the patient care report. The reason for the refusal of evaluation must be documented. % Document situations that preclude the evaluation of a complete set of vital signs. % Record the times the vital signs were obtained. % Any abnormal vital signs should be repeated and monitored closely. % Vitals should be monitored and repeated as outlined in the treatment standards. # Nasogastric/Orogastric tube placement # Spinal Immobilization # Splinting % Selective immobilization using cervical collars, KEDs (or similar devices), spine boards (or similar devices), and improvised devices. This includes screening for appropriate immobilization. % Using pillows, cardboard splints, vacuum splints, traction devices and other improvised devices as appropriate and available.

4 G-1 # Vascular Access % Peripheral, intraosseous access, including pre-established lines % Obtain Vascular access in all patients who have: # Hemodynamic compromise or instability, ongoing blood/fluid loses or potential significant losses, dysrhythmias, dehydration, decreased/altered mental status, respiratory distress, pain or vomiting requiring medication. Consider vascular access in patients based on clinical assessment and judgement. % Normal saline and saline lock as appropriate % Use and maintenance of other crystalloid solutions and preestablished vascular access, including PICC lines, Hickman catheters, hemodialysis lines, and other routes of vascular access (as provider training and comfort level allows) % Obtain a minimum of two large bore IV lines in patients presenting with: # Significant trauma or blood loss (ie Multi-System Trauma, GI Bleed, etc) # Acute MI # Acute CVA % While ILS providers are often limited in the number of IV attempts and fluid administration by this document, ILS providers may exceed those guidelines when functioning under the general direction of the Primary Care Paramedic of the patient. # Cardiac Monitoring/Electrical Therapy % Defibrillation/cardioversion/transcutaneous pacing, including AEDs and manual devices. % ECG and 12-Lead interpretation/monitoring. # Patients requiring continuous monitoring shall be attended by a Paramedic at all times. # Patients requiring cardiac monitoring will have their cases uploaded into the patient care report. # In the situations where the non-transporting Paramedic begins Cardiac Monitoring and/or Electrical Therapy, the cardiac monitor DOES NOT need to be changed to the transporting Paramedics monitor until feasible. The nontransporting Pramedic will accomplany the patient to the hospital with their monitor attached. FOUNDATIONS OF PATIENT CARE

5 G-1 FOUNDATIONS OF PATIENT CARE # Blood glucose monitoring # Monitoring and titration of medication drips % Including medications on pumps when appropriate and training allows # Monitoring of blood product infusions # Monitoring of femoral sheath lines in cardiac catheterization patients # Needle thoracotomy (chest decompression) # Physical restraints as required for patient and provider safety. This does not imply that EMS providers assume law enforcement functions. # ALS providers may decrease the dosage or prolong the administration intervals of any medication with sedative properties when doing so would decrease adverse effects and still likely obtain the clinical goal.

6 G-1 FOUNDATIONS OF PATIENT CARE

7 G-2 MEDICAL DIRECTION October 1, 2013 MEDICAL DIRECTION These standing written orders are written physician orders giving field personnel the authority to implement procedures and administer designated medications. # These standing written orders are to be used only by field personnel operating under a medical control recognized by the Idaho State Board of Medicine. # These standing written orders may be implemented prior to the establishment of direct communication with medical control. % Direct communication with medical control shall be established as soon as feasible in life-threatening situations. # Direct communication with medical control shall be established prior to the release of any patient in the following categories: % Those who have received care in the field and do not fall under specific treat-and-release protocols % Where questions over disposition exist % As mandated for specific situations and protocols # Medical Control shall be documented to include physician and facility as well as relevant details of the direction given. % An acceptable medical control physician includes either the Emergency Department physician at the receiving hospital or if communication with the receiving medical control physician is delayed (greater than two to three minutes) personnel may contact the Emergency Department physician at any one of the other acceptable hospitals. % When a receiving hospital has not been established, on-line medical control shall be the nearest receiving facility. # No procedure or medication shall be used without the proper equipment or beyond the training, capabilities, or certification level of the EMS provider. EXCEPTION: If attempts to establish communication with medical control fail, and a patient is at high risk for mortality or increased morbidity, or if the delay anticipated in establishing communication with medical control may result in mortality or increased morbidity, procedures and/or medications normally restricted to direct medical order may be performed or administered without the direct order of a medical control physician. Communications with medical control shall be established as soon as possible. The reasons for the decision to institute treatment shall be clearly documented both in the chart.

8 G-2 EXCEPTION: As an alternative, Alternative medical direction/physician on scene: Occasionally, a physician other than an approved medical control physician may provide or direct patient care. In those situations the following shall apply: # When a licensed Idaho physician is on location and requests a deviation from the SWOs, the physician must accept responsibility for patient care including attending the patient during transport. While the provider may assist the physician in procedures, the provider shall not exceed his or her scope of practice in performing procedures. # If a licensed Idaho physician is directing patient care on location but will not accept responsibility for patient care, or a licensed Idaho physician is directing patient care by telephone and requests a deviation from the SWOs, the following shall apply: % The physician must be an Idaho-licensed M.D. or D.O. with proper identification or personally known to the provider % Personnel will request that the physician call the on-line medical control physician for consultation % Personnel will establish contact with the medical control physician to confirm orders % Document name of physician/provider on scene and who provided care MEDICAL DIRECTION

9 G-3 HOSPITAL DESTINATION October 1, 2013 HOSPITAL DESTINATION Patient destination shall be based on the following: # Acute Care Facilities: Generally, emergency ambulance transport shall only be provided to acute care facilities accredited by the Joint Commission (formerly JCAHO). In rare instances, transport may be provided to a private ( 1+!! & 4+'! ' * $!&!,, * )- +,' ( *!., ( 1+!! & with permission of the on duty field supervisor and medical control. *****THIS DOES NOT INLCUDE TRANSFERS***** Approved Acute Care Facilities: # Acute Care Facilities in Canyon County: % St. Alphonsus Nampa % St. Alphonsus Health Plaza % St. Lukes Nampa % West Valley Medical Center (Caldwell) # Acute Care Facilities in Ada County % St. Alphonsus Regional Medical Center (Boise) % St. Alphonsus Eagle Health Plaza (Eagle) %, -# 4+ *!! &! $ &, * *!! & %, -# 4+!' & $! al Center (Boise) %, * & 4+ %!&!+,*,!' &! $ &, * '!+ # Informed Patient Preference shall take precedence over all other sections of the destination protocol. If the attending EMS provider makes contact with, (,! &,4+( *!., ( 1+!! & & 0( * ++ ' +(!, $ ( * * & + ' -$ honored in absence of a specific patient request. # Closest Appropriate Facility. If no patient or physician preference is expressed, the medical problem is not emergent, and not specifically otherwise covered in these protocols, patients should be transported to the closest appropriate facility. # Facilities Outside Canyon County. Requests for transport to a facility outside of Canyon County will be honored unless they conflict with the transport agencies policy on minimal staffing. The transporting agencmpg Paramedic will make the determination. Hospitals in Ada County are the only authorized hospitals out of Canyon County.

10 G-3 # Trauma Patients. Level one and two trauma patients shall be transported to Saint Alphonsus Regional Medical Center unless instructed otherwise by the on-line Medical Control physician. Saint Alphonsus Regional Medical Center shall be notified as soon as possible in these situations to ensure rapid notification of appropriate resources. Level three trauma patients do not mandate transfer to the trauma center; however, the clinical judgment of the Paramedic is essential to ensure proper triage of patients to an appropriate receiving center. See Appendix 3A-184 for Trauma Leveling Criteria for Field Providers # Orthopedic Injuries: Isolated orthopedic injuries with suspected vascular!& "-*1 ' % ( *' %!+ + $$,* & +( ' *,,'!, *, -# 4+!' & $! $ Center (Boise/Meridian) or St. Alphonsus Regional Medical Center (Boise). Physician contact may be established to assist in destination determination. # Suspected Acute Coronary Syndrome (cardiac chest pain, etc): A patient with chest discomfort relieved by NTG, without other symptoms, and without EKG changes shall follow the standard destination protocol. Patients with acute chest discomfort and the following signs and symptoms should be transported to St. -# 4+!' & $! $ &, *-Boise or Meridian, or Saint Alphonsus Regional Medical Center Boise or Saint Alphonsus Health Plaza, where interventional cath-lab capabilities exist. % 12-lead EKG consistent with Acute STEMI # Brain Attack: % 2 *!&,, # 3!+!& + -,,*' #! & + & 1% (,oms with an onset of less than 3 ' -*+' 2last known well3, *% 2 *!&,, # 3 should be used when calling report into the receiving facility. # See Appendix A-16 % ' $$' /!& +,!&,!' & -! $!& + * + ' &,!% * % *' % 2last known well3,' / &, +,!%, '.!&, (,! &,!&, % * & 1 Department for treatment. This allows enough time for the ED Staff to evaluate and provide appropriate therapy. If the attending Paramedic is unsure about the appropriate destination due to the patient falling outside the parameters, they should contact medical control for guidance. For select patients, interventional radiology may be considered up to 8-12 hours after last known well, medical control should be contacted for destination determination. HOSPITAL DESTINATION

11 G-3 HOSPITAL DESTINATION # Destination at less than 0-4 ' -*+*' % 2last known well3 & any of the following locations: % St. Alphonsus Nampa, Nampa Health Plaza, Boise, Eagle %, -# 4+ % (, Meridian, Boise % West Valley Medical Center # Destination between 4-8 ' -*+*' % 2last known well3 & & 1' the following locations: % St. Alphonsus Regional Medical Center, Boise %, -# 4+!' & $! $ &, * '!+ # Dialysis: Dialysis Patients with acute decompensation or significant illness/injury should be transported to the following locations: % St. Alphonsus Nampa, Boise % S, -# +4+ '!+ *!! & # Dialysis patients will have their primary facility of choice from which their nephrologist treats them. # Left Ventricular Assist device (LVAD): Due to the complexity of these patients and low frequency in which they are within the community all patients with LVADS should be transported per below: % Facility identified by the patient to be managing their LVAD %, -# 4+ '!+ # Inter-facility Transport: Physician-ordered inter-facility transport shall be to the hospital directed by the transferring physician. In all cases, to comply with EMTALA/COBRA regulations, the physician or designee must write the order. The receiving physician must be specifically documented for hospital to hospital transfers or direct admissions. If, during transport, the patient, *!' *, + 1' &, ( *'.! *4+!$!,1,',!. $1% &, ( *'.! * may divert to the closest appropriate hospital.

12 G-3 # Pregnant Patients: % A pregnant woman who has received pre-natal care and has an established physician may be transported to the hospital of choice % A pregnant woman who has a history of high-risk pregnancies should Meridian Medical Center or Saint Alphonsus Regional Medical Center. These hospitals have Neonatal Intensive Care Units % Complicated and/or imminent deliveries from home, medical facility or birthing center will be transported to the closest appropriate facility # Mass Casualty Incident (MCI): In the event of a MCI, the Incident Commander or his designee shall dictate patient hospital destination. If the patient or attending physician requests transport to a facility not consistent with the above guidelines, the request will be honored only after informing the patient, responsible person, or physician of the unavailability of certain services at that facility. If the patient demonstrates impairment of judgment related to injury, shock, drug effects, or emotional instability, the Paramedic will act in the (,! &,4+ +,!&, * +, &,* & +( ' *,,', % ' +, ( ( *' ( *!,!$!,1 This protocol shall not relieve Treasure Valley Emergency Medical Services System (TVEMSS) ( *+' & & $ ', * +( ' & +!!$!,1,', *%!&, (,! &,4+ destination preference. Where question exists concerning the appropriate patient destination, Medical Control shall be consulted. TVEMSS personnel have the option to transport patients with immediate life-threatening conditions to the closest appropriate facility. HOSPITAL DESTINATION

13 G-4 SPECIAL RESUSCITATION SITUATIONS October 1, 2013 SPECIAL RESUSCITATION SITUATIONS # Withholding resuscitation In situations requiring CPR (e.g., cardiac arrest), resuscitative efforts may be withheld under the following circumstances: % Obvious signs of death defined by: # Rigor mortis # Dependent lividity, or # Injury not compatible with life % In all other situations, full resuscitation efforts shall be initiated unless there is: A DNR order meeting the following criteria: # Idaho Physician Order for Scope of Treatment (POST) form # The physical presence of a physician-signed DNR order in the setting of a hospital (e.g., Idaho Elks Rehabilitation Hospital, Treasure Valley Hospital), or # The physical presence of a physician-signed, out-of-state DNR order, or # The physical presence of a valid State of Idaho Comfort One order or photocopy, or # State of Idaho Comfort One identification being worn by the patient, or # A DNR order written prior to July 1, 1994, regardless of format. See Appendix A-25: In-Field Death/POST/Comfort One/DNR Guidelines for further guidance. If there is a question concerning the appropriateness of CPR initiation, begin CPR and contact Medical Control. # Discontinuation of resuscitation In all cases where CPR efforts have been appropriately initiated, Paramedic consultation with the on-line Medical Control physician is required prior to discontinuation. If CPR has been initiated inappropriately as outlined above, personnel may discontinue CPR without on-line Medical Control.

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15 G-5 AIR MEDICAL RESPONSE October 1, 2013 AIR MEDICAL RESPONSE Any licensed EMS provider or law enforcement agency within the Canyon County EMS system may request an air ambulance. All air medical requests shall go through either the Canyon County, Nampa Police Dispatch Center, or per agency protocol. While a valuable tool in reducing morbidity and mortality in both medical and trauma patients, air medical transport is both expensive and also carries with it inherent safety risks that are often underestimated. The use of air medical resources should be carefully considered and done on a case-by-case basis. Many situations that may call for an air ambulance in one case may be better handled by ground transport in another. This protocol is a supplement to, not a replacement for, good judgment. Air medical transport resources should be considered by the attending Paramedic when it is determined that the patient will reach definitive care quicker by air than by ground or when other ALS resources are needed (i.e. MCI). Providers are expected to consider all the factors in air medical transportation, including, but not limited to: lift-off, response, scene, transport and transfer time when considering the use of air medical resources. Indications Use of an air medical transport is based on many considerations including but not limited to: # Physiologic Criteria % GCS <13 (does not follow commands) % S/S of shock (e.g., rapid HR; altered mental status; cool, clammy, pale skin)kremember that hypotension is a late sign of shock % Pediatric trauma (may not see s/s of shock until late) % Geriatric trauma (may not see s/s of shock until late) % Hypothermia % Airway compromise, actual or potential % Prolonged transport or delayed ALS response/transport that will have a reasonable likelihood of affecting patient mortality/morbidity % Patients with signs of Acute Coronary Syndrome in which ground ALS response is significantly delayed % Current or post-cardiac or respiratory arrest situations in which ground ALS response is significantly delayed

16 G-5 # Anatomic Criteria % Penetrating injuries to the head, neck, chest, abdomen, or thighs % Two or more long bone fractures % Limb paralysis % Limb amputation proximal to the wrist or ankle in which bleeding cannot be controlled % Trauma combined with burns of >20%, particularly those involving the face or airway % Signs of a rupturing aortic aneurism # Mechanism of Injury Mechanism of injury criteria should accompany physiologic and/or anatomic criteria. % High-speed MVC % Prolonged extrication % Fatality within the same vehicle % Ejection from vehicle % Passenger compartment intrusion of >12 inches % Fall greater than 2x patientns height Other Criteria # Areas where access by EMS vehicles or crews is difficult or impossible Launch At times, air medical response may seem unnecessary based on initial dispatch information, location of call, or capabilities of the responding EMS units. While not prohibited, it is generally not prudent to cancel an air ambulance prior to arriving on scene. When the need for air medical transport is suspected but unclear, the air ambulance agency should be launched. # In most cases, an air ambulance should only be cancelled by EMS personnel who have completed an on-scene patient assessment Landing Zones and Safety In Canyon County, landing zones are often handled by law enforcement or the fire service. In some cases, field personnel may be required to establish their own landing zones. # # $ &(($ ' ( # & - ' ' # $ % & ( $ # ' $ 2' & ambulance agencies have developed the following basic landing zone (LZ) and safety guidelines. AIR MEDICAL RESPONSE

17 G-5 AIR MEDICAL RESPONSE Types of Landing Zones Landing zones fall into three basic categories, listed here in order of safety preference. # Established helipads. Usually located at airports or hospitals, heliports are generally constructed with consideration to size, slope, and surface, as well as approach and departure paths # Pre-established (or designated) landing areas (PELA). These are essentially pre-arranged rendezvous locations. By pre-planning specific LZ sites with the air medical provider, the pilots are given the opportunity to survey the area ahead of time to identify potential hazards # On-scene landing zones. Having the aircraft land at the scene typically offers the most expedient evacuation of the patient. Care must be taken to ensure a suitable and safe LZ Landing Zone Officer The most important component of safe scene operations is the LZ Officer. S/he is responsible for the safety of the responding aircraft(s), the LZ set up, and basic communication between flight and ground crews. The LZ Officer should be someone not directly involved in patient care. This position may have a different title in the National Incident Management System (NIMS). Landing Zone Preparation $ ""$ + # & ( & & # & "", $ # ' & 0 ".1 "$ " $ # ( $ # ' necessitate deviation, consult the pilot as soon as possible. # Size J The preferred size of landing zone is 100 ft. x 100 ft. (60 ft. absolute minimum) # Slope J The slope of the ground should be no more than 5 degrees (gentle slope) # Surface J The ground must be a firm surface preferably, with no loose dirt or snow. If necessary and available, consider wetting down dirt surfaces. Loose snow can be compacted with snowmobiles # Hazards/Obstructions J Poles, wires, fences, towers, trees, and unstable ground are all hazards to report to the pilot. % Hazardous Materials J The presence of hazardous materials MUST be relayed prior to their approach to the scene % Clear Area J The area is clear of loose debris, large rocks, posts, stumps, vehicles, people, animals, and other hazards. Caps and hats should be secured % Overhead J Free of overhead obstructions such as wires, antennas, and poles

18 G-5 # Marking/Lighting % The four corners of the landing zone should be marked. During the daytime, this can be done with traffic cones. At night, flashlights, 0 " (' 1$ & "$ +-beam headlights can be used. Flares, if used at all, must be used with extreme caution as they present a fire hazard and should be secured to the ground % Identified hazards should be illuminated if possible. % NEVER direct any lights up at the aircraft or use high-beam headlights The pilot always has the final say regarding landing zones. He/she may request an alternate site. Landing Zone Communications The Landing Zone Officer is responsible for radio communications with the responding air ambulance. Responsibilities include: # Assisting the pilot in locating the LZ with simple directions and easily identifiable landmarks. Avoid using directions such as right and left unless the aircraft is directly in sight # Advising the pilot of LZ conditions, wind speed and direction, and hazards. # Primary communications between ground and & & (' $ )" $ # 0 ( ( F2,M MHz "( $ ) "$ " 0 1 aint Alphonsus channel) is available to most services and is a good back-up channel. Other channels or methods may be used as the situation demands # Hand signals and gestures are discouraged AIR MEDICAL RESPONSE

19 G-5 AIR MEDICAL RESPONSE Landing Zone Safety # Ensure no one approaches the aircraft until specifically directed by the pilot or crew # Unless otherwise directed, always approach from the front half of the & & ( $ 2 "$!($ $ 2 "$! # * + $ ( % "$ (, and while maintaining eye contact. Approach from the downhill side if landed on a slope. When in doubt, wait for a member of the crew to escort you # The tail rotor is an especially dangerous area because, due to its speed, the blades may be nearly impossible to see. NEVER go near the tail of the aircraft while it is running # Rotor wash is the air forced down by the main blades & ( # 0+ # ' 1 near 100 mph. All loose objects such as hats, sheets, and blankets must be secured # Consider dirt and small rocks as potential airborne hazards and wear appropriate personal protective equipment # If you drop something, do not chase it Patient Care Appropriate patient care should continue until the flight crew arrives at the patient)( side ( # ( & ' $ )" # $ ( ", 0 use the air ambulance is coming.1 ( & the flight crew arrives, EMS personnel should assist as needed within their respective scope of practice.

20 G-5 AIR MEDICAL RESPONSE

21 G-6 PRE-HOSPITAL INTEGRATION OF CARE October 1, 2013 PRE-HOSPITAL INTEGRATION OF CARE Protocol # General % )& % $ $ *% & * $ *3)call for help typically generates a response from multiple agencies. This protocol is intended to provide a BASELINE understanding of the interactions that shall take place between transport and non-transport agencies. It is the intent and understanding that all agencies involved in the care of a patient strive to work as a team to maximize quality patient care, seamless interactions, and maximum efficiency. It is also understood that developing those relationships before and after an incident will help achieve the intent of this protocol. It is the responsibility of all responders to recognize the importance of cooperation and understanding in order to provide the patient with the best medical care and treatment possible. It is expected that responding personnel from transport and non-transport agencies go beyond this protocol, through non-incident interactions and communications, to develop a (( & & % (* $ + $ ()* $ $ % % * (3).& * *% $ ) * % + *) $ ideas on how to better the patient care experience. % It is the responsibility of all EMS responders to insure the proper and timely utilization of resources to meet the goals of scene safety, quality patient care, and rapid movement to medical facilities. The role of the first arriving EMS personnel on scene will be to provide any and all necessary care within their scope of practice to the patient. The goal of the EMS system is to provide effective and contiguous patient care on scene and expedite, when appropriate, patient transport to definitive care. # Definition % Integration of Care- # Defined as multiple agency responders working together as a unified team during the treatment and/or transport phase of a patient encounter. % Transfer of Care # The process of transferring care from one provider to another with the ultimate goal being a smooth transition, similar to what would happen in the ED when an ED physician or RN transfers to another provider. The following components should be included in the transfer of care: % Introduction of the transporting provider to the patient with a )* * # $ *)% # * $ *% * *% 1 ) ) % ** ) % $ g to be the one transporting you to the hospital, he is going to ask you )% # # % ( ' + )*% $ ) - " -% (!% $ 0 * "!*% /% + ( husband, etc). % Communicate the current findings and treatment plan in progress % Integrate the transferring provider into the patient treatment process

22 G-6 # Process % Patient care requires an integration of care with other EMS providers to accomplish the goals and mission of providing quality patient care. The following guidelines will be observed when multiple agencies are on scene. % The EMS responder with the highest licensure level is ultimately responsible for the care of the patient. % Multiple Paramedic providers exist within Canyon County staffed on transport and non-transport apparatus. When this occurs, a primary Paramedic needs to be identified. With this, it is also understood that input on patient care should be the responsibility of all providers. To determine the primary paramedic, the following will be observed: # Expectations # The first licensed Paramedic arriving on scene and has begun a detailed assessment, established a patient rapport, or has begun treatment shall assume the primary Paramedic role. # In the event of simultaneous or near simultaneous arrival of the ALS transport and the ALS non-transport agencies, the transport Paramedic shall assume the primary Paramedic role. All providers shall assist in any way possible using a teamwork approach. # Upon the arrival of another licensed Paramedic, the primary Paramedic will give a verbal report to the incoming Paramedic as soon as feasible. # $ - % $!!! " % template, section III). The incoming Paramedic will then integrate into the patient care process and assist in any way possible using a teamwork approach. # The second responding provider should approach the scene with the goal % )! $ 1 * $ - % *% )) )*/% + 2 # All responders shall strive to work in a team-like fashion, holding each other accountable, to allow for maximum utilization of knowledge and resources, and transport the patient to definitive care in a timely manner. % All providers in the system are expected to cooperatively work towards transporting the patient to definitive care. # Primary providers are expected to communicate their treatment plan to the other providers on scene. Primary providers are expected to perform a thorough assessment and coordinate necessary treatments on scene, while completing secondary assessment and other treatments in transport PRE-HOSPITAL INTEGRATION OF CARE

23 G-6 PRE-HOSPITAL INTEGRATION OF CARE Protocol # Integration of care during transport of a patient % If the transporting Paramedic sees a need for additional EMS resources during transport, the transport Paramedic can REQUEST assistance from the non- *( $ )& % (* & (%, () % ( ) # / % + ( - $ & * $ *3) condition may require multiple procedures or other situation when the transport Paramedic sees a need for the continued involvement of the non-transport Paramedic or EMTs. % Teamwork is a vital component to the successful treatment of a seriously ill or injured patient. This concept shall be maintained throughout the call. # Conflict Resolution % In the event that two on-scene paramedics disagree on treatment options and are unable to resolve the differences, the following guidance is provided: # Life threatening decision with discretionary time: Medical Control will be contacted and the issue resolved. ANY decision made by Medical Control will be honored. # Life threatening with no discretionary time: If the time delay to contact medical control is likely to increase the morbidity or mortality of the & * $ * * 1& (# (/ & ( # 2 ) ) ( %, - "" #! * decision and maintain the lead on scene and during transport, assume medical liability, and be responsible for patient care decisions. # Non life threatening with discretionary time: If a non life threatening disagreement regarding patient care exists on scene, the primary paramedic at the time shall make the final decision and, if applicable, will maintain the lead on scene and during transport if requested by the transport paramedic, assume medical liability, and be responsible for patient care decisions throughout transport to the hospital. Medical control is also an option. % After delivery of the patient to the hospital, the responders involved will attempt to resolve the disagreement using the conflict resolution process approved by all EMS agencies. At any time a non-transport paramedic assumes the lead during transport due to a disagreement with the transport medic, or a disagreement occurs on scene and was not resolved, the issue shall be forwarded to the respective Administrations and Medical Director for review. The two parties involved will meet with the Medical Director at the earliest convenience, who will provide guidance on the issue after hearing from all parties involved.

24 G-6 # Miscellaneous Information % Every provider in the EMS system has an obligation to provide quality patient care. Each provider has a duty to act and bring any concerns to the attention of the primary provider. Nothing in this protocol shall indicate poor patient care is acceptable in an attempt to minimize conflict between providers. % Accurate documentation of the patient encounter is considered integral to these protocols and will be provided to the transporting crew as time permits or be sent to the hospital in a timely fashion. Documentation should include a description of the chief complaint, history of the present illness, pertinent past problems, pertinent negatives, vital signs, mental status, and pre-hospital assessment and care. All Advanced Life Support care provided by the non-transport Paramedic will be documented on the form prior to transport as time permits. This document will accompany the patient to the hospital and will be included in both the transport and non-*( $ )& % (* $ /3)& * $ * ( ( & % (*$ )/)* # % If information was not exchanged on scene that may be necessary for the continued care of the patient or patient documentation purposes, providers who were on the scene may exchange pertinent information necessary to fulfill their duties. Information may also be exchanged between the crews caring for the patients, their administrators, or their medical directors for quality assurance purposes and on-going performance improvement. % Orders communicated directly from the on-line medical control physician from the & * $ *3)destination hospital or an acceptable alternate physician may supersede established protocol if such orders fall within the responder scope of practice. PRE-HOSPITAL INTEGRATION OF CARE