Base Hospital and Receiving Facilities Burn Centers Burn Patient Destination Burn Surface Area - Rule of Nines Declining Medical Care or Transport (AMA) Destination Determination Destination - 5150 and Obstetric Considerations Determination of Death DNR and POLST Orders Hazardous Materials Exposure Management Principles Helicopter Transport Criteria MCI Tiers Reporting Requirements - Abuse Restraints Trauma Base Call-In Criteria Trauma Triage Criteria POLICY SUMMARIES and HOSPITAL REFERENCES
John Muir Medical Center Walnut Creek Campus 1601 Ygnacio Valley Road Walnut Creek CA 94598 Contra Costa County Base Hospital Hospital Base Phone ED Phone Taped: (925) 939-5804 Receiving Facility Notification: (925) 947-3379 ED: 939-5800 XCC EMS 2 Alert Code 14524 Contra Costa County Hospitals (Receiving Facilities) Hospital Services ED Phone Contra Costa Regional Medical Center 2500 Alhambra Avenue Martinez CA 94553 Basic ED OB/Neonatal XCC EMS 2 Alert Code (925) 370-5971 14574 Doctors Medical Center San Pablo 2000 Vale Road San Pablo CA 94806 John Muir Medical Center Concord Campus 2540 East Street Concord CA 94520 John Muir Medical Center Walnut Creek Campus 1601 Ygnacio Valley Road Walnut Creek CA 94598 Basic ED STEMI Center Stroke Center Basic ED STEMI Center Stroke Center Basic ED OB/Neonatal Trauma Center STEMI Center Stroke Center (510) 234-6010 13613 (925) 689-0553 14214 Receiving Facility Notification: (925) 947-3379 ED: (925) 939-5800 14524
Kaiser Medical Center Antioch 5001 Deer Valley Road Antioch CA 94531 Basic ED OB/Neonatal Stroke Center (925) 813-6880 (switchboard) 14564 Kaiser Medical Center Richmond 901 Nevin Avenue Richmond CA 94504 Kaiser Medical Center Walnut Creek 1425 South Main Street Walnut Creek CA 94596 San Ramon Regional Medical Center 6001 Norris Canyon Road San Ramon CA 94583 Sutter/Delta Medical Center 3901 Lone Tree Way Antioch CA 94509 Basic ED Stroke Center Basic ED OB/Neonatal STEMI Center Stroke Center Basic ED OB/Neonatal STEMI Center Stroke Center Basic ED OB/Neonatal STEMI Center (510) 307-1758 13653 (925) 939-1788 14284 (925) 275-8338 13623 (925) 779-7273 14294
BURN CENTERS Hospital Services Phone Santa Clara Valley Medical Center 751 S. Bascom Avenue San Jose CA Adult and Pediatric Burn Center 408-885-6666 UC Davis Medical Center Regional Burn Center 2315 Stockton Blvd. Sacramento CA Adult and Pediatric Burn Center 916-734-3636 St. Francis Burn Center 900 Hyde Street San Francisco CA Adult and Pediatric Burn Center (No Helipad available) 415-353-6255
BURN PATIENT DESTINATION General Destination Principles Burned patients with unmanageable airways should be transported to the closest basic ED Patients with minor burns and moderate burns can be cared for at any acute care hospital Adult and pediatric patients with burns and significant trauma should be transported to the closest appropriate trauma center Patient Selection for Initial Transport to Burn Center The following patients may be appropriate for initial transport to a Burn Center: Partial thickness (2nd degree) greater than 20% TBSA Full thickness (3rd degree) greater than 10% Chemical or high voltage electrical burns Smoke inhalation with external burns Procedure for Burn Center Destination Contact Burn Center prior to transport to confirm bed availability Consult base hospital if any questions regarding destination decision
RULE OF NINES BURN SURFACE AREA
DECLINING MEDICAL CARE OR TRANSPORT (AMA) All qualified persons are permitted to make decisions affecting care, including the ability to decline care Any person encountered by EMS personnel who demonstrates any known or suspected illness or Patient injury OR is involved in an event with significant mechanism that could cause illness or injury OR who requests care or evaluation Competency The ability to understand and to demonstrate an understanding of the nature of the illness/injury and the consequence of declining medical care A competent person making decision for him/herself or another qualified by: An adult patient defined as a person who is at least 18 years old; A minor (under 18 years old) who qualifies based on one of the following conditions: o A legally married minor; o A minor on active duty with the armed forces; o A minor seeking prevention / treatment of pregnancy or treatment related to sexual assault; Qualified Person o A minor, 12 years of age or older, seeking treatment of contact with an infectious, contagious or communicable disease or sexually transmitted disease; o A self-sufficient minor at least 15 years of age, living apart from parents and managing his/her own financial affairs; o An emancipated minor (must show proof); OR The parent of a minor child or a legal representative of the patient (of any age). Spouses or relatives cannot consent to or decline care for the patient unless they are legally designated representatives. When, in the field personnel s opinion, patient s decision to decline care poses a threat to his/her well being Base Contact If the patient s competency status is unclear (neither competent nor clearly incompetent) and Requirements treatment or transport is felt to be appropriate Any other situation in which, in the field personnel s opinion, that base contact would be beneficial in resolving treatment or transport issues
DESTINATION DETERMINATION BASIC PROCEDURE Field personnel shall assess a patient to determine if the patient is unstable or stable Patient stability must be considered along with a number of additional factors in making destination and transport code decisions FACTORS TO CONSIDER 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 UNSTABLE PATIENTS STABLE PATIENTS Usually transported to the closest appropriate acute care hospital emergency department or specialized care centers if indicated If the patient or family requests, or if other factors exist which indicate that another facility be considered, field personnel are to contact the base hospital and present their findings, including ETAs to both facilities. Base personnel will assess the benefits of each destination and may direct field personnel to a facility other than the closest. Stable patients are transported to appropriate acute care hospitals within reasonable transport times based on patient s/family preference If a patient does not express a preference, the hospital where the patient normally receives health care or the closest ED is to be considered
Patients on 5150 Holds Obstetric Patients DESTINATION 5150 and OBSTETRIC PATIENTS A patient placed on a 5150 hold in the field shall be assessed for the presence of a medical emergency. Based upon the history and physical examination of the patient, field personnel shall determine whether the patient is stable or unstable. Stable patients on 5150 holds shall be transported to Contra Costa Regional Medical Center Unstable patients on 5150 holds shall be transported to the closest acute care hospital: A patient with a current history of overdose of medications is to be considered unstable A patient with history of ingestion of alcohol / illicit street drugs is considered unstable if: o Significant alteration in mental status (e.g., decreased LOC or extremely agitated); or o Significantly abnormal vital signs; or o Any other history or physical findings that suggest instability (e.g. chest pain, shortness of breath, hypotension, diaphoresis A patient is considered Obstetric if pregnancy is estimated to be of 20 weeks duration or more. Obstetric patients should be transported to hospitals with in-patient OB services in the following circumstances: Patients in labor Patients whose chief complaint appears to be related to the pregnancy, or who potentially have complications related to the pregnancy Injured patients who do not meet trauma criteria or guidelines Obstetric patients with impending delivery or unstable conditions where imminent treatment appears necessary to preserve the mother s life should be transported to the nearest basic emergency department Stable obstetric patients should be transported to the emergency department of choice if their complaints are clearly unrelated to pregnancy
Obvious Death Medical Arrest Traumatic Arrest DETERMINATION OF DEATH Pulseless, non-breathing patients with any of the following: Decapitation, Total incineration, Decomposition Total destruction of the heart, lungs, or brain, or separation of these organs from the body Rigor mortis or post-mortem lividity without evidence of hypothermia, drug ingestion, or poisoning. In patients with rigor mortis or post-mortem lividity: o Attempt to open airway, assess for breathing for at least 30 seconds; assess pulse for 15 seconds o Rigor, if present, should be noted in jaw and/or upper extremities o If any doubt exists, place cardiac monitor to document asystole in two leads for one minute Mass casualty situations Definition: Cardiac arrest with total absence of observers or witness information; or cardiac arrest in which witness information states arrest occurred greater than 15 minutes prior to arrival of prehospital personnel and no resuscitative measures have been done Procedure: BLS personnel Follow Public Safety defibrillation guideline ALS personnel - Do not initiate CPR; Assess for presence of apnea, pulselessness (no heart tones/no carotid or femoral pulses), document asystole in two leads for one minute Definition: Blunt or penetrating traumatic arrest Procedure: BLS personnel Follow Public Safety defibrillation guideline ALS personnel - Do not initiate CPR; Assess for presence of apnea, pulselessness (no heart tones/no carotid or femoral pulses), document asystole or wide-complex pulseless electrical activity (PEA) at rate of 40 or less
Valid DNR Orders Complying with an Honored DNR Order Complying with a POLST Order (Not in Arrest) No valid DNR Order present and request made for no resuscitation DNR and POLST ORDERS A California EMSA/CMA Prehospital DNR Form A California/EMSA POLST form in which Section A (Do Not Attempt Resuscitation/DNR) has been chosen An Advanced Health Care Directive (includes living will or Durable Power of Attorney for Health Care) presented by an agent of the patient empowered to make health care decisions for the patient An EMS-approved standard DNR medallion/bracelet e.g. Medi-Alert A DNR order in the medical record of a licensed healthcare facility (e.g. acute care hospital, skilled nursing facility, hospice or intermediate care facility) signed by a physician. Electronic physician orders are considered signed and will be honored. A verbal DNR order given by the patient s physician who is present at the scene Verify identity of patient Perform no life-saving measures Cancel the responding ambulance Verify identity of patient. Review section B o If Full Treatment marked, patient receives full care o If Limited Additional Interventions or Comfort Measures Only is marked, no advanced airway should be done If the patient presents with advanced or terminal disease and incomplete forms or no forms are presented and an immediate family member, agent, or conservator requests no resuscitation, resuscitative measures may be withheld if there is complete agreement of family and providers on scene. Immediate family members include spouse, domestic partner, adult child(ren) or adult sibling(s) of the patient No base contact is required. If any question of circumstances or disagreement of family or providers, proceed with resuscitation.
HAZMAT RECOGNITION WHILE RESPONDING HAZMAT RECOGNITION WHILE ON SCENE HAZARDOUS MATERIALS EXPOSURE MANAGEMENT PRINCIPLES If alerted to a known or suspected hazmat exposure prior to scene arrival: Request from dispatch the location and safe route to staging area or IC If no staging area, determine location and safe route to report to IC Do not enter contaminated areas or approach contaminated patients until cleared to do so by Incident Commander or designee. Decontaminate patient - Appropriately trained personnel shall perform decontamination in a designated area. Obtain clearance from IC prior to transport Obtain MSDS for chemical if available After patient decontamination, provide care as indicated per treatment guidelines. Provide early alert to hospital repeat decontamination may be needed. If EMS personnel become aware that a patient in their care may have been contaminated by a unknown or suspected hazardous material: EMS personnel should consider themselves contaminated Minimize exposure by evacuating to an uphill/upwind safe location. If in cloud, travel crosswind until out of cloud. Notify fire/medical dispatch and IC of exposure Request Hazardous Materials response team through Sheriff s Dispatch Request backup Fire / Transport as needed for affected EMS personnel and patients
HAZMAT RECOGNITION WHILE ON SCENE (continued) HAZMAT RECOGNITION WHILE TRANSPORTING GENERAL GUIDELINES FOR ALL SITUATIONS Remain in safe area until Incident Commander arrives and provides further instructions. Prepare to be decontaminated Decontaminate EMS personnel and patient(s) - Appropriately trained personnel shall perform decontamination in a designated area. If EMS personnel become aware while transporting that a patient may have been contaminated by a known or suspected hazardous material: EMS personnel should consider themselves contaminated Determine if safe to drive (e.g. rescuers with or without symptoms) If not safe to drive, immediate decontamination is needed. Stop transport, notify Fire/Medical Dispatch and request CCHS HazMat response. Request Fire/Transport backup as needed. Protect from further exposure and prepare to be decontaminated. If safe to drive (decontamination is not immediately indicated), proceed to hospital decontamination staging area. Alert hospital early of the HazMat situation. Request staging site if not known. Prepare to be decontaminated. Provide prehospital medical care as soon as it is safe All precautions should be taken to prevent contamination of hospital emergency department and personnel.
Time Criteria Clinical Criteria Use and Cancellation HELICOPTER TRANSPORT CRITERIA USE HELICOPTER ONLY WHEN BOTH TIME AND CLINICAL CRITERIA MET Helicopter transport generally should be used only when it provides a time advantage. Helicopter field care and transport time (which includes on-scene time, flight time, and transport from helipad to the emergency department) is optimally 20-25 minutes in most cases Also consider: Time to ground transport to a rendezvous site, or a time delay in helicopter arrival Exception: Patients with potential need for advanced airway intervention (GCS 8 or less, trauma to neck or airway, rapidly decreasing mental status) may be appropriate even when time criteria not met Trauma patients who meet high-risk criteria according to EMS trauma triage policy, except for: o Stable patients with isolated extremity trauma o Patients with mechanism but no significant physical exam findings 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 Patients with specialized needs available only at a remote facility such as burn victims/critical pediatric Critically ill or injured patients whose conditions may be aggravated or endangered by ground transport (e.g. limited access via ground ambulance or unsafe roadway) The decision to use or cancel a helicopter rests with the Incident Commander (IC). If criteria not met, helicopter should be cancelled. Considerations for IC: Patient need Estimated ground transport time versus air response and transport Proximity of a helispot or need for a helicopter/ambulance rendezvous site ETA of the helicopter
TIER ZERO TIER ONE TIER TWO TIER THREE MULTICASUALTY INCIDENTS TIER DEFINITIONS and EXAMPLES Official notification of an incident that has the potential to result in activation of the MCI plan at a higher tier, even when the number of known victims is zero. Activation at this tier is required for a Community Warning System Level II incident or any receiving hospital Emergency Department closure or evacuation (not diversion or trauma bypass). Other examples of this might include active shooter where number of victims unknown or cannot be confirmed, emergency landing at airport, actual or potential significant hazmat incident, including transportation incidents. An incident involving 6-10 patients when the scene is contained and the number of patients is not expected to rise significantly. Examples include a multi-vehicle traffic collision, multiple known shooting victims and no ongoing active shooter threat. An incident involving more than 10 patients OR an incident involving less than 10 patients when there is a substantial chance that the number of patients may rise. EMS Transportation Resource Ordering will be processed by EMS Operational Area Communications Center (Sheriff s Dispatch). Examples include a petrochemical incident with a dispersal cloud moving over a populated area, passenger train derailment, or an active shooter with an uncontained scene. Any incident involving more than 50 patients, mass casualties, or a reasonable expectation of mass casualties. EMS Transportation Resource Ordering will be processed by EMS Operational Area Communications Center (Sheriff s Dispatch). Examples include a significant explosion around occupied commercial or multi-resident structure, or in a heavily populated area, or a large-scale evacuation of a hospital or skilled nursing facility.
ABUSE REPORTING RESPONSIBILITIES EMS personnel are mandated reporters. Report when there is reason to suspect abuse, which may be of a physical, sexual, or financial nature, or may involve neglect or domestic violence toward a child, elder, or dependent adult. BASIC ACTIONS CHILD ABUSE REPORTING ELDER ABUSE REPORTING (LONG-TERM CARE FACILITY) Notify the appropriate law enforcement agency immediately if the scene is unsafe or it is suspected that a crime has been committed. Make reasonable efforts to transport the patient to a receiving hospital for evaluation, and advise the receiving hospital staff of abuse/neglect suspicions. Document observations and findings on the patient care report. Contact the appropriate reporting agency by telephoning immediately or as soon as reasonably possible to provide a verbal report. Call Children & Family Services Screening Unit: (all numbers are 24 hours/day) at 1-877-881-1116 Complete a Suspected Child Abuse Report Form within 2 working days (SS 8572) (available online at http://www.ag.ca.gov/childabuse/pdf/ss_8572.pdf ) 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 24-Hour Crisis Line: 1-800-231-4024 Complete a Suspected Dependent Adult/Elder Abuse Form within 2 working days (SOC 341). Available at: http://www.dss.cahwnet.gov/cdssweb/entres/forms/english/soc341.pdf
ABUSE REPORTING RESPONSIBILITIES (Continued) ELDER ABUSE REPORTING (ALL OTHER SITES) SEXUAL ASSAULT DOMESTIC VIOLENCE If the alleged abuse has occurred anywhere else (not at a long-term care facility): 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 within 2 working days (SOC 341). Available at: http://www.dss.cahwnet.gov/cdssweb/entres/forms/english/soc341.pdf Sexual assault shall be reported as above in situations involving elder, dependent adult, child, or domestic violence. It is recommended to transport patients who have been sexually assaulted to Contra Costa Regional Medical Center for evaluation and evidentiary exam; however, the patient may be transported to the receiving hospital of choice or if medically unstable to the most appropriate facility for medical care. Discourage any activity that would compromise evidence collection prior to transport such as bathing, brushing teeth, brushing hair, urinating, defecating or changing clothes. Reporting responsibilities are fulfilled by notifying the local law enforcement agency, and by reporting suspicions and patient findings to receiving hospital staff (if transported)
Restraint Types Restraint Issues Law Enforcement Role Transport Issues RESTRAINTS Leather or soft restraints may be used during transport Handcuffs may only be used during transport if law enforcement accompanies the patient in the ambulance. Patients may not be handcuffed to the gurney. Chemical restraint requires a base hospital order Patients shall be placed in Fowler s or Semi-Fowler s position Patients shall not be restrained in hogtied or prone position Method of restraint should allow for monitoring of vital signs and respiratory effort and should not restrict the patient or rescuer s ability to protect the airway should vomiting occur Restrained extremities should be monitored for circulation, motor and sensory function every 15 minutes Law enforcement agencies are responsible for capture and/or restraint of assaultive or potentially assaultive patients Law enforcement agencies retain responsibility for safe transport of patients under arrest or on 5150 holds Patients under arrest or 5150 hold should undergo a weapons search by law enforcement personnel Patients under arrest must be accompanied by law enforcement personnel If an unrestrained patient becomes assaultive during transport, ambulance personnel shall request law enforcement assistance, and make reasonable efforts to calm and reassure the patient If the crew believes their personal safety is at risk, they should not inhibit a patient's attempt to leave the ambulance. Every effort should be made to release the patient into a safe environment. Ambulance personnel are to remain on scene until law enforcement arrives to take control of the situation.
TRAUMA BASE CALL-IN CRITERIA (IF NOT HIGH-RISK CRITERIA) Evidence of high-energy dissipation or rapid deceleration which may include: o vehicle rollover with unrestrained occupant o intrusion of passenger space by 1 foot or greater o impact of 40 mph or greater (restrained) o persons requiring disentanglement from a vehicle Base Hospital Patient struck by a vehicle with impact 20 mph or less Destination Decision Persons ejected from a moving object (motorcycle, horse, etc.) Required Prior to Significant blunt force to the head. Symptoms may include loss of Transport consciousness, repetitive questioning, abnormal or combative behavior, vomiting, headache, or new onset of confusion Significant blunt force to the neck, thorax (chest/back), abdomen or pelvis Penetrating injury to extremities (above knee or elbow) without apparent fracture Precaution with Elderly Patients Patients 60 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) Additional Considerations: 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 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
HIGH-RISK TRAUMA CRITERIA (Direct Trauma Center Transport) The following meet high-risk criteria and merit direct transport to the trauma center: Physiologic Criteria Anatomic Criteria Mechanism Criteria Combined Criteria (combined mechanism and physical findings) BP < 90 in adults GCS 13 or below if not pre-existing Penetrating injury to head, neck, torso, groin, pelvis or buttocks Fracture of femur Fracture of long bone(s) resulting from penetrating trauma Traumatic Paralysis Amputation above wrist or ankle Major burns associated with trauma Crushed, mangled, or degloved extremity Motor vehicle crash with: o Extrication > 20 minutes o Fatalities in the same vehicle o Ejection Unrestrained motor vehicle crash with: o Head on mechanism > 40 mph o Extrication required Fall 15 feet or greater Auto vs. pedestrian/bicyclist thrown, run over, or struck with significant impact (>20 mph) Note: In the absence of significant symptoms or physical findings with these mechanisms, call base hospital for destination determination Motorcycle crash with: o Abdominal or chest tenderness o Observed loss of consciousness Unrestrained motor vehicle crash with abdominal tenderness Note: Patients with unmanageable airways or trauma arrest not meeting field determination criteria should be transported to the closest receiving facility.