Monterey County EMS Protocol & Policy Update, 2018
Welcome Much change 43 policies created and revised Not to worry. Not all of the changes affect everyone 26 protocols created and revised 9 policies deleted Trauma system organization policies consolidated in a single policy 12-Lead EKG policy PCR and First Responder Report policies updated to reflect the use of the e-pcr
A Few Things ESO training on the epcr will take place this Spring
Policy Update, 2018 Section 1: EMS System Organization and Management 1020-EMS Advisory Committees Updates committee representation and creates alternates for EMCC Revised reporting process for QI committees Minor language and grammar revisions 1030-Trauma System Consolidation of several trauma system policies into a single policy 1500-Policy Definitions Removed definitions from individual policies Definitions contained in a single policy for standardization
Policy Update, 2018 Section 2: Personnel and Training 2000-Paramedic Scope of Practice Conforms policy language to California Code of Regulations, Title 22 No additions to the paramedic scope of practice Pediatric intubation is removed from the Monterey County paramedic scope of practice
Policy Update, 2018 Section 2: Personnel and Training 2010-EMT Scope of Practice Conforms policy language to California Code of Regulations, Title 22 Removes language related to Emergency Medical Responder (EMR)
Policy Update, 2018 Section 2: Personnel and Training 2011-EMT Scope of Practice-Expanded Scope New policy Requires EMT to provide this scope of practice through an EMS service provider which has been approved by the EMS Agency to offer this level of service. Expanded scope includes: Intranasal naloxone Epinephrine auto-injector Blood glucose testing by finger-stick CPAP
Policy Update, 2018 Section 2: Personnel and Training 2020-Scope of Practice-EMR Creates separate policy from BLS Scope of Practice Outlines scope of practice for the Emergency Medical Responder (EMR) Several differences between EMT and EMR scope of practice EMR can use an OPA but not an NPA EMR is not to assist patients with administration of the patient s prescribed medications and/or devices
Policy Update, 2018 Section 2: Personnel and Training 2030-Scope of Practice-Public Safety First Aid New policy Outlines scope of practice for the firefighter or law enforcement officer trained under the Public Safety First Aid regulations in Title 22, Section 1.5 Must have received the required training specified in Title 22, Section1.5
Policy Update, 2018 Section 2: Personnel and Training 2040-Paramedic Accreditation Revision of the policy to provide easier to understand guidance for paramedic accreditation Paramedic service provider organizations are to notify the EMS Agency when a paramedic leaves employment. Notice is to be provided within five business days.
Policy Update, 2018 Section 2: Personnel and Training 2200-Paramedic Training Program Approval Updated to show requirement for paramedic training programs to have accreditation by CAAHEP 2210-EMT Training Program Updated policy language to conform to revisions in Title 22, Chapter 2 Course length is a minimum of 170 hours Course completion requires a minimum of 10 patient contacts Updated policy language includes the process for withdrawal of EMT training program approval EMT training programs are to notify the EMS Agency when scheduling an initial EMT or EMT refresher course
Policy Update, 2018 Section 2: Personnel and Training 2211-EMR Training Program Requirements and Approval New policy Specifies in policy EMS Agency practice for EMR training program requirements and approval Requirements based on Title 22 Public Safety First Aid training program requirements and from the NHTSA National EMS Education Standards 2212-Public Safety First Aid Training Program Requirements and Approval New policy Reflects requirements found in Title 22, Chapter 1.5
Policy Update, 2018 Section 3: Communications 3070-EMResource: Internet-Based EMS Communication System Minor language revisions for clarity Changes monitoring requirements in the hospital from the ED to being continuously monitored. EMResource alerts will be answered within 5 minutes Response to HaveBed drills will be posted within 20 minutes
Policy Update, 2018 Section 3: Communications 3080-Early Hospital Ring-Down Minor language revisions for clarity Patient names will not be broadcast on the radio. Use the phone Several changes in wording from should to shall to ensure specified actions Re-contact with the base hospital shall be made if the patient deteriorates 3090 Base Contact Base contact is to be made for field pronouncement of death Base contact is not required when the patient meets criteria for Determination of Death and should not be routinely used in this situation Language regarding Base Hospital Physician Contact Only removed. Allows use of treatment protocols in base hospital communication failure The base hospital is to contact the receiving hospital to notice the receiving hospital of the patient being transported when the base hospital is not the receiving hospital.
Policy Update, 2018 Section 3: Communications 3091-Base Hospital Communication Failure Minor language revisions for clarity and consistency Language regarding Base Hospital Physician Contact Only removed Allows use of treatment protocols in base hospital communication failure Reminder: Submission of an Unusual Occurrence Report is required in the event of base hospital communication failure Reminder: The paramedic is to attempt to contact the base hospital after treatment is provided under Base Hospital Communication Failure. An Unusual Occurrence Report is to be filed even if base hospital contact is established after treatment is provided under Base Hospital Communication Failure
Policy Update, 2018 Section 4: Response and Transportation 4000-Emergency Medical Scene Management Minor language revisions for clarity and consistency Revised language to improve clarity on treating trapped patients.
Policy Update, 2018 Section 4: Response and Transportation 4010-Paramedic Provider Authorized Stock Title change from Minimum Stock-ALS Units Paramedic units are not to respond to calls for service unless they have the necessary stock to provide treatment under Monterey County policy and protocols Paramedic service providers are encouraged to maintain stock on the vehicle over the required minimum to prevent the unit from going out of service after providing patient treatment Only the items listed may be carried on Monterey County paramedic units This is device or supply type rather than brand or style The EMS Medical Director must approve all items on Monterey County paramedic units Stock levels listed in the policy are minimum levels rather than target levels of equipment and supplies Breakaway flats have replaced scoop stretchers Pediatric (uncuffed) ET tubes are removed. Pediatric laryngoscope is required to manage foreign bodies in the airway Protective equipment is part of the required stock
Policy Update, 2018 Section 4: Response and Transportation 4020-Authorized Stock-BLS Units New policy Policy covers EMT, EMT-Optional Scope, EMR, and Public Safety First Aid units An inventory control program at each BLS service provider is required BLS units are not to respond to calls for service unless they have the necessary stock to provide treatment under Monterey County policy and protocols BLS service providers are encouraged to maintain stock on the vehicle over the required minimum to prevent the unit from going out of service after providing patient treatment Only the items listed may be carried on Monterey County BLS units The EMS Medical Director must approve all items on Monterey County BLS units Stock levels listed in the policy are minimum levels rather than target levels of equipment and supplies Protective equipment is part of the required stock
Policy Update, 2018 Section 4: Response and Transportation 4030-Prehospital Consent-Against Medical Advice (AMA) Policy update to clarify the process to manage the patient who does not wish to receive the care and/or transportation offered by EMS personnel The patient must be an adult or an emancipated minor The patient must be able to understand the nature of the injury or medical condition and understand the risk of refusing care There must be no evidence of altered level of consciousness or substance use causing impaired judgement The patient must be oriented to person, place, time, and situation Base hospital contact or law enforcement involvement may be considered for assistance if the patient has a potentially life threatening condition, mental capacity is in question, if the base can help convince the patient to accept care
Policy Update, 2018 Section 4: Response and Transportation 4040-Field Trauma Triage Minor language changes for clarity and consistency Pregnant trauma victims over 20 weeks gestation are to be transported to a trauma center with a Level III or higher NICU (NMC) The need for ventilatory support is a Step One criteria to transport a trauma victim to a trauma center GCS criteria in Step One is now less than or equal to 13 (< 13) instead of less than 13 (< 13)
Policy Update, 2018 Section 4: Response and Transportation 4050-Psychiatric Evaluation-5150 Transports Complete revision of the policy Continue to take patients with both medical and behavioral health problems to the most appropriate hospital Patients who meet criteria for Trauma, Stroke, or STEMI must go to a designated hospital Follow transport destination request from behavioral health personnel who request a specific hospital because arrangements have been made for the patient at that hospital Trauma, Stroke, or STEMI considerations will override this request
Policy Update, 2018 Section 4: Response and Transportation 4060-Physician On Scene Minor language changes for clarity and consistency Conflict with physician on scene requires submission of an Unusual Occurrence Report Base hospital physician approval needed for orders by a patient s physician to be provided during an inter-facility transfer EMS transport providers are to submit specified data regarding EMT patient care during transport 4080-EMT Patient Care Title change to be consistent with change in policy The transport EMT may provide patient care on scene and during transport when the patient is stable and no ALS interventions have been provided or are anticipated to be provided during transport An Unusual Occurrence Report will be submitted if the patient has a change in condition, the paramedic assumes patient care, and/or the patient is diverted to a specialty center
Policy Update, 2018 Section 4: Response and Transportation 4090-Transfer of Patient Responsibility Process to transfer patient care responsibility from the first responder to the transport paramedic specified Decision to transfer patient care responsibility from the first responder paramedic to the transport paramedic will be made upon arrival of the transport paramedic The first responder paramedic may maintain primary patient care responsibility and this will be clearly communicated upon arrival of the transport paramedic
Policy Update, 2018 Section 4: Patient Care Policies 4508-Use of Restraints Safety of EMS personnel, the patient, and others on scene and during transport is the priority Attempt to de-escalate the situation Restraints may be necessary for protection of EMS personnel and the patient Utilize the minimum restraint necessary Physical and chemical restraint requires constant reassessment of the patient Reassess distal circulation every 5 minutes Patients receiving chemical restraint must also receive physical restraint
Policy Update, 2018 Section 4: Patient Care Policies 4509-Spinal Motion Restriction Name change to follow current terminology Language changes for clarity and consistency Full Spinal Motion Restriction should not be performed based only on mechanism Use the assessment findings to determine the need for spinal motion restriction Do not perform spinal motion restriction on the patient with penetrating trauma unless there are signs of neurological injury or a secondary mechanism and assessment findings are present The backboard is an extrication tool and to be used judiciously. The patient should be removed from the backboard as soon as it is safe and practical to do so
Policy Update, 2018 Section 4: Patient Care Policies 4511-Mechanical Circulatory Devices Patient care orders can not be given from the VAD coordinator Patient care orders can only be accepted from the base hospital Establish early base hospital contact and provide VAD coordinator contact information to the base hospital Transport the patient to the implanting hospital if the patient is considered stable enough to survive the transport The policy contains much information about these devices These patients may be in your community either as residents or as they travel through Be prepared to have to treat a patient with a Mechanical Circulatory Device
Policy Update, 2018 VAD patients: No pulse No NTG or ASA Ok to cardiovert or defibrillate Bring all equipment and caregiver with you. First assess the patient, then assess the device ECG shows native heart rhythm, which may be a malignant rhythm, such as V-fib. TAH patients: + pulse Ok to use NTG Don t cardiovert or defibrillate Bring all equipment and caregiver with you. Very loud, audible galloping sound. First assess the patient, then the device
Policy Update, 2018 Section 5: Hospitals and Critical Care Center 5000-Patient Destination Correction of publishing error Attempt to transport adult family to the same trauma center as the child(ren) 5010-Advanced Life Support-Base Hospital Base hospitals are required to maintain audio recordings of base hospital contacts for a minimum of 2 years 5020-Advanced Life Support-Receiving Hospital Receiving hospitals are required to maintain hospital notification audio recordings for a minimum of 2 years 5060-Trauma Center Standards Administrative changes which apply only to Natividad Medical Center
Policy Update, 2018 Section 5: Hospitals and Critical Care Center 5140-Emergency Department Re-Triage and Rapid Transfer of Trauma Patients to Trauma Center Process remains unchanged Written transfer agreements required between the trauma center and local receiving hospitals Hospitals contacting NMC s transfer center with an emergent trauma re-triage must say Red Box. This lets the transfer center know that it is an expedited re-triage
Policy Update, 2018 Section 5: Hospitals and Critical Care Center 5150-STEMI Receiving Center STEMI Receiving Center may confirm that a transmitted ECG shows a STEMI prior to activating their internal STEMI response Revision includes language regarding STEMI Receiving Center application and annual fees
Policy Update, 2018 Section 5: Hospitals and Critical Care Center 5190-Stroke Center Designation BEFAST stroke scale has replaced the Cincinnati stroke scale Designated Stroke Centers are required to participate in the California Stroke Registry Revision includes language regarding Stroke Center application and annual fees Stroke Centers must maintain certification as a Primary, a Comprehensive, or a Thrombectomy Capable Stroke Center by Joint Commission, HFAP, or DNV
Policy Update, 2018 Section 6: Quality Improvement 6040-Trauma Quality Improvement and System Evaluation Administrative changes 6050-Data Collection-Trauma Administrative changes
Policy Update, 2018 Section 6: Quality Improvement 6170-Pilot Programs-Operational, Clinical Equipment Policy name change Directs that approval by the EMS Medical Director is required when new EMS equipment is being considered
Policy Update, 2018 Section 6: Quality Improvement 6180-Electronic Patient Care Records Policy name change Several outdated policies deleted (6100, 6110, 6120) Policy update to reflect electronic patient care reporting The PCR for Code 3 transports must be completed before clearing the hospital Code two transport epcrs must be submitted within one hour if not left at hospital before departure First responder epcrs must also be submitted within one hour If unable to meet required timelines, a UO must be submitted form will be developed for this process If release section of epcr is signed, ensure patient has been advised of potential consequences of non-transport and evaluation at ED
Policy Update, 2018 Section 6: Quality Improvement 6190 Collection and Submission of EMS Data New policy establishes county-wide electronic EMS data system Establishes responsibilities at every level of system provider agencies, hospitals, EMS Agency, and Dispatch Centers System stakeholders must use County provided system or use system that integrates seamlessly with County system (will be at their own cost) At every level, system security is a major priority providers must ensure security of Personal Health Information (PHI) by establishing policies and procedures to protect it Providers will have access to their own data and system data through Agency prepared reports EMS Agency will submit system to CEMSIS Policy also describes what to do in the event of a system failure (very rare)
Policy Update, 2018 Section 8: Disaster 8070-EMS Duty Officer Administrative change of the EMS Duty Officer phone number: (831) 796-6444 AMR dispatch will answer and request contact information AMR dispatch will contact the EMS Duty Officer Criteria for contacting Duty Officer include MCIs, facility evacuation, physical plant issues, communications system failure, injury or death of system personnel, and incident generating media interest When in doubt-notify Early notification is better The EMS Duty Officer is a resource to support the EMS system 8080-MHOAC Notification and Activation Administrative change of the EMS Duty Officer phone number
ANY QUESTIONS? OKAY! Lets Take A Break Policy Update, 2018
Protocol Update, 2018
Protocol Update, 2018 Cardiac Protocols C-1 Cardiac Arrest-Asystole/PEA Compression and ventilation ratio is 30/2 Ventilate the patient every 5-6 seconds if intubated Epinephrine frequency is every 3-5 minutes Resuscitation will continue for a minimum of 20 minutes or until ROSC Dopamine chart is added
Protocol Update, 2018 Cardiac Protocols C-2 Cardiac Arrest-Ventricular Fibrillation/Pulseless Ventricular Tachycardia Compression and ventilation ratio is 30/2 Ventilate the patient every 5-6 seconds if intubated Epinephrine frequency is every 3-5 minutes Use defibrillator energy setting as specified by the manufacturer Consider transport after 20 minutes if no return of circulation Dopamine chart added
Protocol Update, 2018 Cardiac Protocols C-3 Chest Pain Suspected Cardiac Origin Morphine and Fentanyl standing orders are now found in Protocol M-2 (Pain Control) Transmission of the 12-Lead ECG when a STEMI is identified is now stated in the protocol.
Protocol Update, 2018 Cardiac Protocols C-4 Narrow Complex Tachycardia Cardioversion settings are now according to manufacturer s specifications Sedation with Midazolam is now part of protocol N-1 Chemical Sedation Adenosine is followed by a rapid bolus of saline rather than specified at 10cc
Protocol Update, 2018 Cardiac Protocols C-5 Symptomatic Bradycardia Sedation with Midazolam is now part of protocol N-1 Chemical Sedation Dopamine chart added
Protocol Update, 2018 Cardiac Protocols C-6 Wide Complex Tachycardia With Pulses Sedation with Midazolam is now part of protocol N-1 Chemical Sedation Amiodarone is to be given IV over 10 minutes
Protocol Update, 2018 Environmental Protocols E-1 Acute Venomous Snakebite Assess for oozing at the site of the bite. Indicates likely envenomation Note the progress of swelling every 15-30 minutes Do not restrict blood or lymph flow with a tourniquet Morphine and Fentanyl standing orders are now found in Protocol M-2 (Pain Control) Notify the receiving hospital early to allow time to mix the antivenom
Protocol Update, 2018 Environmental Protocols E-2 Allergic Reaction/Anaphylaxis Albuterol removed from mild reaction Epinephrine moved to first treatment for severe reaction/anaphylaxis Use epinephrine with caution in older patients Dopamine chart added
Protocol Update, 2018 Medical Protocols M-2 Pain Control Doses of Morphine Sulfate and Fentanyl are now standardized. Includes dosing for burn patients and when the paramedic is unable to establish IV.
Protocol Update, 2018 Medical Protocols M-3 Routine Medical Care Protocol now includes criteria for obtaining a 12-Lead ECG. Protocol now includes reminders to do scene size-up and scene evaluation to assess for such things as domestic violence, child or elder neglect, etc.
Protocol Update, 2018 Medical Protocols M-4 Sepsis NEW protocol based on rising awareness of seriousness of sepsis Sepsis is potentially deadly if undetected and not treated aggressively Early suspicion and alerting of hospital is key Based on Systemic Inflammatory Response Syndrome (SIRS) criteria If patient has two or more SIRS criteria, call Sepsis Alert to hospital Criteria are: known or suspected fever heart rate > than 90 respiratory rate > than 20 If patient is hypotensive, give fluid boluses Screening is used for patients 15 years old and greater
Protocol Update, 2018 Neurologic Protocols N-1 Chemical Sedation Intent to have a single protocol to ensure consistency of treatment across all protocols utilizing sedation
Protocol Update, 2018 Neurologic Protocols N-2 Non-Traumatic Neuro Impairment (CVA) Emergent Off-Cycle protocol change Be as specific as possible when obtaining a Last Known Well Time (LKWT). Obtain a cell phone number for a family member Obtain a 12-lead ECG, but do not delay time on scene to do so. Transport patients Code 3 with positive BEFAST findings and LKWT of 20 hours. Provide patient s name and DOB if base contact is by telephone only. Scene time should be kept to 15 minutes or less.
Protocol Update, 2018 Respiratory Protocols R-2 Pulmonary Edema Atrovent removed from protocol Dopamine chart added
Protocol Update, 2018 Respiratory Protocols R-3 Respiratory Distress Capnography is required when using this protocol Titrate oxygen to 94% Sp02 Consider nebulized saline for croup symptoms Use nebulized albuterol for mild respiratory distress Add Atrovent for moderate to severe respiratory distress
Protocol Update, 2018 Trauma Protocols T-1 Burn Care IV fluid boluses changed from 500ml bolus across the board to 250 ml burns with one repeat for <20% BSA, and 1,000 ml fluid bolus for >20% BSA. Pain meds are now in Protocol M-2 (Pain Control) Be prepared to intubate early Stop burning process with water. Do not use ice packs. Oxygen to maintain pulse ox of 94% or higher. Protect against hypothermia Mechanism to remove chemicals is delineated, as well as identification of the chemical when possible.
Protocol Update, 2018 Trauma Protocols T-2 Crush Injury Syndrome Titrate oxygen to maintain a pulse ox of 94%. 12 Lead ECG if chest is accessible to monitor for signs of hyperkalemia Pain meds are now in Protocol M-2 (Pain Control) For suspected Hyperkalemia, use nebulized Albuterol. Base Physician may order Sodium Bicarbonate or Calcium Chloride Do not secure long bone fractures to the backboard
Protocol Update, 2018 Trauma Protocols T-3 Isolated Extremity Injury Pain meds are in Protocol M-2 (Pain Control) Reference to Fentanyl being the preferred pain medication has been deleted. Do not secure long bone fractures to the backboard.
Protocol Update, 2018 A Note About Blood Pressure The minimum systolic blood pressure to provide nitroglycerine or pain control with morphine or fentanyl remains 110. Much discussion about changing to a minimum systolic blood pressure of 90 has occurred. A systolic blood pressure of 90 does not leave any margin for the blood pressure to decrease after medication administration before the patient would be considered in a shock state. Using a minimum systolic blood pressure of 110 has not caused any documented problems for patient care. Affected protocols include: C-3 Chest Pain M-2 Pain Control T-1 Burns T-3 Isolated Extremity Injury E-1 Acute Venomous Snake Bite R-2 Pulmonary Edema T-2 Crush Injury Syndrome
Protocol Update, 2018 Cardiac Protocols-Pediatric CP-4 Symptomatic Bradycardia-Peds Capnography required Fluid bolus maximum of 30ml/kg
Protocol Update, 2018 Cardiac Protocols-Pediatric CP-5 Wide Complex Tachycardia With Pulses-Peds No fluid bolus for the stable patient Cardioversion settings are now according to manufacturer s specifications Maximum single dose of Amiodarone is 300 mg
Protocol Update, 2018 Environmental Protocols-Pediatric EP-1 Acute Venomous Snakebite-Peds Assess for oozing at the site of the bite. Indicates likely envenomation Note the progress of swelling every 15-30 minutes Do not restrict blood or lymph flow with a tourniquet Morphine and Fentanyl standing orders are now found in Protocol M-2 (Pain Control) Notify the receiving hospital early to allow time to mix the antivenom
Protocol Update, 2018 Environmental Protocols-Pediatric EP-2 Allergic Reaction/Anaphylaxis-Peds Albuterol removed from mild reaction Dopamine chart added
Protocol Update, 2018 Medical Protocols-Pediatric MP-2 Pain Control-Peds Doses of Morphine Sulfate and Fentanyl are now standardized Protocol includes pain scales Protocol includes Pediatric Fentanyl Dose Chart Protocol includes how to dilute Fentanyl for administration to pediatric patients
Protocol Update, 2018 Respiratory Protocols-Pediatric RP-2 Respiratory Distress-Peds Capnography is required when using this protocol Titrate oxygen to 94% Sp02 Consider nebulized saline for croup symptoms
Protocol Update, 2018 Trauma Protocols-Pediatric TP-1 Burns-Peds New pediatric Rule of 9 s chart Oxygen to maintain pulse ox of 94% or higher Use sterile water, not ice packs to stop the burning process Protect against hypothermia Pain meds are now in Protocol MP-2 (Pain Control) Be prepared to support airways and ventilations Mechanism to remove chemicals is delineated, as well as identification of the chemical when possible
Protocol Update, 2018 Trauma Protocols-Pediatric TP-2 Isolated Extremity Injury-Peds Pain meds are in Protocol MP-2 (Pain Control Pediatric) Reference to Fentanyl being the preferred pain medication has been deleted Do not secure long bone fractures to the backboard
Protocol Update, 2018 Reminder: Policy 6020 Unusual Occurrence Reporting Revised policy in effect on April 1, 2018 Requires reporting of unusual occurrences Manage interpersonal conflicts under Peer to Peer reporting if possible Situations requiring reporting under Mandatory Reporting may be reported to the employer first Situations requiring immediate reporting of an unusual occurrence are to be reported to the EMS Duty Officer. The EMS Duty Officer should be contacted at (831) 796-6444. AMR dispatch will contact the EMS Duty Officer who will contact the individual reporting the incident.
As we express our gratitude, we must never forget that the highest appreciation is not to utter words, but to live by them. -John F. Kennedy Any Questions?!