Monterey County EMS Agency

Monterey County EMS Agency

Policy & Procedure Update: 2019-2020

EMS System Organization

& Management

Policy Development Process: 1000

Authority for Plans, Policies, Procedures, and Protocols: 1010

EMS Advisory Committees: 1020

Trauma System: 1030

Policy Definitions: 1500

Policy Definitions: 1500

• “In-Extremis” definition clarified

• BEFAST definition identifies the acronym for each letter

• Definitions such as “Field Training Officer” added in preparation for future policies

Personnel & Training

• Scope of Practice for Advanced Life Support: 2000

• Scope of Practice for EMT: 2010

• EMT Expanded Scope of Practice: 2011

• Scope of Practice for Emergency Medical Responder: 2020

• Scope of Practice for Public Safety First Aid: 2030

• Paramedic Accreditation: 2040

• Paramedic Reaccreditation: 2050

• EMT Initial Certification: 2060

• EMT-Expanded Scope Accreditation 2061

• EMT Recertification: 2070

Personnel & Training (cont…)

• Paramedic Preceptor: 2080

• Field Training Officer: 2090

• EMT and Advanced EMT Disciplinary for Relevant Employer Requirements: 2130

• Fireline Paramedic: 2170

• Tactical Medicine: 2180

• EMT Training Program Approval: 2210

• Expanded Scope EMT Training Program Approval: 2211

• EMS Continuing Education: 2220

• Emergency Medical Dispatcher Training Program 2230

• Emergency Medical Dispatcher 2260

EMT Scope of Practice-Expanded Scope

• New policy to define the scope of practice for EMT’s who work for an approved EMT-Expanded Scope Service Provider and have received the specified training.

• Allows for use of:

➢Intranasal naloxone

➢Epinephrine for anaphylaxis and/or severe asthma

➢Finger-stick blood glucose monitoring

➢CPAP

➢Perilaryngeal airway

EMT Certification 2060

• Added language for clarity

• Separated from language for EMT recertification

EMT-Expanded Scope Accreditation 2061

• Specifies requirements for EMT-Expanded Scope accreditation.

• Must be a currently certified EMT

• Must be currently affiliated with an approved EMT-Expanded Scope Service Provider

• Must have completed the required training

EMT Recertification 2070

• Policy separated from EMT Certification policy

• Updated to reflect current regulations in Title 22

• Required by regulation for recertification starting July 1, 2019✓Glucometer training

✓ Epinephrine training

✓Naloxone training

Application will be returned if the required training documentation is not received.

This is a one-time requirement for the first recertification after 7/1/19.

Fireline Paramedic 2170

• Updated language regarding medical control for clarity

• Removed language regarding scope of practice when out of County to improve clarity

Tactical Medicine 2180

• Removed definitions

EMT Training Program 2210

• Updated to reflect changes in Title 22

• Allows for high fidelity simulation skills practice to replace some of the required clinical hours and patient contacts

• Primary instructor qualifications are updated

• Required course content updated to conform to Title 22 changes

➢Use of hemostatic dressings

➢Use of naloxone

➢Use of epinephrine

➢Blood glucose testing by finger-stick glucometer

➢Training in tactical casualty care

EMT-Expanded Scope Training Program 2211

• Sets the standards for the EMT-Expanded Scope training program

• The training program must be approved by the EMS Agency

• EMT training programs and Monterey County approved EMS Continuing Education providers may request approval to offer EMT-Expanded Scope training

EMS Continuing Education Provider 2220

• Policy focus is on the CE provider

• Language about the use of EMS CE by the EMT is removed

Emergency Medical Dispatcher Education and Quality Improvement Program 2230

• Technical updates to the policy language for consistency, clarity, and accuracy

Communications

EMS Communication Systems: 3000

Hospital Communications 3080

EMResource: Internet-Based EMS Communication System: 3070

EMS Communications System 3000

• Definitions removed

• Streamlined policy language

• EMS Communications Center to enter MCI information into ReddiNet

ReddiNet: Internet-Based EMSCommunication System: 3070

• Policy updated to reflect changeover to ReddiNet system from EMResource

• System serves same basic function of providing a “snapshot” of EMS system status

• Testing is done and is monitored (and reported on) by EMS Agency

• Hospitals update status as before – and provide bed availability daily and when requested

• Will be very useful in MCI and disaster situations

Hospital Communications: 3080

• All prehospital reports to a Base Hospital or a Receiving Center will follow the same Situation, Background, Assessment, Recommendations/Recap (SBAR) format: • Identify yourself, organization, unit and type of call, Age, Sex, Chief

Compliant, Code 2 or Code 3, ETA. State urgent issues and immediate needs. Reason for base consult (if applicable): trauma patient, AMA documentation, request for orders, etc.

• A full report should take 60 seconds or less unless multiple patients or other mitigating circumstances.

Hospital Communications: 3080

• Situation – Trauma (MVC, MCC, Falls, Assault, etc.); Medical (Stroke, STEMI, OB, Behavioral Health, etc.). Specific information for each type of patient

• Background – History of current illness/injury, pertinent PMH, meds/allergies

• Assessment – ABC’s, Focused physical assessment, general impressions, vital signs (incl. systolic and diastolic bp) GCS, Lung sounds, pain level, skin signs, pupils, blood glucose, ECG as appropriate; VS to be monitored ever 15” for stable patients, every 5” for unstable

• Recommendation/Recap- Treatment rendered and patient’s response, request what you need from the physician, repeat orders given by a physician.

Response & Transportation

Authorized Stock for ALS: 4010

Pre-Hospital Consent Against Medical Advice: 4030

Authorized Stock for BLS: 4020

Field Trauma Triage Criteria: 4040

Psychiatric Evaluation-5150 Transport: 4050

EMS Aircraft: 4070

Prehospital Determination of Death: 4100

End of Life Care: 4120

Response & Transportation

EMT Expanded Scope Service Provider 4170

Airway Management 4502

CPAP 4503

Use of Restraints 4508

Authorized Stock-ALS 4010

• The stock of supplies and medical equipment is specified in this policy

• Cricothyrotomy set and bite stick have been removed

• Transfer needles have been added

• Minor adjustments in the amount of some items

Authorized Stock-BLS

• The stock of supplies and medical equipment is specified in this policy

• Supplies and medical equipment for EMT-Expanded Scope is included

• Minor changes in stock items and amounts have been made to conform with scope of practice

Pre-Hospital Consent 4030

• Refusal of service section added

• Refusal of service refers to situation where the patient appears to have no medical need, there is no mechanism to suggest injury, and no patient/caregiver relationship has been established.

• Other revisions to improve clarity

Psychiatric Evaluation-5150 Transports: 4050

Procedural Update and Language Clarification:

• EMS personnel shall perform a complete assessment on any patient who has been placed on a 5150 hold prior to transport.

• EMS personnel shall base treatment and transport destination decisions on the patient’s medical and psychiatric condition.

• Patients presenting with acute medical conditions and/or traumatic injury shall be transported to the closest and most appropriate emergency department.

Psychiatric Evaluation-5150 Transports: 4050 (cont…)

• EMS personnel shall obtain the completed 5150 form PRIOR to patient transport

• EMS Personnel shall transport all patients placed on a 5150 hold in compliance with Monterey County EMS Agency Policy 4508: USE OF RESTRAINT

• EMS is NOT permitted to transport a patient in handcuffs without a LEO physically present in the ambulance during transport.

The EMS Aircraft crew may transfer responsibility for patient care to ground ambulance if no interventions beyond the Monterey County Paramedic scope of practice have been utilized, and if both the ground crew and the air crews agree.

EMS Aircraft: 4070

Pre-Hospital Determination of Death: 4100

• ALS personnel may stop CPR that has been started by BLS personnel if the patient meets criteria for Determination of Death

• Definitions have been removed

• Language not related to the determination of death process has been removed

Withholding Resuscitation 4120

• Revision of policy to present the concepts in a more clear manner

EMT Expanded Scope Service Provider 4170

• Provides the requirements and process for an EMS Service Provider to become an EMT-Expanded Scope provider

• All EMT staff are to be trained to this level

• Must document the need to upgrade to this scope of practice

• QI participation is required

Airway Management 4502

• Cricothyrotomy is removed from scope of practice

CPAP 4503

• Streamlined the list of indications for use of CPAP

• Streamlined the list of contraindications for use of CPAP

• Added section for relative contraindications

Use of Restraint: 4508

Procedural Update and Language Clarification:

Priorities are YOUR SAFETY, the safety of your patients, and safe transport!

• Patients who have been placed on a 5150 hold; have demonstrated behavior of being a danger to self or others by EMS personnel; present to EMS in restraints at the sending facility; are in Law Enforcement custody and require EMS personnel to transport- shall be restrained to the gurney utilizing a minimum of two-point (e.g. one wrist one ankle, or two wrists) restraints for the duration of the transport.

Use of Restraint: 4508 (cont…)

• EMS personnel discretion may be used for patients who are:

• <100lbs (45kg)

• <12 years of age

• >75 years of age

• The decision to utilize restraints rely on EMS personnel’s ability to safely control an unrestrained patient should he/she become unpredictably violent in the back of a moving vehicle.

• Decisions to not apply restraints that fall outside of these criteria shall be cleared by EMS personnel’s On-Duty Supervisor.


Procedure:

• The patient must be securely restrained to the gurney PRIOR to placing the patient in the ambulance.

• In addition to restraints, all patients shall be secured to the gurney utilizing all appropriate standard safety belts.

• EMS personnel shall only restrain patients in a manner that allows the rapid access to the airway, full expansion of lungs during respiration, and rapid initiation of CPR.

• EMS personnel shall be securely positioned in the transport vehicle in such a way that safety buckles and restraints are be visible at all times.

• Safety buckles and restraints shall be monitored continually throughout transport; allowing early intervention by EMS personnel should a patient attempt removal of safety buckles and restraints.

• The patient shall remain in restraints until safely inside the receiving facility.

• The use of chemical restraint by DOES NOT satisfy the need for application of physical restraints.

• ALL PATIENTS that have been chemically sedated due to his/her behavior shall also be restrained, as per this policy.


Patient Escape:

• Should a patient escape from restraint and exit the ambulance, the following steps should be initiated:

• Do everything possible to minimize injury to EMS personnel, and patient.

• Contact EMS Communications immediately and advise of the situation, location, and status of patient.

• EMS Communications shall notify Monterey County EMS Duty Officer immediately upon notification of incident.

• Attempt to maintain visual contact with the patient as long as possible.

• Update EMS Communications as needed.

• Remain at the scene until cleared by law enforcement or the On-Duty Supervisor.

• Each crew member must complete a detailed incident report in addition the EPCR.

Hospitals & Critical Care Center

• Patient Destination: 5000

• Paramedic Base Hospital Standards: 5010

• Emergency Department Retriage & Rapid Transport for Trauma: 5140

Patient Destination: 5000

• Hospitals are to accept patients in-extremis regardless of their advisory status.

• 5150 is addressed in policy 4050: Psychiatric Evaluation-5150 Transport

• Air ambulance destination is addressed in policy 4070: EMS Aircraft.

• If a patient with a DNR expires during a transfer, take the patient to the receiving hospital or returned to the sending hospital, whichever is closer.

• Destination for pediatric patients with arrhythmias are to be transported to a designated STEMI center as indicated in the protocol.

ALS Base Hospital Standards: 5010

• Requirements for hospitals clarified.

• Orders from a base hospital must be done via direct communication between the ED Base Physician and the Paramedic on the scene.

Emergency Department Retriage & Rapid Transport for Trauma: 5140

• Clarifies criteria for re-triage based upon CDC Trauma Triage Criteria.

• Separate Adult and Pediatric Re-Triage Procedure

Quality Improvement

• Quality Improvement Program: 6000

• ALS Skills Maintenance Standards: 6090

• Patient Care Report Approved Abbreviations: 6130

• Patient Care Records: 6180

Quality Improvement: 6000

• Clarification that a QI Program must be in compliance with State Regulations and Monterey County policies.

• Includes not only recognition of excellence and opportunities for improvement, but also steps taken to recognize excellence or correct the opportunities for improvement.

Electronic Patient Care Records: 6180

• Section II D was not changed. The requirement is still to complete PCR before leaving the hospital when patient is transported code three; code two transports and first responder PCRs are still due within one hour

• EMS Agency will start enforcing requirement for UO submission for late PCRs at a date to be determined – based on system stakeholder proficiency with ESO system

• Complete PCR must now be completed for person down, just sleeping, or lift assist calls – these calls can present significant liability so thorough documentation is vital

• Policy 6130 – PCR Approved Abbreviations had minor formatting changes

Community Programs

• Special Events- Event Medical Plan & Review: 7001

Special Event-Event Medical Plan and Plan Review 7001

• New policy

• Establishes a framework for EMS Agency approval of special event medical plans which have been submitted to the EMS Agency

• EMS Agency review of special event medical plans is to help ensure the medical/first aid needs of the event participants and spectators is addressed and to limit the impact of the special event on the community and EMS providers

Lets take a break…

Bathroom?!

Snack?!

Adult Protocols (Cardiac)

• Cardiac Arrest Asystole & PEA: C-1

• Cardiac Arrest V-Fib & Pulseless V-Tach: C-2

• Chest Pain of Suspected Cardiac Origin: C-3

• Tachycardia with Pulses: C-4

• Symptomatic Bradycardia: C-5

• Return of Spontaneous Circulation: C-7

Cardiac Arrest Asystole & PEA: C-1

• Changed to algorithm format

• ROSC moved to Protocol C-7

• Consider discontinuation of CPR if a non-shockable rhythm persists despite appropriate ALS interventions for 20 minutes and up to 3 rounds of drugs.

Cardiac Arrest V-Fib & Pulseless V-Tach: C-2


• ROSC moved to protocol C-7

• Transport to a STEMI Receiving Center

Chest Pain of Suspected Cardiac Origin: C-3

•Changed to algorithm format

•Administration of aspirin by BLS is for EMT only

•Assisting the patient with nitroglycerin is in the EMT scope of practice

Tachycardia with Pulses: C-4


• Algorithm breaks down into stable/unstable; narrow or wide QRS

• Sinus Tachycardia or SVT– transport to closest most appropriate hospital.

• Wide complex tachycardias – transport to closest STEMI Receiving Center.

Symptomatic Bradycardia: C-5


• Direction for Transcutaneous pacing in algorithm.

• Stable pathway versus Unstable pathway

• Transport to closest STEMI Receiving Center

Return of Spontaneous Circulation: C-7

• New Protocol

• Algorithm format

• Pathway for blood pressure >90mmHg and one for blood pressure <90mmHg


Adult Protocols (Environmental)

• Allergic Reaction & Anaphylaxis: E-2

Allergic Reaction and Anaphylaxis E-2

• Use epinephrine with caution in patients with known CAD

• Don’t withhold epinephrine in severe cases of anaphylaxis because of patient age

• Early treatment of anaphylaxis is important

• Contact the base hospital early if there is any doubt regarding the use of epinephrine

Adult Protocols (Medical)

• Nausea and Vomiting Management: M-1

• Routine Medical Care: M-3

Nausea and Vomiting Management M-1

• Diphenhydramine added for severe nausea and intractable vomiting that doesn’t respond to ondansetron

Routine Medical Care: M-3

• BLS Care has been expanded.

• ALS Care includes BLS Care, 12-Lead ECG, and advanced procedures as needed.

Adult Protocols (Neurological)

Seizures: N-3

Seizures N-3

• Revised description of the actively seizing patient

Adult Protocols

(Obstetric)

Childbirth and Obstetrical Emergencies: O-1

• More info on APGAR scores added (time intervals)

• Additional OB emergency types added: Vaginal Bleeding, Spontaneous Abortion, Severe Pre Eclampsia/Eclampsia, Breech Delivery, Prolapsed Cord, Limb Presentation

• These calls are rare – but sometimes difficult – with two patients!

Childbirth and Obstetrical Emergencies: O-1

Adult Protocols (Respiratory)

• Airway Management: R-1

• Pulmonary Edema: R-2

This Photo by Unknown Author is licensed under CC BY-SA

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Airway Management: R-1


• Includes Airway Obstruction, and also includes general airway management and assessments

• 02 to maintain Sp02 of 94%

• Needle Cricothyrotomy is no longer included in Monterey County Paramedic Scope of Practice

Pulmonary Edema: R-2

Biggest change is the addition of the option to “double tap”:

• Administer Nitroglycerine (NTG):

• 0.4mg NTG SL spray or tablet: May repeat every 5 minutes for continuing symptoms if systolic BP is > 110mmHg.

• OR

• 0.8mg NTG SL spray or tablet: May repeat every 5 minutes for continuing symptoms if systolic BP is > 160 mmHg.

Pulmonary Edema: R-2

REMEMBER:

• Maximum total dose for either SL dosage: 8.0mg

• Vital signs SHALL be repeated (AND DOCUMENTED!) between NTG doses

• Only increase NTG to 0.8mg while systolic B/P is > 160mmHg; Resume 0.4mg SL if systolic BP drops below 160mmHg

Adult Protocols (Trauma)

• Burn Care: T-1

Burn Care: T-1

• Care for various degrees of burns specified in protocol.

• Elevate HOB unless contraindicated by Spinal Motion Restriction to help minimize facial and airway edema and prevent aspiration.

• NS to be infused at 500 ml/hour in patients aged 14 and older.

• Destination determination clarified.

• No ABA Classification (outdated). Use the Rule of 9’s to calculate Total Body Surface Area (TBSA) burned. Do not include 1st degree burns in your calculation.

Pediatric Protocols (Cardiac)

• Cardiac Arrest Asystole & PEA: CP-1

• Cardiac Arrest V-Fib & Pulseless V-Tach: CP-2

• Tachycardia with Pulses: CP-3

• Bradycardia with Pulses: CP-4

Cardiac Arrest Asystole & PEA-Pediatric: CP-1


•May contact Base Hospital to determine death on scene if patient does not meet criteria in policy 4100 (Prehospital Determination of Death) or Policy 4120 (Withholding Resuscitation)

Cardiac Arrest V-Fib & Pulseless V-Tach-Pediatric: CP-2


• For defibrillation, refer to manufacturer’s recommendation for energy setting.


Tachycardia with Pulses-Pediatric: CP-3


• Algorithm breaks down into narrow or wide QRS; stable/unstable

• Transport to closest STEMI Receiving Center.

Bradycardia with Pulses-Pediatric: CP-4



ROSC-Pediatric: C-6

• New Protocol


• Normal vital signs by age included


Pediatric Protocols (Environmental)

• Allergic Reaction & Anaphylaxis: EP-2

• Heat Emergencies: EP-3

Allergic Reaction/Anaphylaxis-Pediatric EP-2

• Albuterol instead of atrovent is indicated

Pediatric Protocols (Neurological)

• Seizure: NP-1

Seizure-Pediatric NP-1

• Policy refined to focus on seizures

• Hypoglycemia is treated under that protocol

Pediatric Protocols (Respiratory)

• Airway Management-Pediatric: RP-1

Airway Management-Pediatric: RP-1


• Includes airway obstruction, epiglottitis, and effective airway with inadequate ventilation or respiratory arrest.

• 02 to maintain Sp02 of 94%.

• All pathways state rapid transport to closest ED.

Pediatric Protocols (Trauma)

• Burns: TP-1

Burns-Pediatric: TP-1

• Care for various degrees of burns specified in protocol.

• Elevate HOB unless contraindicated by Spinal Motion Restriction to help minimize facial and airway edema and prevent aspiration.

• NS to be infused:• 5 years and under: 125 ml/hour

• 6 – 13 years of age:250 ml/hour

• Destination determination clarified.

• No ABA Classification (outdated). Use the Rule of 9’s to calculate Total Body Surface Area (TBSA) burned. Do not include 1st degree burns in your calculation.

Documents

Monterey County EMS Agency