Policy 9 — Destination DeterminationPolicy 9 — Destination – 5150 and ObstetricPolicy 9 — Burn Patient DestinationPolicy 10 — Declining Medical Care or Transport (AMA) Policy 13 — Trauma Base Call-In CriteriaPolicy 13 — Trauma Triage CriteriaPolicy 19 — Determination of DeathPolicy 20 — DNR and POLST OrdersPolicy 23 — Reporting Requirements - AbusePolicy 30 — RestraintsPolicy 33C — Helicopter Transport CriteriaPolicy 35 — Safely Surrendered BabyPolicy 36 — Hazardous Materials – Exposure Management Principles Policy 39 — 911 Activation for Non-Emergency Transport Providersnote: These are summaries of policies – full policies are available at the EMS website at: http://cchealth.org/ems/policies.php

PolicySummaries

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

• 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

• 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

DESTINATION DETERMINATION – 5150 / OBSTETRIC PATIENTS

PATIENTS ON 5150 HOLDS

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 CenterUnstable 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); oro Significantly abnormal vital signs; oro Any other history or physical findings that suggest instability (e.g. chest pain, shortness

of breath, hypotension, diaphoresis)

OBSTETRIC PATIENTS

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

BURN PATIENT DESTINATION

GENERAL DESTINATIONPRINCIPLES

• 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

DECLINING MEDICAL CARE OR TRANSPORT (AMA)All qualified persons are permitted to make decisions affecting care, including the ability to decline care

PatientAny person encountered by EMS personnel who demonstrates any known or suspected illness or injury OR is involved in an event with significant mechanism that could cause illness or injury OR who requests care or evaluation

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

Qualified Person

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; 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.

Base Contact Requirements

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

• If the patient’s competency status is unclear (neither competent nor clearly incompetent) and 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

TRAUMA – BASE CALL-IN CRITERIA (IF NOT HIGH-RISK CRITERIA)

BASE HOSPITAL DESTINATION DECISION REQUIRED PRIOR TO TRANSPORT

• Evidence of high-energy dissipation or rapid deceleration which may include:o vehicle rollover with unrestrained occupanto intrusion of passenger space by 1 foot or greatero impact of 40 mph or greater (restrained)o persons requiring disentanglement from a vehicle

• Patient struck by a vehicle with impact 20 mph or less• Persons ejected from a moving object (motorcycle, horse, etc.)• Significant blunt force to the head. Symptoms may include loss of

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 WITHELDERLY 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

• BP < 90 in adults • GCS 13 or below if not pre-existing

ANATOMIC CRITERIA

• 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

MECHANISM CRITERIA

• Motor vehicle crash with:o Extrication > 20 minuteso Fatalities in the same vehicleo Ejection

• Unrestrained motor vehicle crash with:o Head on mechanism > 40 mpho Extrication required

• Fall 15 feet or greater• Auto vs. pedestrian/bicyclist thrown,

run over, or struck with significant impact (>20 mph)COMBINED CRITERIA (COMBINED MECHANISMAND PHYSICAL FINDINGS)

• Motorcycle crash with:o Abdominal or chest tendernesso 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.

Note: In the absence of significant symptoms or physical findings with these mechanisms, call base hospital for destination determination

DETERMINATION OF DEATH

OBVIOUS 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 secondso Rigor, if present, should be noted in jaw and/or upper extremitieso If any doubt exists, place cardiac monitor to document asystole in 2 leads for 1

minute• Mass casualty situations

MEDICAL ARREST

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 doneProcedure: • 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 2 leads for 1 minute

TRAUMATIC ARREST

Definition: Blunt or penetrating traumatic arrestProcedure:• 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

A

DNR and POLST ORDERS

VALID DNR 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 sceneCOMPLYING WITH AN HONORED DNR ORDER

• Verify identity of patient• Perform no life-saving measures• Cancel the responding ambulance

COMPLYING WITH A POLST ORDER (NOT IN ARREST)

• Verify identity of patient. Review section B.o If “Full Treatment” marked, patient receives full careo If “Limited Additional Interventions” or “Comfort Measures Only” is marked, no

advanced airway should be done

NO VALID DNR ORDER PRESENT AND REQUEST MADE FOR NO RESUSCITATION

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.

ABUSE REPORTING RESPONSIBILITIESEMS 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.

BASICACTIONS

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

CHILD ABUSE REPORTING

• 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 )

ELDER ABUSE REPORTING(LONG-TERM CARE FACILITY)

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)

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

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

DOMESTIC VIOLENCE

• Reporting responsibilities are fulfilled by notifying the local law enforcement agency, and by reporting suspicions and patient findings to receiving hospital staff (if transported)

RESTRAINTS

RESTRAINT TYPES• 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

RESTRAINT ISSUES

• 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 ROLE

• 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

TRANSPORT ISSUES

• 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.

HELICOPTER TRANSPORT CRITERIAUSE HELICOPTER ONLY WHEN BOTH TIME AND CLINICAL CRITERIA MET

TIME CRITERIA

• 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

CLINICAL CRITERIA

• Trauma patients who meet high-risk criteria according to EMS trauma triage policy, except for:

o Stable patients with isolated extremity traumao 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)

USE AND CANCELLATION

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

SAFELY SURRENDERED BABY PROGRAM

BACKGROUND

• California Law permits parents to voluntarily safely surrender their infant up to 72 hours old at fire stations (hospitals and many medical clinics are also authorized)

• The law was created in an effort to reduce baby abandonments which lead to death in some circumstances

• Parents have a 14-day “cooling off” period to reclaim the surrendered infant. The person surrendering the child has immunity from criminal liability for child endangerment if there is no abuse or neglect involved.

• Self-training is available for personnel who potentially may manage a surrendered infant at cchealth.org/baby-safe

SITE REQUIREMENTS

• Each Safely Surrender Site (Fire Station) should have 2 Newborn Safe Surrender Kits on hand at all times. Replacement kits are available from Contra Costa County Public Health – Maternal and Child Health – (925) 313-6254.

PROCEDURE

• Accept infant – even if more than 72 hours old• By law, the parent is under no obligation to provide information – no questions should be

asked although parents may voluntarily provide information• Assess for medical needs and treat as indicated• Open Newborn Safely Surrender Kit, follow directions and complete documentation• Place confidential coded ankle bracelet on infant and record code on face of kit• Parent is handed two inner envelopes in kit which has matching code, survey forms, and

information about their rights. Parent may leave at this point.• Notify dispatch and request code 2 ambulance to transport to nearest emergency

department• The “Notes” section on face of Kit must be completed and the envelope must

accompany the patient to the emergency department• PCR documentation must include bracelet code in narrative• If suspected abuse or neglect, contact law enforcement

HAZARDOUS MATERIALS – EXPOSURE MANAGEMENT PRINCIPLES

HAZMAT RECOGNITION WHILE RESPONDING

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

HAZMAT RECOGNITION WHILE ON SCENE

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)

• 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.

HAZMAT RECOGNITION WHILE TRANSPORTING

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.

GENERAL GUIDELINES FOR ALL SITUATIONS

• Provide prehospital medical care as soon as it is safe• All precautions should be taken to prevent contamination of hospital

emergency department and personnel

9-1-1 ACTIVATION FOR NON-EMERGENCY TRANSPORT PROVIDERSCriteria for upgrade to advanced life support (ALS) for non-emergency transport providers

DEFINITIONS

• Unstable: A patient who has life- or limb-threatening condition requiring immediate and definitive care. An unstable patient may have respiratory distress, airway compromise, neurological changes from baseline, signs of actual or impending shock or may meet criteria for transport directly to a trauma center.

• Non-emergency ambulance provider: An ambulance provider holding a valid Contra Costa non-emergency ambulance permit

• 9-1-1 ambulance provider: An ambulance provider holding a valid Contra Costa emergency ambulance permit and/or contracting with the County to provide advanced life support ambulance response to 9-1-1 requests

• Code 3: Responding to a location and/or transporting to a receiving facility using red lights and sirens

UNSTABLE PATIENTS

• A patient, determined to be unstable and/or needing Code 3 transportation to a hospital shall be transported by a 9-1-1 provider, whenever possible.

• Non-emergency ambulance providers may transport an unstable patient to the closest/appropriate facility, if they can do so safely and the time from arrival on scene to arrival at the hospital is less than 10 minutes. In all other cases the non-emergency ambulance crew shall activate the 9-1-1 system and request an ALS response.

• Any non-emergency ambulance provider transporting a patient that becomes unstable during transport should divert to the closest/appropriate ED per the Patient Destination Determination Policy (Policy #9). Receiving facilities should receive notification as soon as possible of the need for diversion, patient status and the ETA to that facility.

• All transports by non-emergency ambulance providers of unstable patients, and/or transports requiring Code 3 transportation are considered an unusual occurrence. For each such occurrence an EMS Event report must be completed and submitted to the EMS Agency within 24 hours of the call.

ON-VIEWS• In the event that a non-emergency ambulance provider arrives on the scene of a

collision, illness or injury by coincidence, the crew shall provide appropriate care and immediately activate the 9-1-1 system