Clinical Advisory Subcommittee of the Emergency Medical Care Committee

Meeting Agenda 10:15 A.M., Tuesday November 10, 2015 Health Agency 2180 Johnson Avenue, 2nd floor Large Conference Room San Luis Obispo Members Chair: Dr. Mark Eckert, County Medical Society Sue Fortier, RN, MICNs Rob Jenkins, Fire Service Paramedics Joe Piedalue, Ambulance Paramedics Paul Quinlan, Fire Service EMTs Dr. Jana Reed, Non-Base Station ED Physicians Chad Robertson, ad hoc Dr. Joe Robinson, Base Station ED Physicians Dr. Stefan Teitge, County Medical Society

Staff STAFF LIAISON: Kathy Collins, RN, SCS Coordinator TBD, EMS Division Director Dr. Tom Ronay, Medical Director Vicci Stone, Administrative Services Officer I Todd Spanton, Administrative Services Officer II Tracy Eby, Administrative Assistant

Marigrace Waage, Ambulance EMTs John Prickett, Lead Field Training Officer

AGENDA ITEM LEAD

Call to Order Introductions Dr. Eckert

Public Comment

Discussion Oxygen/Pulse Ox Use– (attached0

Radio Report Policy #122 (attached)

Patient Refusal of Treatment Policy # 203 –(attached)

Prehospital Determination of Death Policy # 126 (attached)

Dr. Ronay & staff

Adjourn Declaration of Future Agenda Items

Dr. Eckert

Meeting Dates for 2016

January 12 March 8

May 10 July 12 Sept 13 Nov 8 1015 hours - 2

nd floor Conference Room, Health Agency

Oxygen Administration

PHARMACOLOGY AND ACTIONS

Oxygen added to the inspired air raises the amount of oxygen in the blood and,

therefore, the amountdelivered to the tissues.

INDICATIONS

Hypoxia or respiratory distress from any cause.

Acute chest pain in which Acute Coronary Syndrome.

Shock (decreased oxygenation of tissues) from any cause.

Major trauma.

Carbon monoxide poisoning.

CONTRAINDICATIONS

None in prehospital setting.

PRECAUTIONS AND SIDE EFFECTS

If the patient is not breathing adequately, assist ventilations. Provision of

oxygen alone is not enough.

A small percentage of patients with chronic lung disease breathe because they are

hypoxic. Administration of oxygen may abolish their respiratory drive. Do not

withhold oxygen because of this possibility, however, be prepared to assist

ventilations.

Monitor oxygen saturation with a pulse oximeter and

If available, monitor ventilations using capnography.

Use just enough oxygen to maintain pulse oximeter reading of >95%.

Restlessness may be an important sign of hypoxia.

ADMINISTRATION

Method Flow Rate O2 % Inspired Air

Room Air 21%

Nasal Cannula 1-6 L 24-44%

None Re-breather 10-12 L 90%

BVM with reservoir 15 L 90%

San Luis Obispo County Public Health Department Page 1 of 3

Division: Emergency Medical Services Agency Effective Date: 09/21/15

POLICY #122: PARAMEDIC BASE STATION REPORT

PURPOSE I.

A. To provide paramedics with a guideline for giving a brief, clear report that provides pertinent information to base hospital personnel.

SCOPE II.

A. This policy applies to all radio and telephone communications, between San Luis Obispo (SLO) County accredited paramedics and SLO County base hospitals, providing patient information.

DEFINITIONS III.

The following terms must precede communication with a base hospital to better identify the type of patient or patient needs. “Notification” – Communicated with intended receiving hospital for routine patients

not needing special orders or destination requests.

“Alert” – Communicated with Specialty Care Base Hospital to identify patients meeting “Alert” triage criteria for a Specialty Care Center, i.e. Trauma Step 1 or 2, STEMI, ROSC or Stroke.

“Consultation for Destination” - Communicated for patients requiring consultation with Specialty Care Base Hospital to identify patients requiring a destination, i.e. Trauma Step 3 & 4 or in circumstances where the initial intended destination needs to be re-routed to a closer or alternate hospital i.e. airway issue.

“Request for Medication” – When requesting a medication order outside of standing orders from a base station physician.

“Consultation for Care” – For circumstances needing base physician assistance when patient care is not clear.

“Termination” – To terminate recitative measures when the patient has not responded or evidence of a DNR/POLST form become available.

POLICY IV.

A. Common radio communication format must be followed, with both parties identifying who they are and with whom they are speaking with each transmission.

B. Use simple language (plain text) and avoid using “10” codes, etc.

C. Paramedics must identify themselves with their identification number and/or transporting unit number when making contact with a base hospital.

D. MICNs must confirm the base hospital name and state their identification number when receiving the base station report.

POLICY #122: PARAMEDIC BASE STATION REPORT Page 2 of 3

PROCEDURE V.

A. All hospital notifications must include the following:

1. Transport Code.

2. Type of notification.

3. Age.

4. Sex.

5. Chief complaint/mechanism of injury.

6. Medications, treatment or protocol followed.

7. Estimated Time of Arrival (ETA).

B. Additional information for Specialty Care Centers or other special requests/notifications.

1. STEMI ALERT

a. For patients positive for STEMI.

b. Confirmation of ECG reading meeting “Acute MI Suspected” or equivalent reading free of artifact.

c. ETA when SLO County STEMI Base (French Hospital) is not the receiving hospital.

2. Return of Spontaneous Circulation (ROSC)

a. For patient with ROSC.

b. ETA when SLO County STEMI Base (French Hospital) is not the receiving hospital.

3. Trauma ALERT

a. For patient meeting Step 1 or 2 of the Trauma Triage criteria.

b. Format in addition to age and gender to include: MIVT.

(1) M – Mechanism of injury.

(2) I – Injuries identified and/or chief complaint.

(3) V – Vital signs including:

(a) Blood pressure - communicating a BP < 90 that occurs

anytime during the call.

(b) Pulse rate.

(c) Respiratory rate.

(d) Glasgow Coma Scale (GCS).

(4) T – Treatments.

c. ETA when SLO County Trauma Base (Sierra Vista Hospital) is not the receiving hospital.

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4. Stroke ALERT

a. For patients meeting Stroke Alert criteria.

b. State time patient was “last seen” normal.

c. In addition to routine, include which BEFAST information was positive:

(1) B - Balance (changes or problems from normal).

(2) E - Eyes (sudden change in vision or double vision).

(3) F - Facial droop.

(4) A - Arm drift.

(5) S – Speech abnormities.

(6) T – Time last seen normal (not time of symptoms noticed).

5. Destination Consults

a. Trauma patients - follow MIVT format.

b. If there is a change in the intended destination, communicate need with hospital initially contacted.

c. ETA when the base hospital or specialty care center contacted is not the receiving hospital.

AUTHORITY VI.

Health and Safety Code, Division 2.5, Sections 1798 &1798

POLICY REFERENCE NO. 203

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SAN LUIS OBISPO COUNTY EMERGENCY MEDICAL SERVICES AGENCY PREHOSPITAL POLICY

Policy Reference No: 203 [01/10/2013]

Formerly Policy No: 122 Effective Date: 05/01/2010 Supersedes: 01/01/2000 Review Date: 06/01/2012 PATIENT REFUSAL OF TREATMENT AND/OR TRANSPORT

PURPOSE

To establish operating policies for prehospital personnel at the scene of an emergency in San Luis Obispo County when patients, parents or legal representatives refuse medical treatment or ambulance transportation. AUTHORITY

A. California Health and Safety Code, Division 2.5, Section 1797.220, 1798 (a) (1).

B. California Welfare and Institutions Code, Sections 305, 625, 5150 and 5170.

C. Title 22, California Code of Regulations, Sections 100167 and 100169. DEFINITIONS

A. Adult: A person at least eighteen (18) years of age.

B. Advanced Life Support (ALS) Personnel: Individuals licensed as Paramedics by the State of California.Is this in our general definition list?

C. Against Medical Advice (AMA): When a competent individual who is determined by prehospital or Base Hospital personnel to have a medical problem that requires immediate treatment and/or ambulance transportation, and who, having been advised of his/her condition, including the known and unknown risks and/or possible complications of refusing medical care, still declines treatment and/or transport.

D. Competent: The patient is alert and oriented and has the capacity to understand the circumstances surrounding his/her illness or impairment and the risks associated with refusing treatment or transport.

E. Emergency: A condition or situation in which an individual has a need for immediate medical attention or where the potential for need is perceived by prehospital personnel, or the patient.

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F. Incident Commander: The highest-ranking representative (or designee) of the public safety agency on scene responsible for overall incident/scene management. Again on our general lsit?

G. Minor: A person less than eighteen (18) years of age.

H. Minor Not Requiring Parental Consent: A person under the age of 18 who:

1. Has an emergency medical condition and a parent is not available.

2. Is married or previously married.

3. Is on active duty in the military.

4. Is fifteen (15) years of age or older living separate and apart from his/her parents and managing his/her own financial affairs.

5. Is twelve (12) years of age or older and in need of care due to rape.

6. Is twelve (12) years of age or older and in need of care due to a contagious reportable disease or condition.

7. Is an emancipated minor as decreed by a court and who possesses a valid identification card issued by the California Department of Motor Vehicles.

I. Partial Refusal of Treatment: A competent individual who has a medical condition requiring specific procedure(s) and/or medication(s), and refuses those specific procedure(s) and/or medication(s). The individual has otherwise consented to treatment and/or transportation as recommended by prehospital personnel and/or Base Hospital.

J. Patient Care Report (PCR): Report completed by prehospital personnel to document patient assessment and care. This report may be written or electronic. In our general list?

K. Prehospital Personnel: First Responders, EMT-Is and Paramedics who respond to medical emergencies.

L. Prehospital Provider: EMS provider, either public or private, that responds to emergency medical incidents. General List?

M. Refusal of Transport to the Closest Facility or designated Specialty Care Center: When a competent individual consents to transportation by ambulance but refuses to be transported to the closest facility or designated Specialty Care Center. This does not apply to patients who are stable and when transport beyond the closest facility is not contraindicated.

N. Refusal of Treatment or Transport: When a competent individual is refusing treatment and/or transportation by ambulance to a hospital for one of the following reasons:

1. Individual does not present with any complaint or injuries and advises prehospital personnel upon contact that he/she does not want further assessment or examination.

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2. Individual has a medical condition requiring medical attention; however, the individual is making personal arrangements to seek medical care at a hospital, urgent care, or private physician’s office. This arrangement must be reasonable and acceptable to prehospital personnel. The individual has been advised of his/her potential condition, including the known and unknown risks and/or possible complications of refusing medical care, and the individual still declines treatment and/or transport.

3. A patient request transport to other than the Specialty Care Center as described in the triage guidelines.

O. Refusal of Treatment and/or Transport Form: Form developed and implemented by the prehospital provider for use when an individual refuses treatment and/or transportation. This form should have provisions to document AMA, Refusal of Treatment or Transport, Partial Refusal of Treatment, and Refusal of Transport to the Closest Facility.

P. Welfare and Institutions (W&I) 5150 Hold: Holding a patient against his/her will for evaluation under the authority of Welfare and Institutions Code, Section 5150, because the patient is a danger to him/herself, a danger to others, and/or is gravely disabled, e.g., unable to care for self. A law enforcement officer or County mental health worker may place a written order.

POLICY

A. A competent adult or competent emancipated minor has the right to determine the course of his/her own medical care and shall be allowed to make decisions affecting his/her own medical care.

B. With the exception of minors not requiring parental consent, a patient less than eighteen (18) years old may not refuse evaluation, treatment, or transport for an emergency condition unless a parent or legal guardian concurs with such refusal.

C. A competent adult may refuse medical treatment or ambulance transportation provided that he/she has been advised of the risks and consequences that may result from refusal of treatment or transportation.

D. Refusal of treatment or transportation should not be considered for patients who do not have the capacity to make competent decisions regarding his/her own care. A patient’s competence may be significantly impaired by mental illness, drug or alcohol intoxication, or physical or mental impairment. Patients who have attempted suicide, verbalized suicidal intent, or for whom other factors lead prehospital personnel to suspect suicidal intent, should not be regarded as competent.

E. Law enforcement or Base Hospital contact shall be initiated when item D above and/or an AMA condition exists.

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PROCEDURES

A. When a competent adult, or minor not requiring parental consent, refuses indicated emergency treatment or transportation:

1. Prehospital personnel shall advise the patient of the risks and consequences that may result from refusal of treatment or transportation including the possible risk of death or disability from any undiagnosed condition being untreated.

2. Prehospital personnel shall advise the patient that there is a risk of death and disability from any undiagnosed condition being untreated. Following this explanation, If the patient still refuses, prehospital personnel shall obtain the patient’s or his/her legal representative’s signature on the prehospital provider’s refusal of treatment and/or transport form.

3. In all cases, the patient or his/her legal representative, as appropriate, shall sign the prehospital provider’s refusal of treatment and/or transport form. The signature should be witnessed, preferably by a family member.

4. If the patient, parent, or legal representative refuses to sign the prehospital provider’s refusal of treatment and/or transport form, prehospital personnel should note and initial that the patient refused to sign. Prehospital personnel or other witnesses present should sign the form.

5. Base Physician Consultation:

i. ALS personnel shall contact the Base Hospital physician for consultation in cases where ALS interventions are performed, or when indicated by ALS personnel judgment.

ii. Base Hospital/Receiving Hospital shall be notified that the patient is refusing transport to the closest facility for unstable patient, as defined in Policy 619 Shock (Medical) or Policy 660 General Trauma Policy 602 Adult Hemodynamic Instability Definitions or Policy 621 623 [01/15/2013]Pediatric Hemodynamic Instability Definitions, is refusing transport to the appropriate facility.

iii. When Base Hospital physician consultation is indicated, ALS personnel shall advise the physician of all of the circumstances, including indicated care or transportation, reasons for refusal, and the patient’s plan for follow-up care with his/her own private physician or provider

iv. Base Hospital physician consultation is not required for isolated injury without potential for significant airway, hemodynamic, orthopedic, or neurological compromise.

6. When Base Hospital physician consultation is indicated, ALS personnel shall advise the physician of all of the circumstances, including indicated care or transportation, reasons for refusal, and the patient’s plan for follow-up care with his/her own private physician or provider.

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6. The patient and family should be advised to seek medical care immediately or call 911 if the patient develops adverse symptoms at any time.

B. If prehospital or Base Hospital personnel determine that a patient with an emergency condition is not competent to refuse evaluation, treatment or transportation, the following alternatives exist:

1. Patients should be transported to a hospital under implied consent.

2. If the Base Hospital physician determines that it is necessary to transport the patient against his/her will and the patient resists, or the prehospital personnel believe the patient will resist, assistance from law enforcement or County Mental Health shall be requested to assist in the transportation of the patient. Law enforcement or County Mental Health may consider the placement of a W&I 5150 hold on the patient, but this is not required for transport.

3. If prehospital personnel believe a parent or other legal representative of the patient may not be acting in the best interest of the patient in refusing indicated immediate care or transportation, assistance from law enforcement personnel shall be requested.

4. At no time are prehospital personnel to put themselves in danger by attempting to transport or treat a patient who refuses. Prehospital personnel should use good judgment and request appropriate assistance, as needed.

C. When an unstable patient, as defined in Policy 619 Shock (Medical) or Policy 660 General Trauma Policy 602 Adult Hemodynamic Instability Definitions or Policy 621 623 [01/15/2013]Pediatric Hemodynamic Instability Definitions, is refusing transport to the closest facility, the patient, parent, or legal representative should sign the prehospital provider’s refusal of treatment and/or transport form. The requested Base Hospital/Receiving Hospital shall be notified that the patient is refusing transport to the closest facility. Prehospital personnel shall document patient requests and Base Hospital’s determination on the PCR.

D. Documentation Guidelines

A PCR and a prehospital provider’s refusal of treatment and/or transport form must be completed for each incident of refusal of emergency medical evaluation, care, or transportation.

Prehospital providers are responsible for developing and implementing refusal of treatment and/or transport forms and ensure that PCR documentation includes:

1. A patient history and assessment indicating the method used to establish competency.

2. A mental status examination of the patient that clearly indicates his/her decision making capacity.

3. The reason that the patient is refusing care, evaluation, treatment or transportation.

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4. A statement that the patient, parent or legal representative understands the risks and consequences of refusing medical treatment and/or transportation that was offered.

5. All alternatives presented to the patient.

6. Base Hospital and/or Base physician contacted if applicable.

7. Signature of patient, parent or legal representative, and prehospital personnel on the refusal of treatment and/or transport form.

San Luis Obispo County Public Health Department Page 1 of 3

Division: Emergency Medical Services Agency Effective Date: 09/10/15

POLICY #126: PREHOSPITAL DETERMINATION OF DEATH

PURPOSE I.

A. To establish criteria for the determination of death and outline the procedure to be followed by EMS personnel in San Luis Obispo (SLO) County.

DEFINITIONS II.

Multi-Casualty Incident (MCI): Any situation where the number of patients exceeds the number of medical personnel available to treat each patient as defined in SLO County Emergency Medical Services Agency (EMS Agency) Policy# XXX: Multi-Casualty Incident Operations

Obvious Death Criteria: When a patient is documented to be pulseless and apneic and one or more of the following conditions is present:

1. Decapitation

2. Evisceration of heart or brain

3. Incineration

4. Rigor Mortis

5. Decomposition

Patient must not be a victim of:

1. Cold water drowning

2. Barbiturate overdose

3. Hypothermia

Patient Care Record (PCR): Written and/or electronic report completed by EMS personnel to document patient assessment and care.

Resuscitation: Advanced Life Support (ALS) interventions whose purpose is to restore cardiac or respiratory activity.

1. Cardiopulmonary resuscitation (CPR)

2. Defibrillation or cardioversion (including AED)

3. Assisted ventilation in the absence of spontaneous respirations

4. Endotracheal intubation – oral or nasal

5. Administration of cardiac drugs. Is this list necessary for the definition?

Triage: The sorting of patients to determine the priority of care given, usually used during MCIs.

POLICY III.

A. All patients require immediate medical evaluation.

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B. Patients with absent vital signs and without signs of Obvious Death shall be treated with resuscitative measures unless the First Responder is presented with an operative Do Not Resuscitate Order (DNR) as defined in EMS Agency Policy# 127: Do Not Resuscitate (DNR) / End of Life Level of Care.

C. A First Responder may determine death when the criteria of Obvious Death are present.

D. An “on-duty EMT, Paramedic or Fight Nurse” may additionally determine death when one or more of the following conditions are present:

1. Reliable history of cardiac arrest with no CPR for more than 20 minutes

2. Adult blunt traumatic arrest (> 18 years old) – absent signs of life (systole/apneic) upon EMS arrival

3. Adult penetrating traumatic arrest (> 18 years) absent signs of life upon EMS arrival and the transport to the Trauma Center or a hospital is greater than 20 min

4. Severe or multiple injuries clearly incompatible with life.

E. STEMI Base Hospital Physician shall be contacted:

1. If Information becomes available, that would have prevented the initiation of resuscitation if that information were available before CPR was initiated. (i.e. Physician Orders for Life Sustaining Treatment (POSLT) or advanced directive).

2. For termination of resuscitative measures for adult medical cardiac arrest unresponsive to ALS procedures after 20 min of resuscitation (may include a sustained capnography reading of < 10 mmHg).

F. When the patient is determined to be dead

1. The Coroner shall be contacted.

2. Deceased patients should not be moved unless directed by the Coroner, except to access other patients requiring medical care or assessment, for the safety of First Responders, or for other extraordinary circumstances.

3. A cellular or landline telephone to the Base Hospital should be used rather than radio communication in order to maintain patient confidentiality and family privacy when contacting a Base Hospital or Coroner.

4. Whenever resuscitation is terminated in the field, all IV lines, airways, etc., shall be left in place.

G. During an MCI

1. CPR may be withheld until adequate First Responders are available or the patient meets the criteria of Obvious Death.

2. No Base Hospital contact is necessary.

3. A triage tag with the time of the initial evaluation and findings shall be applied.

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4. Deceased patients should not be moved unless directed by the Coroner, as needed to access other patients requiring medical care or assessment, for the safety of First Responders, or for other extraordinary circumstances.

H. Nothing in this policy shall prevent peace officers from acting within the scope and course of their official duties and pronouncing death as permitted by the policies of their agencies.

PROCEDURE IV.

A. In any case where a determination of death is made in the field a PCR must be completed and reviewed by the provider agency‘s quality improvement (QI) program. The incident and the patient’s condition shall be described clearly and completely on the PCR, including the following:

1. The circumstances under which resuscitation was not initiated or was terminated, including results of the physical exam, and/or any additional findings such as a lack of heart and lung sounds, fixed and dilated pupils, skin lividity, and ECG tracing if available.

2. The resuscitation measures performed, if any, and the results thereof.

3. The name of the First Responder making the determination of death, and the name of the Base Hospital physician who pronounced the patient, as appropriate.

4. The time of pronouncement/determination of death.

5. Capnography reading and cardiac monitoring documentation of cardiac asystole in more than one lead, if available.

AUTHORITY V.

A. Health and Safety Code, Division 2.5, Section 1798 and Division 7, Section 7180.

California Code of Regulations, Title 22, Division 9, Sections 100015, 100144, 100147, and 100169.

California Probate Code Sections 4780-4785.