v22 2015 MonroeLivingston Regional EMS System Overview Role of medical control physician Medicallegal concerns of medical control Appropriate Hospital Destinations Discussion of regional protocols ID: 1047893
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1. On-Line Medical Control Coursev2.2 2015Monroe-Livingston Regional EMS System
2. OverviewRole of medical control physicianMedical-legal concerns of medical controlAppropriate Hospital DestinationsDiscussion of regional protocolsReview of important protocolsUtilization of CHEMPACKhttp://chemm.nlm.nih.gov/chempack.htm
3. Medical DirectionIndirect Medical Control (“Off-Line”)Establishment and review of protocols and standing ordersResponsibility of Regional Medical Director in conjunction with Regional Emergency Medical Advisory Committee (REMAC)Continuing medical education of providersQuality Assurance / Quality ImprovementSystem supervision
4. Medical DirectionDirect Medical Control (“On-Line”)Real-time communication between prehospital provider and medical control physician by phone or radioDirect on-scene supervisionLocally can only be provided by REMAC certified physician
5. Medical-Legal ConcernsClaims against EMS1 : 24,000 – 27,317 patient encounters1 : 19,995 patient transports37% MVC; 36% patient handling; 12% clinicalIn NYS, medical control duties fall under “Good Samaritan Laws”Exception is in cases of “Gross Negligence”Willful and wanton misconductReckless disregard of the consequences
6. Medical-Legal ConcernsLiability in On-Line Medical Direction:Authorize or demand provider to function above and beyond level or scope of practiceWillfully / wantonly disregard protocolsWillfully / wantonly disregard lawsIssue orders to providers which are clearly harmful, reckless or negligent
7. Medical-Legal Concerns - HIPAAConsent for medical control is considered to be “implied”This does not establish a pre-existing relationship with the patient as defined by EMTALAPatient need not be transported to command hospitalPatient follow upOfficially, can provide EMS follow-up about a patient contact in an “educational setting”Patient findings/outcome in relation to prehospital treatment
8. Medical-Legal Concerns - HIPAAIdentifying information can be transmitted over the radio or phone and is NOT considered a HIPAA violationExamples: Name and DOB for inbound Stroke or STEMI patientAlways request or transmit only the “minimum necessary”
9. Appropriate Destinations
10. Destination SelectionBurnMajor TraumaPsychiatricSTEMIStrokeVentricular Assist Device
11. Burn DestinationURMC / Strong Memorial HospitalAll types of burnsAdult and pediatric
12. Major Trauma DestinationURMC / Strong Memorial HospitalOnly Level 1 Trauma Center in the regionAdult and pediatricDecision to bypass closest facility and transport to Level 1 based upon CDC trauma triage guidelinesOnly exceptions to this are:Difficulties establishing airwayTraumatic arrest
13. Trauma Triage Guidelines – Physical ExamVital SignsGCS <14SBP <90 mmHgRR <10 or >29<20 in infant under 1Anatomy of InjuryAll penetrating injuries to head, neck, torso, and extremities proximal to elbow and kneeFlail chest2 or more proximal long fracturesCrushed, degloved or mangled extremityAmputation proximal to wrist or anklePelvic fracturesOpen or depressed skull fractureParalysis
14. Trauma Triage Guidelines – Mechanism of InjuryFallsAdults: >20 ftChildren: >10 ft (or 2-3x height of child)High-Risk Auto CrashIntrusion >12 inches in occupant site or >18 inches anywhereEjection from vehicleDeath in same passenger compartmentAuto vs Pedestrian or Bicyclist with speed >20 mphMotorcycle crash >20mph
15. Psychiatric / MHA Destination“Medical clearance” can occur at any area hospital with subsequent transfer to psychiatric center if necessaryDesignated Psychiatric Centers (Article 9.39)Rochester GeneralUnity / Park Ridge HospitalUnity / St. Mary’s HospitalURMC / Strong Memorial HospitalClifton Springs HospitalNewark-Wayne Community HospitalWyoming County Community Hospital
16. Psychiatric / MHA DestinationTransport guidelines for a patient requiring emergency department based psychiatric services:Transport the patient to the destination noted on the transport papersIn the absence of transport papers, transport to Article 9.39 hospital where current psychiatric treatment is being providedIf patient is not in a current treatment program, transport to nearest Article 9.39 hospital
17. Mental Health Assessment HoldMHA hold can be done by 3 partiesLaw enforcementDirector of CPEP unitCrisis response teamNon-CPEP physicians can not institute an MHA hold
18. STEMI DestinationSTEMI centers are those with 24-hour access to cardiac catheterization capabilitiesRochester General HospitalUnity / Park Ridge HospitalURMC Strong Memorial HospitalTransport to STEMI destination based upon:Patient with non-traumatic chest pain (or equivalent)Computer interpretation of a “suspected acute MI”ECG with good baseline
19. Stroke DestinationPatients meeting the acute stroke criteria:One or more abnormal findings on Cincinnati Stroke ScaleLast seen normal < 5 hours agoBlood glucose > 60 mg/dlRegional NYS DOH Stroke CentersNoyes Memorial HospitalRochester General HospitalUnity / Park Ridge HospitalURMC / Highland HospitalURMC / Strong Memorial Hospital
20. Ventricular Assist Device & Total Artificial Heart DestinationAny patient accessing the EMS system in the MLREMS region should be transported to the VAD/TAH center, regardless of the patient’s chief complaintURMC / Strong Memorial Hospital is the only VAD/TAH center in the regionProtocol also requires notification of the URMC Heart Failure Coordinator en route
21. System Protocols
22. ProtocolsServe as guidelines to prehospital providers regarding patient careBased upon a chief complaintInclude standing orders for medication administration as well as certain proceduresIncludes requirements for contacting Medical Control for certain medications or proceduresDefine a range of activates: Treatment Procedures Communication Destination Special Policies
23. ProtocolsDelineate the treatment and responsibilities of providers based upon certification level and scope of practiceStreamlined to the following provider levels:Certified First Responder (CFR)Intranasal Narcan*EMT-BAED, Albuterol*, Aspirin, BVM, CPR, EpiPen*, Glucometer*, Nitro SL^, Oral glucose, Oxygen, Intranasal Narcan* EMT-PRSI, HAZMAT* Agency must be approved for use of meds and provider must have completed requisite additional training^ May assist with patient taking own prescribed doses
24. Protocols Commonly Requiring Medical Control1.2 On-scene medicalpersonnel1.3 Advanced Directives1.4 Determination ofDeath 1.5 Termination ofResuscitation2.6 Pediatric ALTE2.8A BehavioralEmergencies2.8B Excited Delirium 2.10 Acute CoronarySyndrome2.13 Croup2.18 Hypotension / Shock2.19B Hypothermic CPR2.24 Pain management2.25 Poisoning2.26 CHF2.27 RSI2.29 Respiratory Distress2.30 Sedation2.31 Seizures2.34 Vascular accessAll protocols can be viewed at www.mlrems.org
25. 2.6 Pediatric ALTE
26. 2.8A Behavioral Emergencies
27. 2.8B Excited Delirium Syndrome
28. 2.8B Excited Delirium Syndrome
29. 2.10 Acute Coronary Syndrome
30. 2.10 Acute Coronary Syndrome
31. 2.13 Croup
32. 2.18 Hypotension / Shock
33. 2.24 Pain Management
34. 2.26 Pulmonary Edema / CHFFurosemide and morphine are not in the protocolFurosemide has been removed entirely from prehospital formularyBiPAP may also be used in place of CPAP by agencies that have the appropriate equipment
35. 2.27 Rapid Sequence IntubationThis protocol is reserved only for RSI credentialed EMT-P providersStrict oversight is provided by the Medical Director’s officeFacilitated intubation (sedative without paralytic) is NOT authorized
36. 2.27 Rapid Sequence Intubation
37. 2.29 Respiratory Distress
38. 2.30 Sedation
39. 2.30 Sedation
40. 2.31 Seizures
41. Unique Situations and Protocols
42. 1.2 On-Scene Medical PersonnelPrehospital providers are required to request proof of medical provider licensure prior to accepting orders to direct care
43. 1.2 On-Scene Medical PersonnelPatient’s personal physician on scene:Must write and sign PCR for all orders given to EMS providersIf physician refuses to sign, medical control must be contactedCan take over complete care of the patient only if they accompany patient to hospital
44. 1.2 On-Scene Medical PersonnelBystander physician on sceneCan only assume responsibility after approval from medical controlAll orders must be written and signed for in the PCR by the bystander providerBystander provider must accompany the patient to the hospitalResident physician is not qualified in this capacity unless independently licensed
45. 1.2 On-Scene Medical PersonnelRN, LPN, PA, NP etc. on sceneMay assist with care at the direction/discretion of prehospital provider May not take responsibility for, or provide orders to EMS personnel
46. 1.3 Advanced Directives
47. 1.4 Determination of Death
48. 1.5 Termination of Resuscitation
49. Refusal of Treatment / TransportArea of greatest concern for medical directorsBegins with definition of “patient encounter”Refers to visual contact with a patientCan be either the result of either the patient calling or 3rd party callerPatient evaluation consists of:Visual assessmentFocused examVital SignsDetermination of Medical Decision Making Capacity
50. Refusal of Treatment / TransportMLREMS Policy 9.5 states that patients at the scene of an emergency who demonstrate capacity for medical decision making shall be allowed to make decisions regarding their own medical careIncludes refusal of evaluation, treatment or transportA patient must have the ability to understand the nature and consequences of their medical care decision
51. Refusal of Treatment / TransportMedical control consultation is encouraged prior to patient refusal in the following circumstances:Age greater than 65 years or less than 2 monthsPulse <50 or >120Systolic BP <90 or >200Respirations <10 or >29Chief complaint of Chest Pain, SOB, syncopeSignificant mechanism of injuryConsultation is required for parent/guardian refusing the transport of child with an ALTE
52. Consultation for RefusalPurpose is to provide a “second opinion” with the goal of helping the patient realize the seriousness of their condition and to accept transport and hospital evaluationProvider is unsure if the patient is medically capable to refuse treatment/transportProvider disagrees with the patients decision to forgo transport due to unstable vital signs, clinical factors found during the assessment or provider discretion due to high risk criteria
53. Taking the Call
54. Medical Control ReportRequired documentationRequired by StateLegal documentVoice recording back-upUsed for QA/QI
55. Medical Control Report – The CallIdentify yourselfBe prepared to spell your last name for proper documentation on the Prehospital Care Report (PCR)Prehospital provider should give a brief reportProvider name and levelReason for call: meds, orders, advicePertinent patient historyPatient vital signsCompleted interventionsEstimated time of arrival to facilityProvide orders/advice and ensure that caller repeats back the order correctly
56. Consultation for RefusalAttempt to speak with the patientIdentify yourself as a physician providerHave the patient explain in their words why they are refusing and if they understand the possible outcomes of refusal with respect to their current complaintEnsure that the patient does not have any condition that would consider them to be incapable of medical decision capability
57. Conditions Precluding CapacityAltered mental status from any causeAge less than 18 unless emancipated minorUnless consent from legal guardian obtainedAttempted suicide, danger to self or others, or verbalizing suicidal intentActing in an irrational manner, such that a reasonable person would believe that the capacity to make medical decisions is impaired
58. Recent Changes and Additions for 2015Other Important Protocol and Medication Changes
59. 2.39 Smoke Inhalation Protocol
60. NorepinephrineDopamine has been removed, and replaced with Norepinephrine for management of fluid-refractory shock in Protocols 2.10 (Acute Coronary Syndrome), 2.18 (Hypotension/Shock), 2.26 (Pulmonary Edema/CHF), 3.2 (ROSC – Adults), and 4.2 (ROSC – Pediatrics)
61. KetamineKetamine has been added to the formulary for RSI providers only. Ketamine as indicated in the protocols for RSI (2.27) as an alternative induction agent, Excited Delirium (2.8B) as a chemical restraint, and Facilitated Extrication (2.40) as a dissociative.
62. MidazolamThe maximum total amount of midazolam to be administered on standing order has been increased to 10 mg. Providers may give 2.5-5 mg (adult) or 0.1 mg/kg up to 2.5 mg (pediatric) per dose and must call medical control for any total administered quantity beyond 10mg. This has been standardized across all protocols that utilize midazolam (Behavioral Emergencies and Excited Delirium 2.8A and 2.8B, Sedation 2.30, and Seizure 2.31).
63. 2.37 Total Artificial Heart
64. 2.40 Facilitated Extrication
65. 2.41 Sepsis
66. CHEMPACKNerve Agent Exposure
67. CHEMPACK: PurposeFederal forward deployment program that strategically pre-places nerve agent antidotes to allow rapid and improved capability to respond to a nerve agent attackProgram is part of the Strategic National Stockpile program
68. CHEMPACK: PurposeAccessed in the event that large quantities of antidote are required after nerve agent exposureLife Saving InterventionAntidote need is beyond local suppliesNOT to be used for prophylaxis or pre-treatment
69. CHEMPACK: For exposure toChemical WeaponsSarin (GB)Tabun (GA)Soman (GD)Cyclosarin (GF)VX (O-ethyl S)Organophosphate PesticidesParathionMalathionChlorpyrifosDiazinon
70. CHEMPACK: ContentsLarge supplies of the following designed for either hospital or EMS use:AutoinjectorsMark I Kits: Atropine and 2-PralidoximeAtropen: AtropineDiazepamMulti-Dose VialsAtropinePralidoximeDiazepam
71. CHEMPACK: AccessingNeed for CHEMPACK occurs when surge of patients exhausts standard supply of antidoteMedical decision to activate can be made by:Attending Physician of Emergency DepartmentHospital Incident Commander
72. Chempack: AccessingRGH, Unity, or URMC/StrongAttending physician requests to open CHEMPACK and begin using suppliesUsually through on-call pharmacist, but check to confirm your hospital specific planHospital activates its Incident Command SystemMonroe County 911 Supervisor notified
73. Chempack: AccessingOther hospital within the region:Attending physician activates Hospital Incident Command SystemRequests the asset through the Monroe County 911 Center
74. Course CompleteContinue to next slide for course completion information
75. Completing the CourseReview the entire set of MLREMS Protocols www.mlrems.orgTake the web-based post-testIf you pass the test, you will be able to print a certificate for your recordsOnly REMAC certified Medical Control physicians may give medical control adviceNO EXCEPTIONS