Monterey County of Monterey Ems System Policy Policy Number: 1020

Patients shall remain in restraints for the duration of the transport. G.7. Except for brief removal of restraints to enable a patient to utilize the bathroom during a long-distance transport, restraints shall not be removed until the patient is safely inside the receiving facility and patient care has been transferred to the receiving facility staff. H.8. The use of chemical sedation DOES NOT satisfy the need for application of physical restraints. Patients who have been chemically sedated due to dangerous, aggressive, or unpredictable behavior shall also be placed in restraints for the duration of the transport. 1.9.Patient restraints shall never be imposed as a means of coercion, discipline, convenience, or retaliation. C. Spit hoods 1. A spit hood shall not be applied to the patient if the patient is having any affect from pepper spray or other contaminants. 2. The use of pulse oximetry is required. a. If unable to obtain accurate O2 saturation readings, the spit hood should not be used. b. The pulse oximetry should be monitored every 5 minutes and documented on the patient care record (PCR). 3. The patient must not be placed prone or restrained in the prone position. 4. The spit hood shall be removed if any of the following are present: a. Patient complaint of shortness of breath. Monterey County EMS System Policy 4508 b. The patient shows any signs of increased anxiety and attempts at calming the patient are ineffective. c. Signs of hypoxia such as: 1) Drowsiness 2) Increasing agitation 3) Decreased responsiveness I.4) O2 saturation less than 94% IV. PATIENTS IN LAW ENFORCEMENT CUSTODY A. Patients in law enforcement custody who require EMS transport shall either be transported in restraints or handcuffed by a law enforcement officer. 1. A. Patients who are handcuffed require a law enforcement officer to accompany the patient in the back of the ambulance during transport to the receiving facility. EMS personnel are not authorized to use handcuffs or manage the restraint of a patent placed in handcuffs. B. Patients who are restrained with EMS restraints (not handcuffs) do not require the presence of a law enforcement officer in the back of the ambulance during transport to the receiving facility. V. PATIENT ESCAPE: Should a patient escape from restraints and exit the ambulance, the following steps should be initiated: A. Do everything possible to minimize injury to EMS personnel and the patient. B. Contact EMS Communications immediately and advise them of the situation, location, and status of the patient. C. EMS Communications shall notify law enforcement and request their presence at the scene of the incident. EMS Communications shall also notify the Monterey County EMS Duty Officer. D. EMS personnel shall attempt to maintain visual contact with the patient as long as possible and shall update EMS Communications as needed. E. EMS shall remain at the scene until cleared by law enforcement or the On- Duty Supervisor. F. In addition to the ePCR, each crew member of the EMS team transporting the patient at the time of the patient’s escape shall complete a detailed incident report. VI. DOCUMENTATION: Monterey County EMS System Policy 4508 When a patient is transported in restraints, the following information must be documented: A. Reason(s) for use of restraints (danger to self/others, risk/history of violence, etc.). B. Type of restraints used and what limbs are in restraints. C. Assessment of patient condition shall be conducted and documented at least every 15 minutes. Documentation shall include the patient’s level of consciousness, respirations, and distal perfusion to any restrained extremities. VII. NOTES Please refer to Monterey County EMS Agency Policy #4050- Psychiatric Evaluation- 5150 Transports and Protocol M-5 Agitated/Combative Patient for further guidance. END OF POLICY Monterey County of Monterey EMS System Policy 4512-A LAW ENFORCEMENT ADMINISTRATION OF INTRANASAL NALOXONE (NARCAN) REPORT Reporting Law Agency Date Officer Name Time Call Number Responding Fire Dept. Call Address Responding Ambulance Patient Name Patient Date of Birth Initial Assessment □ □ □ □ Awake? Yes No Speech clear? Yes No Approximate Breaths per Minute Treatment Provided Reposition Airway Rescue Breathing □ □ □ □ Yes No Yes No CPR Administer Naloxone □ □ □ □ Yes No Yes No Other Assessment After Treatment □ □ □ □ Awake? Yes No Speech clear? Yes No Approximate Breaths per Minute After completing, email to County of Monterey County EMS Agency within 48 hours Email: [email protected]@countyofmonterey.gov Monterey County of Monterey EMS Agency Policy 4512 B Law Enforcement Intranasal Naloxone Program Application Applicant Information Agency: Date: Address: Street Address City State ZIP Code Phone: Email Law Enforcement Agency Point of Contact Name: Title: Email: Phone: Attachments to Submit Please attach your agency’s training course outline as outlined in County of Monterey County EMS System Policy #4512. Email application and attachments to: Kimberley Hernandez, EMS Analyst [email protected] [email protected] 1 County of Monterey County EMS System Policy Policy Number: 4512 Effective Date: 7/1/2023 Review Date: 6/30/2026 LAW ENFORCEMENT ADMINISTRATION OF INTRANASAL NALOXONE (NARCAN) I. PURPOSE To establish the process for law enforcement agencies and personnel to obtain approval to administer intranasal naloxone. To delineate the procedure for the use of intranasal naloxone by law enforcement agencies. II. POLICY A. Law enforcement personnel working for agencies in Monterey County that have received approval by the Monterey County of Monterey EMS Agency may administer 4 mg. intranasal naloxone following the procedure outlined in this policy. B. To obtain EMS Agency approval, law enforcement agencies must complete the following before using intranasal naloxone. 1. Submit an application to the EMS Agency requesting approval of the intranasal naloxone program. (The application is attached as Policy 4512 B.) 2. Submit the training course outline to the EMS Agency as outlined below. 3. Designate a point of contact for the program and provide contact information for the individual to the EMS Agency. C. Law enforcement personnel must have successfully completed CPR and First Aid training or retraining to the standards set in California Code of Regulations, Title 22, Chapter 2.3Section 100017. D. The course of instruction in the administration of intranasal Naloxone must, at a minimum, include the topics and skills required by California Code of Regulations, Title 22, Division 9, Chapter 2.3 Section 100019(f). The course may not be held until the EMS Agency has granted course approval. Course approval may be granted for up to four (4) years. E. Retraining in the use of intranasal Naloxone will be provided to the law enforcement personnel at least every two years. Retraining will include demonstration of the procedure for administering intranasal naloxone. F. Law enforcement personnel shall follow the guidelines established by the American Heart Association for CPR. G. The EMS Agency will review each use of intranasal naloxone. Monterey County EMS System Policy 4512 III. PROCEDURE TO ADMINISTER INTRANASAL NALOXONE A. Identify the victim of a possible opioid overdose. B. Ensure EMS has been activated. C. Maintain standard blood and body fluid precautions and use personal protective equipment. D. Stimulate the patient. If unresponsive, use a sternal rub technique. E. Ensure an open airway using Basic Life Support techniques. F. Perform rescue breathing, if indicated, using bag-valve-mask or protective face shield. G. If the patient is in cardiac arrest as demonstrated by the absence of breathing and a pulse, begin CPR. H. Administer 4 mg intranasal naloxone, following the procedure learned in training. I. Continue CPR, rescue breathing, or provide other first aid as indicated. J. Prepare for possible narcotic reversal behavior or withdrawal symptoms such as vomiting, agitation, aggression, irritability, etc. K. Notify responding EMS personnel of administration of naloxone. L. Report the use of naloxone to the EMS Agency on the designated report form. IV. PROCEDURE FOR REPORTING ADMINISTRATION OF INTRANASAL NALOXONE A. Following the use of naloxone, complete Law Enforcement Administration of Intranasal Naloxone (Narcan) Report. (The form is attached as Policy 4512 A.) B. Forward Report through law enforcement agency’s chain of command to the County of Monterey County EMS Agency within 48 hours of naloxone administration. END OF POLICY Monterey CountyCounty of Monterey EMS System Policy Policy Number: 5140 Effective Date: 7/1/20263 Review Date: 6/30/20296 EMERGENCY DEPARTMENT RE-TRIAGE AND RAPID TRANSFER OF TRAUMA PATIENTS TO TRAUMA CENTER I. PURPOSE To allow for the expedited transport and care of the Major Trauma Patient who arrives at a non- Trauma Center Emergency Department. II. POLICY A. Under the Field Trauma Triage Criteria (Policy #4040), Major Trauma Patients are to be triaged by EMS personnel directly to a Trauma Center. Trauma patients who present at other facilities non-Trauma Center Emergency Departments via EMS or another arrival mode should be considered for re-triage and transfer to a trauma center for definitive care. If patients are seriously injured, the re-triage and transfer process should be done as quickly as possible. B. Transferring facilities should use the attached algorithm to assist with identification of those trauma patients who would benefit from care at a Trauma Center. C. Transferring facilities should use the process outlined in the attached algorithm to facilitate transfer to the Trauma Center. D. The re-triage and transfer of trauma patients will be monitored at Trauma Evaluation Quality Improvement Committee (TEQIC) meetings. E. Local Base and Receiving Hospitals shall have: 1. Written transfer agreements (for both adult and pediatric patients) with an appropriate designated Level I or Level II Trauma Center. 2. Guidelines for identification of patients who should be considered for transfer to a Trauma Center that are consistent with Monterey Countythe County of Monterey EMS Agency policies and protocols. 3. A procedure for arranging the transfer of appropriate patients (adults and pediatrics), including but not limited to: a. Notification of the receiving Trauma Center physician. b. Arranging for transport by either ground or air. F. The Trauma Center shall have: 1. Written transfer agreements with: a. The nearest designated Level I Trauma Center. b. An appropriate specialty center providing tertiary-level care for burn injuries. Monterey CountyCounty of Monterey EMS System Policy 5140 c. An appropriate facility for patients with spinal cord injuries. d. The nearest designated Pediatric Trauma Center. 2. A procedure for arranging the transfer of appropriate patients (adult and pediatric), including but not limited to: a. Notification of the receiving center physician. b. Arranging for transport by either ground or air Monterey County Emergency Trauma Re-Triage Procedure – Adult (age 15 and older) Step 1 Determine if patient meets Emergency See Criteria below – Adult patients are age 15 and older. Trauma Re-Triage Criteria Step 2 Contact Adult Trauma Center Natividad Medical Center – contact the Natividad Transfer Center. Tell the transfer center you have a “Red Box Trauma Re- Triage”. Transfer center will arrange report and transport. Phone 855-445-7872; Fax: 916-646-7100 Santa Clara Valley Medical Center Trauma Report: 408-947-4087 Burn Line: 408-885-6666 Regional Medical Center Trauma Line: 408-729-2841 Stanford Medical Center Trauma Line: 800-800-1551 Step 3 If not transporting to NatividadMC: If level of transport is within paramedic scope of practice and timely Determine appropriate level of transport transfer is needed, contact the EMS dispatch Communications Center and arrange transport. (Can be done to request a Code- 3 Emergency Interfacility Transfer. Transport simultaneously while contacting the should generally arrive within 10-15 minutes. Phone 831-796-6444 Trauma Center) If level of transport exceeds paramedic scope of practice, contact EMS Dispatch Communications Center for Critical Care Transport (CCT), or arrange transport by Air Ambulance, or arrange for nursing staff to accompany an ALS paramedic ambulance. Step 4 Prepare patient, diagnostic imaging Fax additional paperwork that is not ready at time of transport disc(s), and paperwork for immediate departure. Do not delay transport. transport. LEVELS OF TRANSPORTATION – SCOPE OF PRACTICE – PROVIDER CONTACT NUMBERS Level of Transportation ALS AMBULANCE CCT-RN AMBULANCE AIR AMBULANCE Provider(s) Paramedic and EMT Critical Care Transport – RN & EMT RN and Paramedic Scope of Care/Practice Standard paramedic scope. No Mechanical ventilation, most Mechanical paralyzing agents or blood medications including paralyzing ventilation, most products. Can sedate intubated agents, blood products. medications patients with midazolam. Can including monitor chest tubes not to paralyzing agents, suctionnot requiring suction. blood products. Contact Number AMR – 831-796-64446 AMR – 831-796-64446 CALSTAR/ 831-796-6447 831-796-6447 REACH 800-252-5050 Mercy Air 800-222-3456 Monterey CountyCounty of Monterey EMS System Policy 5140 EMERGENCY TRAUMA RE-TRIAGE CRITERIA – ADULT **The following criteria are intended to serve as guidelines, based on County of Monterey Policy 4040 (Field Trauma Triage Decision Algorithm). The decision of whether to activate an emergency trauma re-triage is at the discretion of the emergency department physician.** Mental Status & Vital Signs: ❖ Unable to follow commands (Motor GCS < 6) ❖ Respiratory rate < 10 or > 29 breaths/min, or respiratory distress, or need for respiratory support ❖ Age 15-64 years: Systolic Bblood pPressure (SBP) < 90 mmHg, or HR > SBP ❖ Age > 64 years: SBP < 110 mmHg, or HR > SBP Injury Pattern: ❖ ❖ Glascow Coma Scale <13 ❖ Respiratory rate < 10 or > 29, or need for ventilatory support ❖ All pPenetrating injuries to head, neck, torso, and extremities proximal to elbow and knee ❖ Chest wall instability, or deformity, or suspected (e.g., flail chest) ❖ Fracture of Ttwo or more proximal long -bones fractures ❖ Crushed, degloved, mangled, or pulseless extremity ❖ Amputation proximal to wrist or ankle ❖ Pelvic fractures ❖ Skull deformity or Open or depressedsuspected skull fracture ❖ Suspected spinal injury with new motor and/or sensory lossAcute paralysis ❖ Active bleeding requiring a tourniquet or wound packing with continuous pressure Mechanism of Injury: ❖ Falls from height > 10 feet ❖ High-risk auto crash • Ejection (partial or complete) from automobile • Need for extrication for entrapped/pinned patient with significant pain or injuries • MVC at > 45 mph with significant pain or injury • Death in same passenger compartment ❖ Rider separated from transport vehicle with significant impact (e.g., motorcycle, ATV, horse, etc.) ❖ Auto vs pedestrian/bicyclist thrown, run over, or with significant impact Provider Jjudgement: Patients who, in the judgment of the evaluating emergency physician, are anticipated to have a high likelihood of requiring emergencyt life- or limb-saving surgery or other emergency intervention (within 2 hours of arrival at the Trauma Center) requiring the specialized services of a Trauma Center. ❖ within 2 hoursS Monterey CountyCounty of Monterey Emergency Re-Triage Procedure – Pediatric (age 14 and younger) Monterey CountyCounty of Monterey EMS System Policy 5140 Step 1 Determine if patient meets Emergency See criteria below – Pediatric patients are younger than age Trauma Re-Triage Criteria 15age 14 and younger. Step 2 Contact Pediatric Trauma Center Santa Clara Valley Medical Center Trauma Line: 408-885-6666 Burn Line: 408-885-6666 Stanford Medical Center: 800-800-1551 Step 3 Determine appropriate level of If level of transport is within paramedic scope of practice and transport and arrange transport. (Can timely transfer is needed, contact the EMS dispatch be done simultaneously while Communications Center to request a Code-3 Emergency contacting the Trauma Center.) Interfacility Transfer. Transport should generally arrive within 10-15 minutes. If level of transport exceeds paramedic scope of practice, contact the EMS Dispatch Communications Center for Critical Care Transport (CCT), (45-minute ETA), or arrange transport by Air Ambulance, or arrange for nursing staff to accompany an ALS paramedic ambulance. Step 4 Prepare patient and paperwork for Fax additional paperwork that is not ready at time of transport immediate transport. Prepare patient, departure. Do not delay transport. diagnostic imaging disc(s), and paperwork for immediate transport. Level of ALS AMBULANCE CCT-RN AMBULANCE AIR Transportation AMBULANCE Provider(s) Paramedic and EMT Critical Care Transport – RN & EMT RN and Paramedic Scope of Care/Practice Standard paramedic scope. No Mechanical ventilation, most Mechanical paralyzing agents or blood medications including paralyzing ventilation, most products. Can sedate intubated agents, blood products. medications patients with midazolam. Can including monitor chest tubes not paralyzing agents, requiring suction. blood products. Contact Number AMR – 831-796-6444 AMR – 831-796-6444 CALSTAR/ 8 REACH 800-252-5050 Mercy Air 800-222-3456 EMERGENCY TRAUMA RE-TRIAGE CRITERIA – PEDIATRIC **The following criteria are intended to serve as guidelines, based on County of Monterey Policy 4040 (Field Trauma Triage Decision Algorithm). The decision of whether to activate an emergency trauma re-triage is at the discretion of the emergency department physician.** Mental Status & Vital Signs: ❖ Unable to follow commands (Motor GCS < 6) ❖ Respiratory rate < 10 or > 29 breaths/min, or respiratory distress, or need for respiratory support ❖ Age 0-9 years: Systolic Blood Pressure (SBP) < 70 mmHg + (2 x age in years) ❖ Age 10-14 years: SBP < 90 mmHg Injury Pattern: ❖ Penetrating injuries to head, neck, torso, and extremities proximal to elbow and knee ❖ Chest wall instability, deformity, or suspected flail chest ❖ Fracture of two or more proximal long bones ❖ Crushed, degloved, mangled, or pulseless extremity ❖ Amputation proximal to wrist or ankle ❖ Pelvic fractures ❖ Skull deformity or suspected skull fracture ❖ Suspected spinal injury with new motor and/or sensory loss ❖ Active bleeding requiring a tourniquet or wound packing with continuous pressure Monterey CountyCounty of Monterey EMS System Policy 5140 Mechanism of Injury: ❖ Falls from height > 10 feet ❖ High-risk auto crash • Ejection (partial or complete) from automobile • Need for extrication for entrapped/pinned patient with significant pain or injuries • MVC at > 45 mph with significant pain or injury • Death in same passenger compartment • Child age 0-9 years unrestrained or in unsecured child safety seat ❖ Rider separated from transport vehicle with significant impact (e.g., motorcycle, ATV, horse, etc.) ❖ Auto vs pedestrian/bicyclist thrown, run over, or with significant impact Provider Judgement: Patients who, in the judgment of the evaluating emergency physician, are anticipated to have a high likelihood of requiring emergency surgery or other emergency intervention (within 2 hours of arrival at the Pediatric Trauma Center) requiring the specialized services of a Pediatric Trauma Center. EMERGENCY TRAUMA RE-TRIAGE CRITERIA – PEDIATRIC Blood Pressure/ Perfusion: ❖ Hypotension or tachycardia (based on age-appropriate chart below) or clinical signs of poor perfusion (see below) ❖ Need for more than two crystalloid boluses (20 ml/kg each) or need for immediate blood replacement (10 ml/kg) GCS/Neurologic ❖ GCS ≤ 13 ❖ GCS deteriorating by 2 or more during observation ❖ Open or depressed skull fracture ❖ Cervical spine injury with neurologic deficit Anatomic Criteria ❖ Penetrating injuries to head, neck, chest, or abdomen ❖ Flail chest ❖ Two or more proximal long-bone fractures ❖ Crushed, degloved, mangled, or amputated extremity proximal to wrist or ankle ❖ Burns with anatomic factors Respiratory Criteria ❖ Respiratory failure or intubation required Provider judgment ❖ Patients who, in the judgment of the evaluating emergency physician, are anticipated to have a high likelihood for emergent life- or limb-saving surgery or other intervention within 2 hours. Pediatric Clinical Signs of Poor Pediatric Glascow Coma Scale – Verbal Scale < 2 years of age Perfusion Cool, mottled, pale or cyanotic skin 5 Coos and Babbles Low urine output 4 Irritable Lethargic 3 Only cries to pain Prolonged capillary refill 2 Only moans to pain 1 None Normal Vitals (Broselow) AGE WEIGHT HEART RATE SYSTOLIC BP BROSELOW COLOR Newborn 3-5 kg 80 – 190 65-104 Grey – Pink 1 Year 10 Kg 80-160 70-112 Purple 3 Years 15 Kg 80-140 75-116 White 5 Years 20 Kg 75-130 80-112 Blue 8 Years 25 Kg 70-120 80-112 Orange 10 Years 30 Kg 65-115 85-126 Green Important Pediatric Emergency Trauma Re-Triage Exceptions: 1. Pregnant patients of any age should be transferred to an adult trauma center. Monterey CountyCounty of Monterey EMS System Policy 5140 2. Patients with trauma and mMajor burns should be preferentially transferred to a Pediatric Trauma Center with a one of the bBurn cCenters. 3. Contact hospital first for major extremity injuries with vascular compromise. END OF POLICY County of Monterey County EMS System Policy Policy Number: 5150 Effective Date: 7/1/2023 Review Date: 6/30/2026 STEMI RECEIVING CENTERS I. PURPOSE To define requirements for designation as a Monterey County ST-Elevation Myocardial Infarction (STEMI) Receiving Center (SRC). II. POLICY A. The County of Monterey County EMS Agency Medical Director may designate a hospital as a SRC if all of the following requirements are met: 1. The hospital shall have established protocols for triage, diagnosis, and cardiac catheterization laboratory (Cath lab) activation following field notification. 2. Once a hospital is notified that a possible STEMI patient is en route to their facility and an ECG is received from the field and confirmed to be a STEMI by the STEMI Receiving Center, the SRC shall activate their internal STEMI response. 3. The hospital shall have a single call activation system to activate the Cardiac Catheterization Team directly. 4. Written protocols shall be in place for the identification of STEMI patients. a. At a minimum, these written protocols shall be applicable in the intensive care unit/coronary care unit, Cath lab, and the emergency department. 5. The hospital shall be available for treatment of STEMI patients twenty-four (24) hours per day, seven (7) days per week, three hundred and sixty-five (365) days per year. 6. The hospital shall have a process in place for the treatment and triage of simultaneously arriving STEMI patients. 7. The hospital shall maintain STEMI team and Cardiac Catheterization Team call rosters. 8. The Cardiac Catheterization Team shall be immediately available. 9. The hospital shall agree to accept all STEMI patients except in situations of internal disaster. 10. SRCs shall comply with the requirement for a minimum volume of procedures for designation required by the County of Monterey County EMS Agency a. Cardiac catheterization laboratory team and interventional cardiologists shall meet or exceed current ACC/AHA/SCAI standards for competence regarding the number of procedures performed annually. 11. The hospital shall have and maintain the following personnel: County of Monterey County EMS System Policy 5150 a. SRC Medical Director 1) The STEMI Medical Director shall be a physician certified by the American Board of Internal Medicine (ABIM) with current ABIM sub-specialty certification in Cardiovascular Disease and Interventional Cardiology who will ensure compliance with these SRC standards and who is responsible for the STEMI program, performance improvement, and patient safety programs related to the STEMI critical care system. b. SRC Program Manager 1) The SRC Program Manager shall have experience in Emergency Medicine or Cardiovascular Care, who shall assist the SRC Medical Director to ensure compliance with these SRC standards and who is responsible for monitoring, coordinating, and evaluating the STEMI program. c. Intra-aortic balloon pump technician(s) d. Appropriate Cardiac catheterization nursing and support personnel e. Physician Consultants 1) Cardiology interventionalist 2) CV Surgeon f. Clinical Capabilities 1) Performance (timeliness) and outcome measures will be assessed initially in the EMS survey process and will be monitored closely on an ongoing basis. 11. The hospital shall have job descriptions and organizational structure clarifying the relationship between the STEMI medical director, STEMI program manager, and the STEMI team. 12. A STEMI Receiving Center without cardiac surgery capability on-site shall have a written transfer plan and agreements for transfer to a facility with cardiovascular surgery capability. III. QUALITY/PERFORMANCE IMPROVEMENT A. The County of Monterey County EMS Agency shall be responsible for ongoing performance evaluation and quality improvement of the STEMI critical care system. B. The SRC shall participate in the County of Monterey County EMS Agency quality improvement processes related to the STEMI critical care system. 1. Participation in the County of Monterey County EMS STEMI QI Committee as described in County of Monterey County EMS System Policy #1020, EMS Advisory Committees. 2. Meetings to be held on a quarterly basis initially. County of Monterey County EMS System Policy 5150 3. Written internal quality improvement plan/ program description for STEMI patients shall include appropriate evidence of an internal review process that includes: a. Death rate (within 30 days, related to procedure regardless of mechanism) b. Emergency CABG rate (result of procedure failure or complication) c. Vascular complications (access site, transfusion, or operative intervention required) d. Cerebrovascular accident rate (peri-procedure) e. Post-procedure nephrotoxicity (increase in serum creatinine of >0.5) f. Sentinel event, system and organization issue review and resolution processes. 4. Participation in Prehospital STEMI related educational activities IV. APPLICATION PROCESS A. A hospital requesting designation as a SRC shall apply to the County of Monterey County EMS Agency following the application process outlined in this policy. The application (see attached) shall be submitted at least three (3) months prior to the desired date of implementation. B. Submit applicable designation fees to cover initial and ongoing County of Monterey County EMS Agency costs to support the STEMI program. 1. STEMI Receiving Center Application Fee: Hospitals applying for STEMI Receiving Center designation will be assessed the STEMI Receiving Center Application Fee. This fee will cover the costs associated with the designation process. These costs may include contract costs for plan development, Requests for Proposal development, review of proposals, out of area site team costs, legal reviews, and agency costs in excess of the costs associated with the day-to-day STEMI system regulation. Fees paid that are in excess of actual costs will be returned to applicants. 2. STEMI Receiving Center Designation Fee: The County of Monterey County Board of Supervisors will establish an annual STEMI Receiving Center Designation Fee. This fee covers the cost of monitoring the operation of the STEMI System in compliance with State of California EMS Authority regulations and County of Monterey County EMS Agency policies and protocols. The fee will be based on the time requirements of the STEMI System Medical Director, STEMI System Coordinator, and other staff activity dedicated to STEMI issues as well as associated overhead and program support costs. 3. The County of Monterey County EMS Agency will provide the designated STEMI Receiving Center(s) written notice of any increase in the designated fee at least 180 days (6 months) prior to the effective date of the increase with an explanation for the increase and the basis on which it was calculated. County of Monterey County EMS System Policy 5150 V. DESIGNATION CRITERIA A. Hospitals wishing to be designated as a STEMI Receiving Center by the County of Monterey County EMS Agency shall meet the following requirements: 1. Current California licensure as an acute care facility providing Basic or Comprehensive Emergency Medical Services. 2. Obtain and maintain accreditation as a STEMI Receiving Center from the American Heart Association, Mission: Lifeline program or equivalent. 3. Establish transfer agreement(s) between the applicant SRC hospital and each STEMI Referral Hospital (SRH) in the County of Monterey County whereby applicant SRC agrees to immediately and rapidly accept the transfer of a STEMI patient from the transferring SRH upon notification of STEMI ALERT and request by the SRH-affiliated physician. 4. Submit the Application for STEMI Receiving Center Designation, the STEMI Center Designation Criteria Evaluation Tool, and all required supporting documentation to the EMS Agency. 5. Enter into and maintain a written STEMI Receiving Center agreement with the County of Monterey County EMS Agency that defines the roles and responsibilities of the STEMI Receiving Center and the EMS Agency relative to the care of STEMI patients. 6. Develop and maintain appropriate internal (hospital) policies addressing the following: a. Cardiac interventionalist activation with the on-call cardiologist immediately available. b. Cardiac catheterization team activation with team arrival within thirty minutes of activation. c. Activation of the cardiac interventionalist and catheterization team upon notice that a patient with STEMI is being transported to their facility. d. Contingency plans for personnel and equipment to include activation of a second cardiac interventionalist and catheterization lab team should this be needed. e. Coronary angiography. f. PCI and use of fibrinolytics. g. Interfacility transfer STEMI policies/protocols. h. Collection of data and a process for sharing requested data with the Monterey County EMS Agency and the STEMI QI Committee. 7. Initiate and maintain a hospital STEMI QI committee. 8. A needs assessment documenting the needs of the community for a designated STEMI Receiving Center. County of Monterey County EMS System Policy 5150 B. The County of Monterey County EMS Agency will designate a hospital as a STEMI Receiving Center if all of the requirements of this policy are met and if a needs assessment demonstrates a need for an additional STEMI Receiving Center. C. STEMI Receiving Center designation period will coincide with the period covered in the written agreement between the STEMI Receiving Center and the County of Monterey County EMS Agency. VI. REDESIGNATION A. A SRC may be redesignated following a satisfactory review in accordance with current standards and the terms of the written agreement. B. Redesignation of a SRC shall require submission of an Application for STEMI Receiving Center Designation, the STEMI Center Designation Criteria Evaluation Tool, and updated supporting documentation to the EMS Agency. C. The SRC must be current with the submission of all data required by the County of Monterey County EMS Agency and the State of California EMS Authority. D. SRCs shall respond in writing regarding program compliance. E. On-site SRC visits for redesignation shall occur every three years, in coordination with the terms of the STEMI Receiving Center agreement with the County of Monterey County EMS Agency. The SRC shall receive written notification of the site visit from the County of Monterey County EMS Agency. F. SRCs shall notify the County of Monterey County EMS Agency by telephone, followed by a letter or email within 48 hours, of changes in program compliance or performance. VII. DATA COLLECTION, SUBMISSION, AND ANALYSIS A. Participation in National Cardiac Data Registry (NCDR) and/or other EMS Agency approved or requested registry is required for initial and continued designation. B. Participation in County of Monterey County EMS Agency data collection is required for continued designation. Data shall be submitted to the County of Monterey County EMS Agency on a quarterly basis or as required by the EMS Agency C. STEMI Patient data elements shall include, but not be limited to those data elements described in California Code of Regulations, Division 9, Title 22 and as requested by the County of Monterey County EMS Agency. 1. D. STEMI QI COMMITTEE 1. The County of Monterey County EMS STEMI QI Committee is described in County of Monterey EMS System Policy 1020, EMS Advisory Committees, with required participation by County of Monterey County STEMI Receiving Centers. 2. The County of Monterey County EMS STEMI QI Committee will be responsible for a quality improvement process that shall include, but not be limited to: County of Monterey County EMS System Policy 5150 a. Evaluation of program structure, process, and outcome. b. Review of STEMI-related deaths, major complications, and transfers. c. Evaluation of regional integration of STEMI patient movement d. Compliance with the California Evidence Code, Section 1157.7 to ensure confidentiality, and a disclosure-protected review of selected STEMI cases. VIII. BASIS FOR LOSS OF DESIGNATION The County of Monterey County EMS Agency may suspend or revoke the approval of an SRC at any time for failure to comply with any applicable policies, procedures, or regulations, including failure to submit required data within the applicable timeframes. Grounds for loss of designation may include, but are not limited to: A. Inability to meet and maintain STEMI Receiving Center Designation Criteria B. Failure to provide required data and/or to participate in STEMI system QI activities C. Other criteria as defined and reviewed by the EMS Agency STEMI QI Committee END OF POLICY STEMI Center Designation Criteria Evaluation Tool APPLICATION FOR STEMI RECEIVING CENTER DESIGNATION Hospital:_____________________________________________________________________________ Contact: _________________________________ Phone #: ____________________________________ Title: ____________________________________ E-Mail: _____________________________________ Administration/ Staffing A. Medical Director (attach resume) Name: ____________________________ Title: ________________ E-mail: _______________________ Phone #: ___________________ B. STEMI Program Manager (attach resume) Name: _________________________________________ Title: ________________ E-mail: _______________________ Phone #: ___________________ C. Cardiac Catheterization Lab Contact (if different from STEMI Program Manager) (attach resume) Name: _________________________________________________________________________ Title: _________________ E-mail: ________________________ Phone #: __________________ STEMI Receiving Center Requirements: A. Is your hospital licensed by the California Department of Health Services and accredited by a Heart Attack Receiving Center from Yes □ No □ the American Heart Association, Mission: Lifeline program or as a Chest Pain Center by the Society of Cardiovascular Patient Care? (Provide copy of current accreditation documentation) B. Is your hospital approved for Emergency Percutaneous Coronary Yes □ No □ Interventions (PCI)? C. Number of PCIs per year:___________________ (PCI will be defined as a therapeutic coronary intervention such as angioplasty, Stent placement, etc. Total personally performed therapeutic PCIs per year at all institutions, not just this hospital. This would include any PCI as defined above and not restricted to acute myocardial infarction.) STEMI Center Designation Criteria Evaluation Tool D. Is there a cardiovascular surgical call panel? Yes □ No □ (Provide copies of Interventional Cardiologists daily roster On-Call Schedules [primary and backup] and proof that physicians will be immediately available upon notification.) E. Do you have a Cath Lab team available or on call 24/7/365? Yes □ No □ (Provide copies of Cath Lab Team daily roster On-Call schedules [primary and backup] and proof that team will be immediately available upon notification.) F. Does your hospital meet all requirements of the current County of Monterey Yes □ No □ County EMS System Agency pPolicy #5150 – STEMI Receiving Centers? G. Does your hospital have a special permit for cardiovascular surgery? Yes □ No □ H. Number of cardiovascular surgeries per year: ________ I. Cardiovascular surgeon? Yes □ No □ J. Is there a dedicated recorded phone line, capable of being answered Yes □ No □ 24/7/365 for paramedic notification of STEMI patients? Policies: G. Is there currently a hospital policy for the treatment of myocardial Yes □ No □ infarction that define who shall receive emergent angiography and who shall receive emergent fibrinolysis? H. Does the policy include diversion of STEMI patients only during times Yes □ No □ of Internal Disaster? (Please attach) I. Is there currently a hospital policy regarding prompt acceptance of Yes □ No □ STEMI patients from other STEMI Referral Hospitals that do not have Emergency PCI capability? J. Is there currently a hospital policy for activation of the Cardiac Yes □ No □ Catheterization team when notified of an EMS transported STEMI? (Please attach) K. Does the hospital provide continuing education opportunities for EMS Yes □ No □ personnel in areas of 12-lead ECG acquisition and interpretation, as well as assessment and management of STEMI patients? (Provide documentation showing educational presentations) STEMI Center Designation Criteria Evaluation Tool Data: L. Does your hospital participate in the County of Monterey County STEMI data Yes □ No □ collection? M. Do you have a formal quality improvement process to review STEMI-related Yes □ No □ deaths, major complications, and performance standards? N. Does your facility meet the primary door-to-balloon time of 90 minutes or Yes □ No □ less 90% of the time? O. Is a process in place to provide the required data to the County of Monterey County Yes □ No □ EMS Agency on no less than a quarterly basis? ______________________________________________________________________________ On behalf of the above-named hospital and physicians, I agree to all provisions identified in County of Monterey EMS SystemCounty pPolicy #5150 – STEMI Receiving Centers. __________________________________________________ ______________________ Signature – Administrator Date __________________________________________________ Print Name Please contact the County of Monterey County EMS Agency at [email protected] [email protected] prior to submission of the application for initial or continued designation. Request contact with the STEMI program staff member for the purpose of submission of a STEMI Receiving Center application for designation or continued designation. STEMI Center Designation Criteria Evaluation Tool STEMI Designation Standard Objective Measurement Meets Comments Standard Current License to provide Copy of License Yes Basic Emergency Services in Monterey County No Current copy of Joint Copy of Certification Yes Commission, HFAP or DN Certification No Cardiac catheterization lab On-call schedules for three (3) Yes available 24/7/365 months On-call policy and procedures No documented Intra-aortic balloon pump Staffing policies demonstrate Yes capability with staffing support of operations available 24/7/365 Intra-aortic balloon pump No capability for # of patients: ___ Dedicated telephone line for Operational dedicated base Yes base hospital contact by hospital telephone line. paramedics Telephone number: No _______________________ Notification of cardiologist Copy of policy for notification Yes and staff of a STEMI alert of cath lab team and cardiologist No Interfacility transfer Copy of transfer agreements to Yes agreements with Monterey allow automatic acceptance of County hospitals that are not all STMEI patients transferred No designated as STEMI from Monterey County Receiving Centers hospitals Cardiovascular surgical California permit number Yes services available 24/7/365 No Accept all patients identified Copy of policy Yes as STEMI by EMS personnel No STEMI Team activation by ED Copy of policy Yes physician upon notice of STMEI patient by EMS No personnel Contingency plans for more Copy of contingency Yes than one STEMI patient at plans/policies the same time No STEMI Center Designation Criteria Evaluation Tool STEMI Center Designation Criteria Evaluation Tool HOSPITAL PERSONNEL STEMI Receiving Center Program Medical Director: Yes 1. Board Certified in Cardiovascular Disease Copy of Board Certification in 2. Board Certified in Cardiovascular Disease Interventional Cardiology Copy of Board Certification in 3. Credentialed Interventional Cardiology No member of medical staff with privileges for Primary PCI 4. Trained in cardiac radiographic imaging Documentation of training in and radiation radiographic imaging and protection radiation protection 5. Job description Copy of job description 6. Participates in Documentation of Monterey Monterey County County STEMI QI program STEMI activities participation STEMI Receiving Center Program Manager: Yes 1. Current RN License Copy of current RN license or documentation of same 2. STEMI program Documentation of STEMI No experience program experience 3. Participates in Documentation of Monterey Monterey County County STEMI QI program STEMI activities participation Cardiac Cath Lab Manager Job description Yes No Cardiology Interventionalist Copy of On-call schedule for 3 Yes months No Cardiothoracic Surgery Current Board Certification Yes On-call policy No STEMI Center Designation Criteria Evaluation Tool CLINICAL CAPABILITIES Process performance 3 months of data documenting Yes door to device time in less than 90 minutes for 90% of STEMI No patients Cath Lab and Copy of policy for STEMI Yes Interventionalist activation activation No Policy identifying criteria for Copy of policy Yes patients to receive emergent angiography or emergent No fibrinolysis based on physician decision for individual patients PERFORMANCE IMPROVEMENT Program Review Copy of policy for QI review of: Yes • Deaths • Complications No • Sentinel events • System issues • Organizational issues Written QI plan Yes No EMS QI program participation Written agreement to Yes participate in EMS STEMI QI program No Data submission to the EMS Written agreement to submit Yes Agency EMS Agency required data on a regular basis to be determined No by the EMS Agency STEMI Registry Data submitted to a STEMI Yes Registry approved by the EMS Agency No EMS Education Copy of EMS educational Yes activities over the previous 3 months No STEMI Center Designation Criteria Evaluation Tool ADMINISTRATION Application submitted to the Date application received by Yes Date of application County of Monterey County the County of Monterey receipt by the County EMS Agency County EMS Agency No of Monterey County EMS Agency: ____________ Written agreement with the Date agreement received by Yes Date agreement County of Monterey County the County of Monterey signed by both EMS Agency County EMS Agency No hospital and the County of Monterey County EMS Agency: ______________ County of Monterey County EMS System Policy Policy Number: 5190 Effective Date: 7/1/2023 Review Date: 6/30/2026 STROKE CENTERS I. PURPOSE To define requirements for designation as a Stroke Center in the County of Monterey County. II. POLICY A. Hospitals requesting designation as a Primary Stroke Center by the County of Monterey County EMS Agency shall meet the following minimum criteria: 1. Adequate staff, equipment, and training to perform rapid evaluation, triage, and treatment for the stroke patient in the emergency department. 2. Standardized stroke care protocol/order set. 3. Stroke diagnosis and treatment capacity twenty-four (24) hours per day, seven (7) days per week, three hundred and sixty-five (365) days per year. 4. Data-driven, continuous quality improvement process including collection and monitoring of standardized performance measures. 5. Continuing education in stroke care provided for staff physicians, staff nurses, staff allied health personnel, and EMS personnel. 6. Public education on stroke and illness prevention. 7. A clinical stroke team, available to see in person or via telehealth, a patient identified as a potential acute stroke patient within 15 minutes following the patient’s arrival at the hospital’s emergency department or within 15 minutes following a diagnosis of a patient’s potential acute stroke. a. At a minimum, a clinical stroke team shall consist of: 1) A neurologist, neurosurgeon, interventional neuro-radiologist, or emergency physician who is board certified or board eligible in neurology, neurosurgery, endovascular neurosurgical radiology, or other board-certified physician with sufficient experience and expertise in managing patients with acute cerebral vascular disease as determined by the hospital credentials committee. 2) A registered nurse, physician assistant, or nurse practitioner capable of caring for acute stroke patients that has been designated by the hospital who may serve as a stroke program manager. 8. Written policies and procedures for stroke services which shall include written protocols and standardized orders for the emergency care of stroke patients. These policies and procedures shall be reviewed at least every three (3) years, revised as needed, and implemented. County of Monterey County EMS System Policy 5190 9. Data-driven continuous quality improvement process including collection and monitoring of standardized performance measures. 10. Neuro-imaging services capability that is available twenty-four (24) hours per day, seven (7) days per week, three hundred and sixty-five (365) days per year, such that imaging shall be initiated within twenty-five (25) minutes following emergency department arrival. 11. CT scanning or equivalent neuroimaging shall be initiated within twenty-five (25) minutes following emergency department arrival. 12. Other imaging shall be available within a clinically appropriate timeframe and shall at a minimum include: a. MRI b. CTA and/or Magnetic resonance angiography (MRA) c. TEE or TTE 13. Interpretation of imaging: a. If teleradiology is used in image interpretation, all staffing and staff qualification requirements contained in this section shall remain in effect and shall be documented by the hospital. b. Neuro-imaging studies shall be reviewed by a physician with appropriate expertise, such as board-certified radiologist, board-certified neurologist, board-certified neurosurgeon, or residents who interpret such studies as part of their training in ACGME-approved radiology, neurology, or neurosurgery training program within forty-five (45) minutes of emergency department arrival. 1) For the purpose of this subsection, a qualified radiologist shall be board certified by the American Board of Radiology or the American Osteopathic Board of Radiology. 2) For the purpose of this subsection, a qualified neurologist shall be board certified by the American Board of Psychiatry and Neurology or the American Osteopathic Board of Neurology and Psychiatry. 3) For the purpose of this subsection, a qualified neurosurgeon shall be board certified by the American Board of Neurological Surgery. 14. Laboratory services capability that is available twenty-four (24) hours per day, seven (7) days per week, three hundred and sixty-five (365) days per year, such that services may be performed within forty-five (45) minutes following emergency department arrival 15. Neurosurgical services shall be available, including operating room availability, either directly or under an agreement with a thrombectomy-capable, comprehensive or other stroke center with neurosurgical services, within two (2) hours following the arrival of acute stroke patients to the primary stroke center. County of Monterey County EMS System Policy 5190 16. Acute care rehabilitation services. 17. Transfer arrangements with one or more higher level of care centers when clinically warranted or for neurosurgical emergencies. 18. There shall be a stroke medical director of a primary stroke center, who may also serve as a physician member of a stroke team, who is board-certified in neurology or neurosurgery or another board-certified physician with sufficient experience and expertise dealing with cerebral vascular disease as determined by the hospital credential committee. B. Hospitals requesting designation as a thrombectomy-capable stroke center by the County of Monterey County EMS Agency shall meet the following minimum criteria: 1. Satisfy all the requirements of a primary stroke center as provided in Section II A. 2. The ability to perform mechanical thrombectomy for the treatment of ischemic stroke twenty-four (24) hours per day, seven (7) days per week, three hundred and sixty-five (365) days per year. 3. Dedicated neuro-intensive care unit beds to care for acute ischemic stroke patients twenty-four (24) hours per day, seven (7) days per week, three hundred and sixty- five (365) days per year. 4. Satisfy all the following staff qualifications: a. A qualified physician, board certified by the American Board of Radiology, American Osteopathic Board of Radiology, American Board of Psychiatry and Neurology, or the American Osteopathic Board of Neurology and Psychiatry, with neuro-interventional angiographic training and skills on staff as deemed by the hospital’s credentialing committee. b. A qualified neuro-radiologist, board-certified by the American Board of Radiology or the American Osteopathic Board of Radiology. c. A qualified vascular neurologist, board-certified by the American Board of Psychiatry and Neurology or the American Osteopathic Board of Neurology and Psychiatry, or with the appropriate education and experience as defined by the hospital credentialing committee. d. If teleradiology is used in image interpretation, all staffing and staff qualification requirements contained in this section shall remain in effect and shall be documented by the hospital. e. The ability to perform advanced imaging twenty-four (24) hours per day, seven (7) days per week, three hundred and sixty-five (365) days per year, which shall include, but not be limited to, the following: 1) Computed tomography angiography (CTA) 2) Diffusion-weighted MRI or CT Perfusion 3) Catheter angiography 4) Magnetic resonance angiography (MRA) County of Monterey County EMS System Policy 5190 5) And the following modalities available when clinically necessary: a) Transesophageal echocardiography (TEE) b) Transthoracic echocardiography (TTE) 5. A process to collect and review data regarding adverse patient outcomes following mechanical thrombectomy. 6. Written transfer agreement(s) with at least one comprehensive stroke center. C. Hospitals requesting designation as an acute stroke ready center by the County of Monterey County EMS Agency shall meet the following minimum criteria: 1. A clinical stroke team available to see in person or via telehealth a patient identified as a potential acute stroke patient within twenty (20) minutes following the patient’s arrival at the hospital’s emergency department. 2. Written policies and procedures for emergency department stroke services that are reviewed, revised as needed, and implemented at least every three (3) years. 3. Emergency department policies and procedures that include written protocols and standardized orders for the emergency care of stroke patients. 4. Data-driven continuous quality improvement process including collection and monitoring of standardized performance measures. 5. Neuro-imaging services capability that is available twenty-four (24) hours per day, seven (7) days per week, three hundred and sixty-five (365) days per year, such that imaging shall be performed and reviewed by a physician within forty- five (45) minutes following emergency department arrival. 6. Neuro-imaging services shall, at a minimum, include CT or MRI or both. 7. Imaging interpretation: a. If teleradiology is used in image interpretation, all staffing and staff qualification requirements contained in this section shall remain in effect and shall be documented by the hospital. b. Neuro-imaging studies shall be reviewed by a physician with appropriate expertise, such as a board-certified radiologist, board-certified neurologist, a board-certified neurosurgeon, or residents who interpret such studies as part of their training in ACGME-approved radiology, neurology, or neurosurgery training program within forty-five (45) minutes of emergency department arrival. 1) For the purpose of this subsection, a qualified radiologist shall be board-certified by the American Board of Radiology or the American Osteopathic Board of Radiology. 2) For the purpose of this subsection, a qualified neurologist shall be board-certified by the American Board of Psychiatry and Neurology or the American Osteopathic Board of Neurology and Psychiatry. County of Monterey County EMS System Policy 5190 3) For the purpose of this subsection, a qualified neurosurgeon shall be board-certified by the American Board of Neurological Surgery. 8. Laboratory services shall, at a minimum, include blood testing, electrocardiography and x-ray services, and be available twenty-four (24) hours per day, seven (7) days per week, three hundred and sixty-five (365) days per year, and able to be completed and reviewed by physician within sixty (60) minutes following emergency department arrival. 9. Neurosurgical services shall be available, including operating room availability, either directly or under an agreement with a thrombectomy-capable, primary or comprehensive stroke center, within three (3) hours following the arrival of acute stroke patients to an acute stroke-ready hospital. 10. Provide IV thrombolytic treatment and have transfer arrangements with one or more thrombectomy-capable, primary or comprehensive stroke center(s) that facilitate the transfer of patients with strokes to a stroke center for care when clinically warranted. 11. There shall be a medical director of an acute stroke-ready hospital, who may also serve as a member of a stroke team, who is a physician or advanced practice nurse who maintains at least four (4) hours per year of educational time in cerebrovascular disease. 12. The clinical stroke team for an acute stroke-ready hospital at a minimum shall consist of a nurse and a physician with training and expertise in acute stroke care. D. EMS receiving hospitals that are not designated to provide stroke critical care services shall work cooperatively with stroke receiving centers and the Monterey County EMS Agency to do the following, at a minimum: 1. Participate in the County of Monterey County EMS Agency’s quality improvement system, including data submission as determined by the County of Monterey County EMS Agency medical director. 2. Participate in interfacility transfer agreements to ensure access to the stroke critical care system for potential stroke patients. III. APPLICATION PROCESS A. To apply for designation as a Stroke Center in County of Monterey County, an interested hospital shall: 1. Submit an application packet that contains all of the required documentation outlined in the Stroke Center application checklist. The application (see attached) shall be submitted at least three (3) months prior to the desired date of implementation. 2. Submit the applicable designation fees to cover initial and ongoing County of Monterey County EMS Agency costs to support the stroke program. County of Monterey County EMS System Policy 5190 a. Stroke Center Application Fee: A stroke center application fee will be established. This fee will cover the costs associated with the designation process. These costs may include contract costs for plan development, Requests for Proposal development, review of proposals, out of area site team costs, legal reviews and agency costs in excess of the costs associated with the day-to-day stroke system regulation. The stroke center application fee will be assessed for hospitals applying for stroke center designation. Fees paid in excess of actual costs will be returned to applicants. b. Stroke Center Designation Fee: The County of Monterey County Board of Supervisors will establish an annual Stroke Center Designation Fee. This fee covers the cost of monitoring the operation of the stroke system in compliance with State of California EMS Authority regulations and County of Monterey County EMS Agency policies and protocols. The fee will be based on the time requirements of the stroke system medical director, stroke system coordinator, and other staff activity dedicated to stroke issues as well as associated overhead and program support costs. c. The County of Monterey County EMS Agency will provide the designated stroke center(s) written notice of any increase in the designated fee at least 180 days (6 months) prior to the effective date of the increase with an explanation for the increase and the basis on which it was calculated. 3. Develop transfer agreements with other County of Monterey County hospitals to accept any stroke patients from those facilities. A copy of these agreements shall be included in the application packet. IV. DESIGNATION CRITERIA A. Hospitals wishing to be designated as a Stroke Receiving Center (Acute Stroke Ready Hospital, Primary Stroke Center, Thrombectomy-Capable Stroke Center or Comprehensive Stroke Center) in the County of Monterey County shall meet the following requirements: 1. Current California licensure as an acute care facility providing Basic or Comprehensive Emergency Medical Services. 2. Submit the Stroke Center Designation Application, the Stroke Center Designation Criteria Evaluation Tool, and all required supporting documentation to the EMS Agency. 3. Enter into and maintain a written Stroke Center agreement with the County of Monterey County EMS Agency that defines the roles and responsibilities of the hospital and the EMS Agency relative to the care of stroke patients. 4. Receive and maintain current certification as an Acute Stroke Ready Hospital, a Primary Stroke Center, a Comprehensive Stroke Center, or a Thrombectomy County of Monterey County EMS System Policy 5190 Capable Stroke Center by the Joint Commission, the Healthcare Facilities Accreditation Program (HFAP), or Det Norske Veritas Healthcare, Inc (DNV). 5. Develop and maintain appropriate internal (hospital) policies addressing the following: a. Designation of the Stroke Center Medical Director and the Stroke Center Nurse Program Manager. b. Staff and physician coverage. The policy shall includeing availability requirements for timely staff and physician response upon notification or arrival of a stroke patient to the emergency department c. Interfacility transfer policies, protocols, and agreements. d. Collection of data and a process for sharing required data with the Monterey County EMS Agency and the Stroke QI Committee e. Active and regular participation in the County of Monterey County EMS Stroke QI activities including the County of Monterey County EMS Agency Stroke QI Committee. 6. Initiate and maintain a hospital Stroke QI Committee. 6.7. For Primary and Comprehensive Stroke Center applications, a needs assessment documenting the needs of the community for a designated Stroke Center at the requested level. 7.8.Participate in the California Stroke Registry. B. For Stroke Ready applications, Stroke center designation will be provided to a hospital following satisfactory review of written documentation and initial site survey by the County of Monterey County EMS Agency staff and receipt of stroke center fees by the County of Monterey County EMS Agency. B.C. For Primary and Comprehensive Stroke Center applications, the County of Monterey EMS Agency will designate a hospital at the requested level if all of the requirements of this policy are met and if a needs assessment demonstrates a need for an additional Stroke Receiving Center. C.D. The stroke center designation period will coincide with the period covered in the written agreement between the Stroke Receiving Center and the County of Monterey County EMS Agency. V. REDESIGNATION CRITERIA A. A stroke center may be redesignated following a satisfactory review of written documentation and a site survey. County of Monterey County EMS System Policy 5190 B. Redesignation of a stroke center shall require submission of a Stroke Center Designation Application, the Stroke Center Designation Criteria Evaluation Tool, and updated supporting documentation to the EMS Agency. C. On-site stroke center surveys for redesignation shall occur every three years in coordination with the terms of the Stroke Center agreement with the County of Monterey County EMS Agency. D. Stroke centers must be current with the submission of all data required by the County of Monterey County EMS Agency and the State of California EMS Authority. VI. QUALITY/PERFORMANCE IMPROVEMENT A. The County of Monterey County EMS Agency shall be responsible for ongoing performance evaluation and quality improvement of the stroke critical care system. B. Stroke centers shall participate in the County of Monterey County EMS Agency quality improvement processes related to the stroke critical care program. C. Stroke centers shall participate in the Stroke QI Committee, as described in County of Monterey County EMS System Policy #1020 EMS Advisory Committees, with attendance at not less than 80% of the meetings. D. Participation in the County of Monterey EMS Agency-designated data collection system is required for continued designation. Data shall be submitted to the County of Monterey EMS Agency on a quarterly basis or as required by the EMS Agency. D.E. A stroke center shall develop a written internal quality improvement plan/program description for stroke patients. 1. The plan will include a Community Stroke Reduction Plan including participation in outreach programs to reduce cardiovascular disease and stroke. E.F. Stroke centers shall provide continuing education to EMS personnel, the clinical stroke team, and related hospital staff. F.G. The Monterey County EMS Agency Stroke Critical Care System shall have a quality improvement process that shall include, at a minimum: 1. Evaluation of program structure, process, and outcome 2. Review of stroke-related deaths, major complications, and transfers. 3. A multidisciplinary Stroke Quality Improvement Committee, including both prehospital and hospital members. 4. Participation in the QI process by all designated stroke centers and prehospital providers involved in the stroke critical care system. 5. Evaluation of regional integration of stroke patient movement. 6. Participation in the stroke data management system. County of Monterey County EMS System Policy 5190 7. Compliance with the California Evidence Code, Section 1157.7 to ensure confidentiality, and a disclosure- protected review of selected stroke cases. VII. BASIS FOR LOSS OF DESIGNATION The County of Monterey EMS Agency may suspend or revoke the approval of a Stroke Receiving Center at any time for failure to comply with any applicable policies, procedures, or regulations, including failure to submit required data within the applicable timeframes. Grounds for loss of designation may include, but are not limited to: A. Inability to meet and maintain Stroke Receiving Center Designation Criteria. B. Failure to provide required data and/or to participate in Stroke system QI activities. C. Other criteria as defined and reviewed by the EMS Agency Stroke QI Committee. END OF POLICY Nationally Accredited for Providing Quality Health Services Application for Stroke Center Designation Hospital: ____________________________________________________________________________________ Contact: __________________________________________ Phone #: ___________________________________ Title: ____________________________________________ E-Mail: _____________________________________ Stroke Center Designation Level Requested (Comprehensive, Primary, Stroke Ready): _____________________ • Is your hospital licensed by the California Department of Health Services and accredited by a CMS-approved accrediting body as Yes □ No □ a Primary or Comprehensive Stroke Center? • Does your hospital have a special permit for Neurosurgical Services? (Not required for designation as an Acute Stroke Yes □ No □ Ready Hospital or a Primary Stroke Center) Administration/Staffing A. Stroke Center Medical Director (attach resume) Name of Proposed Stroke Center Medical Director: __________________________________________ Title: ____________________________ Phone: ________________________ Email: __________________________________________________________ o Board Certified in: Emergency Medicine □ Neurology □ Other: ____________ □ B. Stroke Center Coordinator/Program Manager (attach resume) Name of proposed Stroke Center Coordinator: _____________________________________________ Title: _____________________________ Phone #: _______________________ Email: ___________________________________________________________ C. Stroke Center administrative contact Name: ______________________________________________________________________________ Title: ____________________________ Phone #: _________________________ Email: ____________________________________________________________ • Do you use tele-neurology? Yes □ No □ o If yes, please include a copy of the contract with the tele-neurology service including timeframes for examination of Stroke/ TIA patients. • Do you use tele-radiology for interpretation of radiological studies? Yes □ No □ o If yes, please include a copy of the agreement with teleradiology service including timeframes for reading and interpreting radiological studies for Stroke/ TIA patients. • Do you have a dedicated and audio recorded phone line, capable of being Yes □ No □ answered 24 hours per day, seven days per week, for paramedic notification of Stroke/ TIA patients? Policies: • Does your organization have policies on the treatment of Stroke patients that define Yes □ No □ who shall receive emergent tPA or other IV thrombolytic medication? (Please attach) • Does your organization have a policy on the treatment of Stroke that includes Yes □ No □ emphasis on rapid treatment? (Please attach) • Does your organization have data and quality improvement policies that meet the Yes □ No □ requirements in the County of Monterey EMS System Policy #5190County (Stroke Centers) policy? (Please attach) Data: • Does your organization agree to participate in the California Stroke Registry/California Yes □ No □ Coverdell Program? • Does your organization agree to report data on stroke patients, including outcome Yes □ No □ data, to the EMS Agency every quarter? • Please attach the previous 6 months’ worth of the following data for your organization: o Total number of Stroke patients that were seen and treated at hour hospital. ______ o Total number of Stroke patients that were transferred from an acute care hospital ______ to your facility for definitive care. o Total number of Stroke patients who met criteria for receiving IV thrombolytics. ______ o Total number of Stroke patients who met criteria for receiving IV thrombolytics ______ who refused the therapy. o Total number of Stroke patients who received IV thrombolytics. ______ o Total number of Stroke patients who were discharged alive. ______ o Total number of Stroke patients who were discharged to a rehabilitation ______ facility. o Total number of Stroke patients who were discharged home alive ______ Completed by (please print): _______________________________________________ Date: _________________________ Signature: _____________________________________________________________________________________________ Please contact the County of Monterey County EMS Agency at [email protected] [email protected] prior to submission of the application for initial or continued designation. Request contact with the Stroke program staff member for the purpose of submission of a Stroke Receiving Center application for designation or continued designation. List of neurologists/neurointerventionalists/interventional radiologists proposed for call for Stroke/TIA patients Physician Name At which hospitals does the physician Number of Stroke/TIA have privileges? Pts/year __________________________ _________________________________ _______________________ __________________________ _________________________________ _______________________ __________________________ _________________________________ _______________________ __________________________ _________________________________ _______________________ __________________________ _________________________________ _______________________ __________________________ _________________________________ _______________________ __________________________ _________________________________ _______________________ __________________________ _________________________________ _______________________ __________________________ _________________________________ _______________________ __________________________ __________________________________ _______________________ __________________________ __________________________________ _______________________ __________________________ __________________________________ _______________________ __________________________ __________________________________ _______________________ __________________________ __________________________________ _______________________ __________________________ __________________________________ _______________________ __________________________ __________________________________ _______________________ __________________________ __________________________________ _______________________ __________________________ __________________________________ _______________________ __________________________ __________________________________ _______________________ __________________________ ___________________________________ _______________________ ACUTE STROKE READY HOSPITAL DESIGNATION CRITERIA EVALUATION TOOL Stroke Designation Standard Objective Measurement Meets Comments Standard Current License to provide Copy of License Yes Basic Emergency Services in Monterey County No Current copy of Joint Copy of Certification Yes Commission, HFAP or DNV Certification No An acute Stroke team On-call schedules for 3 months. May use telehealth available within 20 minutes On-call policy and procedure. Yes for this requirement of patient’s arrival in ED Emergency Department protocol for initial screening and treatment of suspected stroke No patients. Written policies and Copy of policies, procedures Yes Include protocols procedures for Stroke and standardized services No orders and order sets Data-driven, CQI process 3 months’ worth of CQI data Yes including collection and Data showing identification of monitoring of standardized areas in need of improvement No performance measures and how the issue was dealt with. Data reporting mechanism Copy of agreement with Yes AHA Get With The AHA/ASA Get With The Guidelines - Stroke Guidelines – Stroke No Neuro-imaging capability Policies/protocols supporting Yes CT and/or MRI 24/7/365 operations No One of the following: Copy of appropriate board If using • Qualified Radiologist certification Yes telemedicine, • Qualified Neurologist hospital must • Qualified Neurosurgeon On-call schedules for 3 months document this No standard Laboratory services 24/7/365 Copy of Yes Blood testing, ECG, policies/procedures/protocols and x-ray services for lab services No Provide IV thrombolytic Copy of Yes treatment to qualified policies/procedures/protocols patients for administration of tPA No ACUTE STROKE READY HOSPITAL DESIGNATION CRITERIA EVALUATION TOOL Stroke Designation Standard Objective Measurement Meets Comments Standard Medical Director: Copy of CE units for previous 2 Yes • Physician years • Advanced practice nurse No Both must maintain at least 4 hours per year of educational time in cerebrovascular disease If no neurosurgical services Supporting policies, procedures Yes Required if no available: Plan to transfer and agreements neurosurgery within 2 hours No In-patient acute care Policies/procedures for Yes rehabilitation inpatient rehabilitation Agreement with other inpatient No acute rehabilitation Designated telephone Actual number on file Yes number for prehospital No Written transfer guidelines Transfer policies/procedures Yes for higher level of service Copy of agreement No Continuing Education Copy of approval letter with CE Yes Provider provider number No Stroke contingency plans Pertinent policy and procedures Yes Expectation of no • Personnel to minimize disruption advisory status • Imaging equipment No except for internal • Bed capacity disaster STAFFING Acute Stroke Care team: One of the following: Copy of appropriate board Board certified or • Neurologist certification Yes board eligible in • Neurosurgeon neurology, • Interventional On-call schedule for 3 months neurosurgery, neuroradiologist No endovascular • Emergency Physician Copy of job description neurosurgical radiology, with experience and expertise in dealing with cerebral vascular disease One of the following: Copy of license Yes Demonstrated • Registered Nurse competency in caring • Physician assistant Copy of job description No for acute stroke • Nurse practitioner patients PRIMARY STROKE CENTER DESIGNATION CRITERIA EVALUATION TOOL Stroke Designation Standard Objective Measurement Meets Comments Standard Hospital must meet all requirements of an Acute Stroke Ready Hospital plus: An acute Stroke team On-call schedules for 3 months. available within 15 minutes On-call policy and procedure. Yes Emergency Department protocol for initial screening and No treatment of suspected stroke patients. Immediate, telemetry or Immediate: __________ Yes critical care beds Telemetry: __________ Number of beds Critical Care: _________ No Neurosurgical services Number of operating rooms on Yes May be under including operating room license: __________ agreement with Copy of agreement(s) with other No another Stroke Stroke Centers Center If no neurosurgical services Supporting policies, procedures Yes Required if no available: Plan to transfer and agreements neurosurgery within 2 hours No Inpatient acute care Policies/procedures for Yes May contract with rehabilitation inpatient rehabilitation other acute inpatient Agreement with other inpatient No rehabilitation acute rehabilitation provider Designated telephone Actual number on file Yes number for prehospital personnel to contact ED No Written transfer guidelines Transfer policies/procedures Yes for higher level of service Copy of agreement No Monterey County designated Copy of approval letter with CE Yes Continuing Education provider number Provider No Stroke contingency plans Pertinent policy and procedures Yes Expectation of no • Personnel to minimize disruption advisory status • Imaging equipment No except for internal Bed capacity disaster STAFFING Acute Stroke Care Team PRIMARY STROKE CENTER DESIGNATION CRITERIA EVALUATION TOOL Stroke Designation Standard Objective Measurement Meets Comments Standard One of the following: Copy of appropriate board Board certified or • Neurologist certification Yes board eligible in • Neurosurgeon neurology, • Interventional On-call schedule for 3 months neurosurgery, neuroradiologist No endovascular Emergency Physician Copy of job description neurosurgical radiology, with experience and expertise in dealing with cerebral vascular disease One of the following: Copy of license Yes Demonstrated • Registered Nurse competency in caring • Physician assistant Copy of job description No for acute stroke Nurse practitioner patients THROMBECTOMY-CAPABLE STROKE CENTER DESIGNATION CRITERIA EVALUATION TOOL Stroke Designation Standard Objective Measurement Meets Comments Standard Meets all requirements of Yes Primary Stroke Center plus: No Ability to perform mechanical Copy of on-call schedules for Yes thrombectomy for the interventionalists treatment of ischemic stroke No 24/7/365 Staffing: Must have all the following staff qualifications: A qualified physician, board Copy of interventionalist CV certified by the American Yes Board of Radiology, American Osteopathic Board of No Radiology, American Board of Psychiatry and Neurology or the American Osteopathic Board of Neurology and Psychiatry, with neuro- interventional angiographic training and skills on staff A qualified neuro-radiologist, Copy of radiologist CV Yes board-certified by the American Board of Radiology No or the American Osteopathic Board of Radiology A qualified vascular Copy of CV neurologist, board certified Yes by the American Board of Psychiatry and Neurology or the American Osteopathic No Board of Neurology and Psychiatry, or with appropriate education and experience as defined by the hospital credentials committee If teleradiology is used in Yes image interpretation, all staffing and staff No qualifications shall remain in effect and shall be documented by the hospital The ability to perform advanced imaging 24/7/365, Yes THROMBECTOMY-CAPABLE STROKE CENTER DESIGNATION CRITERIA EVALUATION TOOL Stroke Designation Standard Objective Measurement Meets Comments Standard to include but not be limited On-call schedules for the last 3 to: months • CTA No • Diffusion-weighted MRI or CT Perfusion • MRA • Catheter angiography The following modalities must be available when Demonstrated on site survey Yes clinically necessary: • Carotid duplex No ultrasound • TEE • TTE A process to collect and Written Yes review data regarding policies/protocols/procedures/ adverse patient outcomes plans No following mechanical thrombectomy Monterey CountyCounty of Monterey EMS System Policy Policy Number: 6030 Effective Date: 7/01/20263 Review Date: 6/30/20296 EMERGENCY MEDICAL DISPATCH PROVIDER QUALITY IMPROVEMENT I. PURPOSE To establish and define the Quality Improvement (QI) aspect of Emergency Medical Dispatch (EMD). II. POLICY A. A Monterey CountyCounty of Monterey authorized EMDmergency Medical Dispatch provider shall have a QI plan that at a minimum includes: 1. System Monitoring. 2. Specific Call Review. 3. Call Review Documentation. 4. Call Audit Procedure. 5. Integration into the EMS system QI program. B. System Monitoring 1. All calls received for EMD will be recorded and maintained for a minimum of 100 days, as required by California Government Code Section 34090.6. 2. All EMD reports submitted to the EMS Agency shall include at a minimum the following for each call: a. Time of call to include all primary and secondary public safety answering points (PSAPs) time of call entry and acknowledgement of call by primary and secondary PSAP. b. Time of ambulance dispatch c. Time of ambulance en route to call d. Time of ambulance on scene of incident e. Time treatment instructions initiated, if applicable f. Time treatment instructions completed, if applicable. C. Specific Call Review 1. The EMD provider will submit the following items in a monthly report to the Monterey CountyCounty of Monterey EMS Agency: Monterey CountyCounty of Monterey EMS System Policy 6030 a. The designated Emergency Medical Dispatch Quality Assurance Coordinator (EMD-Q) will review 100% of all choking, CPR, and childbirth calls received in the designated dispatch center for EMD. b. The designated EMD-Q will review 100 calls or 3% of all other calls, whichever is greater, received in the designated dispatch center for EMD. Calls reviewed will be randomly selected to include calls from all shifts and all dispatchers. c. Periodic sSpecific subject audits as determined by the EMS Agency and/or the designated EMD-Q such as, but not limited to:. 1) Review requested by an EMS or EMD provider, or the Monterey CountyCounty of Monterey EMS Agency. 2) Medical Priority Dispatch (MPDS) instructions given to caller 3) Code 2 dispatch that returns Code – 3 to the hospital. 4) Level of dispatch upgraded after initial dispatch, e.g., Code – 2 to Code – 3 5) Hazmat or disaster plans utilized D. Call Review Documentation: A list of situations, actions, or deviations from MPDS protocol that the designated EMD-Q questioned , along with the response from the dispatcher and the action taken are to be documented and reported to the EMS Agency. E. Call Audit Procedure: The EMD-Q shall utilize the International Academies of Emergency Dispatch (IAED) Performance Standards to review and audit calls. F. Confidentiality: All dispatch documentation, recordings, and QI evaluations are subject to review by the Monterey CountyCounty of Monterey EMS Agency. All proceedings, documents, and discussions on EMD QI are confidential and covered under Sections 1040, 1157, 1157.5, and 1157.7 of the California Evidence Code. . END OF POLICY County of Monterey EMS System Policy Policy Number: 6040 Effective Date: 7/1/2023 Review Date: 6/30/2026 TRAUMA QUALITY IMPROVEMENT AND SYSTEM EVALUATION I. PURPOSE To define standards, evaluate methodologies, and utilize the evaluation results for continuous trauma system quality improvement in performance and patient care, and to establish requirements for data collection and management by trauma system participants in Monterey County.the County of Monterey. II. POLICY A. Trauma system participants within the Monterey County of Monterey Emergency Medical Services (EMS) System will maintain a comprehensive internal Quality Improvement (quality improvementQI) program, as outlined in County of Monterey EMS System Policy 6000 (Emergency Medical Services Quality Improvement). B. Trauma system participants will participate fully in and cooperate with the Monterey County EMS Agency’s quality improvement QI programs. C. All The Trauma Center s shall complete a trauma registry entry for all patients who meet the criteria identified in the National Trauma Data Standard (NTDS) Inclusion Criteria and by the California Emergency Medical Services Information System (CEMSIS) Ttrauma requirements. III. REQUIREMENTS A. Trauma Center (Internal) Quality Improvement Requirements: 1. Internal MedicalTrauma QI uality Improvement Program – A Trauma Center center must have a formal, and fully-functionalfully functional, internal quality improvement program for its trauma service. Each Trauma Center shall have a written Quality Improvement Plan which shall include: a. Trauma Medical Director (Chief of Trauma),: The Trauma Medical Director who shall be responsible for the hospital trauma care, compliance with the EMS Agency trauma plan/ and trauma standards, and for participation in the Trauma QI program. b. Trauma Program Manager,: The Trauma Program Manager who shall be answerable to the Chief Nursing Officer or the Chief Medical Officer., and theThis position will shall have at least 1 FTE dedicated to this role. The Trauma Program Manager shall oversee the trauma registrar and will perform the following functions: 1) Perform cCase reviews of ALLall trauma casesincidents; County of Monterey County EMS System Policy 6040 2) Identify trauma cases that meet Monterey County of Monterey Minimum Audit Criteria for External Quality ImprovementQI Review; 3) Analyze trends; 4) Analyze all trauma patient calls to the trauma base hospital diverted to non-trauma centers; 5) Perform detailed auditsAudit of all trauma deaths, major complications, transfers, unexpected outcomes (positive or negative), and unusual occurrences; and 6) Provide loop closure for identified opportunities for improvement. c. Trauma Registrar, who: shall The Trauma Registrar will maintain the efficient operation of the Trauma trauma Registryregistry, ensure consistency and quality in the data collection system, enter information into the trauma database, and retrieve data for quality improvement purposes. d. Coordination of anIAn internal multi-disciplinary trauma committee that includes members of emergency medicine, general surgery, and other departments that are responsible for care of the trauma patient. The audit process will include a log of follow-up problems and periodic multi- disciplinary trauma conferences to critique selected trauma cases. This committee will follow the applicable provisions of Evidence Code Section 1157.7 to ensure confidentiality. e. Provision of a system for patients and others as defined in Title 22, Division 9, Chapter 7, Section 100265(e), to provide input and feedback to hospital staff regarding the care provided. f. The County of Monterey County EMS Agency designated Trauma Center’s Trauma Medical Director and Trauma Program Manager shall each attend at least 50% of Santa Clara County’s Trauma Care System Quality Improvement Committee (TCSQIC) and Trauma Executive Committee meetings. g. Generation and submission of required trauma reports to the Monterey County EMS Agency within the specified time. h. Investigation of all unusual occurrences, as identified internally or referred by the Monterey County EMS Agency. The investigation should take no longer than fourteen (14) days OR a limited time mutually agreed upon by the Trauma Center and Monterey County EMS Agency. The results (including any resolution or identification of further actions required) will be reported directly back to Monterey County EMS Agency within three (3) days of the investigation’s conclusion. B. Trauma System (External) Quality Improvement Plan County of Monterey County EMS System Policy 6040 1. Written Confidentiality confidentiality Agreement Requirements: Contract agreements shall be made with system participants regarding participation in the Monterey CountyEMS Agency’s Quality ImprovementQI Program. 2. The Monterey County EMS Agency will conduct audits for compliance with statutory, regulatory, California Emergency Medical Services Authority (EMSA), and contractual compliance every three (3) years, or more frequently as determined by the EMS Agency. 3. Trauma Care System Quality Improvement Committee (TCSQIC) a. The County of Monterey County EMS Medical Director and the EMS Agency Trauma Coordinator shall each attend at least 50% of Santa Clara County’s TCSQIC and Trauma Executive Committee meetings. 4. The Trauma Evaluation and Quality Improvement Committee (TEQIC) : TEQIC is a multi-disciplinary medical advisory committee to the County of Monterey County EMS Agency, comprised of representatives from prehospital agencies, non-Trauma Center facilities, and the Trauma Center. This is a confidential committee. a. Monterey County The EMS Agency shall conduct TEQIC meetings as deemed necessary, but no less than two (2) times per year. b. Oath of Confidentiality: The proceedings and records of this committee are confidential and are protected under Sections 1040 and 1157.7 of the Evidence Code of the State of California. Members shall not divulge or discuss information that would have been obtained solely through TEQIC membership. After review, all paperwork shall be disposed of in an appropriate confidential manner. Members and invited guests of the TEQIC shall sign a Confidentiality Agreement as a condition of attendance. The Monterey County EMS Agency shall maintain signed copies of the agreements on file. c. The Trauma Evaluation and Quality Improvement Committee (TEQIC) shall: 1) Establish audit filters; 2) Monitor the process and outcome of trauma patient care and present opportunities for analysis of data and information of scientific value for studies and strategic planning of the trauma system; 3) Serve in an advisory capacity to the Monterey County EMS Agency on trauma care systems issues and policies, which include the appropriateness and effectiveness of the Trauma Triage policy; and 4) Provide educational forums for trauma care when trends are identified. County of Monterey County EMS System Policy 6040 d. Membership: The membership of the Monterey County EMS Agency Trauma Evaluation and Quality Improvement CommitteeTEQIC shall include the positions included in Section VIII of Monterey County County of Monterey EMS System Policy #1020 (EMS Advisory Committees). Other attendees may be included by special invitation of the County of Monterey County EMS Agency. e. TEQIC Chairperson: The Chairperson for TEQIC shall be the County of Monterey County EMS Agency Trauma Coordinator. The Chairperson shall preside over the committee and make recommendations to the Monterey County EMS Agency Medical Director as directed by the membership of the committee. f. TEQIC Process: 1) TEQIC shall meet a minimum of two (2) times per year for chart review, and jointly for formal education and/or trauma system evaluation according to the needs of the committee. 2) Scope of Review: The review conducted by the committee shall include trauma patient care in Monterey County and transfer of trauma patients to other hospitals or designated Trauma trauma Centers. The committee review shall include and be limited to prehospital trauma care activities and trauma patient care from time of injury through rehabilitation. 3) Preparation of cases for TEQIC review: The Trauma trauma Center center shall prepare appropriate materials for its cases to be presented to the TEQIC to include: a) Audit reports as requested by the EMS Agency and/or TEQIC. A formal chart review may be performed by the Monterey County EMS Agency Medical Director and the EMS Agency Trauma Coordinator prior to a TEQIC meeting. A letter will be sent out approximately one month prior to the review of the charts, outlining the scheduling, the procedure, and the trauma charts needing to be pulled for review. b) The field representative shall provide the prehospital provider component for presentation when pertinent to the care of the trauma patient. 4) The Monterey County EMS Agency shall provide: a) Staff support for documentation (minutes) of TEQIC meetings, to include any memorandum(s) issued by the Monterey County EMS Agency in response to Committee recommendations; b) Distribution of meeting announcements; c) Preparation of TEQIC agenda; and County of Monterey County EMS System Policy 6040 d) Maintenance of records of proceedings. g. Conclusion of TEQIC case review: Feedback to prehospital providers, the Trauma Center, and other receiving hospitals is critical to the audit process. Action items will be discussed and decided at the conclusion of each system review. The committee shall discuss each system issue and arrive at a conclusion for action that may include one or more of the following: 1) No further review or action required. 2) Request for additional information and a follow-up report from the involved institution or prehospital care provider. 3) Formal recommendations. h. Member removal from the TEQIC: The following shall be cause for removal of a member from the committee: 1) Breach of confidentiality; 2) Excessive absence, defined as failure to attend at least one (1) TEQIC meeting over the course of a calendar year; or 3) Disruptive or rude behavior. i. Minimum Audit Criteria for External external Quality ImprovementQI Reviewreview: 1) Absence of a patient care report for a patient transported by prehospital personnel within 24 hours of the transport. 2) Transport EMS personnel scene time exceeding 20 minutes of patient care prior to departure to the hospital. 3) All trauma patients who are diverted or transferred during the acute phase of hospitalization to another trauma center, acute care hospital, or specialty hospital (e.g., burn center, replantation center, or pediatric trauma center). 4) All outgoing trauma transfers performed within 24 hours of hospital arrival. 5) Any case the Monterey County EMS Agency feels would benefit from a TEQIC review. END OF POLICY Monterey County of Monterey EMS System Policy Policy Number: 6050 Effective Date: 7/1/2023 Review Date: 6/30/2026 TRAUMA CARE DATA COLLECTION AND MANAGEMENT I. PURPOSE To establish requirements for data collection and management by trauma system participants. II. POLICY A. Pre-hospital providers shall record the Centers for Disease Control (CDC)American College of Surgeons (ACS) National Guidelines for the Field Triage of Injured Patients 4-step field triage criteria resultsfindings for all trauma patients, as defined in Monterey County of Monterey EMS System Policy #4040 (Field Trauma Triage Criteria). B. The Trauma trauma Center center shall complete a trauma registry entry for all patients who meet the following trauma registry inclusion criteria: 1. ICD-10 codes identified in the Trauma Center’s center’s current trauma registry AND 2. Physically evaluated by a trauma surgeon in the emergency department or resuscitation area; OR 3. Death in the emergency department due to a traumatic injury(ies); OR 4. Transfer for trauma services (note: may include interfacility and intrafacility). 5. Exclusion: Isolated burn without penetrating or blunt mechanism of injury. C. The registry shall include, but not be limited to, the data elements in compliance with the National Trauma Data Base and the California Emergency Medical Services Information System (CEMSIS) Trauma trauma requirements. D. The Trauma trauma Receiving receiving facility shall submit data to the Monterey County EMS Agency on all patients who meet the National Trauma Data Standard Inclusion Criteria. The Monterey County EMS Agency will define the specific data elements in collaboration with the Trauma Evaluation and Quality Improvement Committee (TEQIC). E. EMS base and receiving hospitals that are not designated as a Trauma trauma Center center shall submit data to the Monterey County EMS Agency on all patients who meet the criteria outlined in County of Monterey County EMS System Policy #5140 (Emergency Department Re-triage and Rapid Transfer of Trauma Patients to Trauma Center) as well as on other trauma patients as requested by the Monterey County EMS Agency. The Monterey County EMS Agency will define the specific data elements in collaboration with the TEQIC. County of Monterey County EMS System Policy 6050 F. Cooperation with other counties and LEMSAs: 1. When patients from the Monterey CountyCounty of Monterey EMS system are transported to a Trauma trauma Center center in another EMS outside the system or county, Natividad Medical Center will acquire injury/outcome data. 1.2. andIf clinically appropriate, Natividad will attempt to repatriate patients whose condition has stabilized to Natividad if clinically appropriate. 2.3.Hospitals and ambulance providers within the Monterey County of Monterey EMS system shall cooperate with requests from the Monterey County EMS Agency and other EMS agencies in data collection and evaluation efforts. END OF POLICY Monterey County EMS System Policy Policy Number: 6090 Effective Date: 7/1/2025 Review Date: 6/30/2026 ANNUAL ALS SKILLS MAINTENANCE VERIFICATION AND POLICY REVIEW I. PURPOSE To ensure competency and to mitigate the risks associated with high risk/low frequency skills. To standardize Monterey County paramedic skill maintenance verification. To require review of Monterey County EMS System policies, procedures, and protocols by Monterey County accredited paramedics through a mandatory annual policy review. II. POLICY A. All paramedics accredited in Monterey County shall meet the standards for skills maintenance verification and policy review as defined in this policy. The EMS Agency will not provide paramedic accreditation renewal without successful completion of the required skills maintenance and policy review requirement. B. The paramedic shall complete the skills maintenance requirements and policy review each calendar year or as specified for the specific procedure. 1. The skills maintenance requirement is waived by the EMS Agency for the year in which initial paramedic accreditation is received when accreditation begins in the last calendar quarter. 2. The policy review requirement is not waived by the EMS Agency but may be met as part of the employer orientation. 3. Each skill must be performed in each calendar year except as described in Item1 of Subsection II(B) above and for Needle Cricothyrotomy, which must be performed once during the first half of the calendar year and once during the last half of the calendar year. The training videos for needle cricothyrotomy are to be viewed and documented every three months (four times each calendar year). C. The paramedic is responsible to ensure that they meet the standards specified in this policy. D. Annual Skills and Policy Review Form 6091 shall be submitted by each paramedic reaccrediting in Monterey County for each year of the reaccreditation cycle. 1. ALS Skills Verification Forms 6091A through 6091H shall be made available at the EMS Agency’s request for program monitoring.maintained by the paramedic for a period of four years from the date of skills verification or until paramedic Monterey County EMS System Policy 6090 licensure expires, whichever come first. These forms shall be available for review by the EMS Agency upon request. III. PROCEDURE A. ALS skill maintenance: 1. The paramedic shall perform each of the skills listed in the Annual Skills and Policy Review Form 6091 to maintain paramedic accreditation. 2. The paramedic’s employer shall submit a comprehensive plan of correction to the EMS Agency for approval by the EMS Agency when the paramedic is unable to perform any of the skills. This plan of correction shall be submitted to the EMS Agency within five (5) business days. The EMS Agency shall respond to the paramedic’s employer with plan approval or revision within five (5) business days. Training under the plan of correction shall be completed within fifteen (15) calendar days of the EMS Agency response to the employer. This training shall result in the successful completion of the skills demonstration and policy review process. B. Policy review: Annually, the employer shall verify that the paramedic understands Monterey County EMS System policies, procedures, and protocols. Emphasis shall be given to EMS policies, procedures, and protocols that have changed or are new. C. Skills maintenance and policy review reporting: 1. The paramedic service provider shall verify that the paramedic has met the standards in this policy and Policy 6091 Annual Skills and Policy Review Form 6091. Skills verification will be documented on Form 6091 supported by Forms 6091A through 6091H. Completion of the requirements for the policy review will be documented on Form 6091. 2. Paramedic service provider shall retain these documents for a period of four years. The paramedic service provider shall provide the paramedic with copies of forms 6091A through 6091H. D. EMS Agency review of records: 1. The EMS Agency may review all records to ensure compliance with this policy. END OF POLICY ANNUAL SKILLS AND POLICY REVIEW FORM-6091 1a. Name as shown on Paramedic License 1b. License Number Paramedic License(Last Name, First Name): 1c. Signature of person 1d. Employer demonstrating competency: Skill Verification of Competency 1. Orotracheal Intubation (Adult) Verifier Affiliation: Date: Signature of person verifying competency Print Name: License Number: 2. Supraglottic Airway (Adult) Verifier Affiliation: Date: Signature of person verifying competency Print Name: License Number: 3. Supraglottic Airway (Pediatric) Verifier Affiliation: Date: Signature of person verifying competency Print Name: License Number: 4. Pleural Decompression Verifier Affiliation: Date: Signature of person verifying competency Print Name: License Number: 5. Transcutaneous Cardiac Pacing Verifier Affiliation: Date: Signature of person verifying competency Print Name: License Number: 6. Synchronized Cardioversion Verifier Affiliation: Date: Signature of person verifying competency Print Name: License Number: 7. EZ IO (Adult/Pediatric) Verifier Affiliation: Date: Signature of person verifying competency Print Name: License Number: 8. Epinephrine for Hypotension (Push Dose) Print Name: Date: Signature of person verifying competency Verifier Affiliation: Certification/License Number: 9. Needle Cricothyrotomy-Adult Print Name: Date: Videos Signature of person verifying competency Verifier Affiliation: License Number: 10. Needle Cricothyrotomy-Pediatric Print Name: Date: Videos Signature of person verifying competency Verifier Affiliation License Number: 11. Annual Protocol/Policy Review Verifier Affiliation: Date: Signature of person verifying competency: Print Name: License Number: County of Monterey EMS System Form 6091 A completed Annual Skills and Policy Review Form is required to accompany the paramedic reaccreditation application of every individual who is either maintaining paramedic accreditation without a lapse, or to renewing paramedic accreditation with a lapse of less than six months. 1a. Name of Paramedic License Holder Provide the complete name, last name first, of the paramedic demonstrating skills competency. 1b. Paramedic License Number Provide the paramedic license number of the paramedic demonstrating skills competency. 1c. Signature Signature of the paramedic demonstrating skills competency. By signing this section, the paramedic is verifying that the information contained on this form is accurate and that the paramedic has demonstrated competency in the skills listed in the skills sheet. 1d. Employer Provide the name of the current paramedic employer(s). Verification of Competency 1. Verifier Affiliation: Provide the name of the EMS service provider or base hospital that the qualified individual verifying competency is affiliated with. 2. Once competency has been demonstrated by direct observation of an actual or simulated patient contact, i.e. skills station, the individual verifying competency shall sign the Annual Skills and Policy Review Form for that skill. 3. Qualified individuals who verify skills competency shall be currently licensed as: a paramedic, registered nurse, physician assistant, or physician and shall be either a qualified instructor designated by an EMS approved training program (paramedic training program or continuing education training program) or be a qualified individual designated by an EMS service provider. EMS service providers include, but are not limited to, public safety agencies, private ambulance providers, and other EMS providers. 4. License Number: Provide the certification or license number for the individual verifying competency. 5. Date: Enter the date that the individual demonstrated competency in theeach skill. 6. Print name – Print the name of the individual verifying competency in the skill. A completed Annual Skills and Policy Review Form shall be provided to the County of Monterey County EMS Agency for every year of the paramedic reaccreditation cycle in compliance with County of Monterey County EMS System Policiesy 2050 and EMS Policy 6090. A copy of this form shall be retained by the paramedic license holder and the EMS provider agency for a minimum of 4 years as outlined in County of Monterey County EMS System Policy 6090. Orotracheal Intubation 6091-A Effective: Expires: 7/1/2023 6/30/2026 Approval: Medical Director Signed: Low Frequency/High Risk: John Beuerle, MD Orotracheal Intubation Applies To: Approval: EMS Director Signed: Paramedics Teresa Rios Terminal Performance Objective Secure placement of an endotracheal tube (ETT) in the trachea to ensure a patent airway for positive pressure ventilation. Before performing orotracheal intubation, paramedics must: 1. Determine BLS airway adjuncts are inadequate for effective positive pressure ventilation (PPV) and confirm the need for Endotracheal Intubation (ETI)1 2. a. NOTE: Orotracheal intubation is approved only for adult patients 2. Recognize signs of a difficult airway, if present, and select, prepare and employ the appropriate alternative tools and techniques to secure the airway (e.g. ET Introducing Stylet, Rescue Airway). 3. Correctly assemble all equipment required for ETI within 60 seconds. 4. Provide optimal ventilation and oxygenation (minute volume) to the patient while ETI equipment is prepared. 5. Test the cuff of the ET Tube by inflating it with air and ensuring that there is not a leak in the cuff. While performing orotracheal intubation, paramedics must: 1. Position the patient to best facilitate the intubation. 2. Visualize anatomical structures including the glottic opening (vocal cords) during direct laryngoscopy. a. Use manual percutaneous laryngeal manipulation to assist with visualization of the glottic opening as needed. 3. Minimize oral trauma during laryngoscopy by utilizing correct technique. 4. Place the clinically indicated size ETT securely in the trachea at the correct depth within 30 seconds. 5. Inflate the cuff with enough air to seal the trachea, estimating inflation pressure by palpation of the pilot balloon. 6. Confirm placement of the ETT in the trachea by: a. Direct visualization of the tube passing through the cords. b. IMMEDIATELY attach Waveform capnography and commence ventilation while confirming proper airway placement. 1) Confirm appropriate waveform is present AND capnography number is present and consistent with clinical condition or in the event of mechanical failure c. Auscultate lung fields and epigastrium, visualize adequate chest rise and fall. d. Print strip of capnogram and retain for documentation. e. If only right lung sounds heard, carefully adjust ETT as necessary by slowly withdrawing ETT and listening for onset of left lung sounds. Once bilateral lung sounds occur, secure the tube. f. Remove ETT immediately if esophageal placement suspected. 7. Immediately re-establish PPV at the clinically required rate and tidal volume (minute volume) and oxygen at 10- 15 LPM following ETT placement. 1 2015 AHA Guidelines for CPR and ECC, Part 8 Adult Advanced Cardiovascular Life Support, pp S730-S735 2 PHTLS, Ninth Edition 8. Resume BLS PPV within 10 seconds following unsuccessful ETI attempts. a. Employ supraglottic airway after two (2) failed ETI attempts, if BLS airway adjuncts are inadequate for effective PPV. b. Passing the laryngoscope past the teeth with the intent of placing an ETT is considered an intubation attempt. c. A maximum of two (2) attempts per patient is permitted. 9. Secure the ETT in the trachea at the correct depth with tape or a commercial device. 10. Stabilize the patient’s airway and prevent tube migration by using a device to prevent rotation, flexion, or extension of patient’s head. 11. Efficiently employ post-ETI diagnostic tools to thoroughly assess overall effectiveness of ventilatory support throughout the duration of respiratory management efforts, including: a. Visualize symmetrical rise and fall of the chest with PPV. b. Monitor pulse oximetry – the target SpO2 is greater than or equal to 94% if spontaneous circulation is present. b. c. Monitor ETCO2 for appropriate waveform morphology and target CO2 levels. 1) The target range for ETCO2 level is between 30 – 45 mmHg if spontaneous circulation is present. 2) In cardiac arrest, metabolic derangements will significantly alter ETCO2 values and waveform morphology. Target range for ETCO2 level is between 15mmHg – 45mmHg during CPR. 3) Recognize that in a patient with traumatic brain injury, ETCO2 less than 35 mmHg due to hyperventilation may cause harm. Minute volume should be adjusted accordingly while maintaining optimal oxygenation, reserving hyperventilation for those patients showing signs of cerebral herniation only.3 d. Monitor ECG for dysrhythmia due to vagal stimulation or other treatable causes. e. Frequent auscultation of lung fields and epigastrium, at a minimum after every patient movement. f. Constant evaluation of ventilatory compliance and resistance during PPV. 12. Immediately identify malfunctioning equipment, ineffective techniques or changes in post-ETI PPV compliance/resistance and employ alternative measures to achieve effective ventilations. 13. Reconfirm correct ETT placement each time the patient is moved and before transfer of care to hospital staff. a. Record and/or print the waveform ETCO2 strip: after every patient movement, AND just prior to transfer of care to the hospital staff and attach the strip to the completed PCR. 14. Maintain effective ventilation and oxygenation. 15.14. . 16.15. Accurately document all assessment findings, therapeutic treatments, and the patient’s response to therapy. Critical Success Targets for ETI 1. ETT securely placed in the trachea followed by effective PPV. 2. Chest rise and fall with each ventilation cycle 3. Ventilatory rate and tidal volume appropriate for patient condition and response 4. Sp02 of greater than 94% in patients with spontaneous circulation 5. Recognition of an esophageal intubation 6. Limited interruption of PPV (30 seconds maximum) 7. Evaluation and documentation of ETCO2 morphology and values. System Benchmark 1. ETT securely placed in the trachea within 2 attempts in 85% of the indicated patients 2. Recognition of misplaced or dislodged ETT in 100% of the occurrences 3. Appropriate clinical interpretation of digital waveform capnography with every orotracheal intubation. Core Competency Requirements to be covered during education/ training on ETI 1. Respiratory A&P and Pathophysiology 2. Assessment of airway and breathing 3. Techniques for PPV 4. Airway pressure secondary to PPV – mean vs. peak 5. Possible complications of PPV – gastric, pulmonary, cerebral, and cardiovascular complications of over-inflation 6. Determination of PPV adequacy and efficacy 7. Differentiation between effective and ineffective patient response to PPV via BLS measures 8. Indications and contraindications for ETI 9. Selection of correct equipment required for ETI (e.g. ET size) 10. Identification of the difficult airway and employment of alternative techniques and tools 11. Laryngoscopy techniques 12. ETT placement techniques 13. Stabilization of patient’s head to prevent dislodgement of airway 14. Post-placement ETT monitoring 15. Complications, risks, consequences of failure to complete post-placement ETT monitoring 16. Auscultation and diagnostic differentiation of lung sounds 17. Use of diagnostic tools; (i.e.:, ETCO2 monitoring) 18. Recognition of complications (Dislodgement, Obstruction, Pneumothorax, Equipment Failure, or DOPE) 19. Team leadership and patient safety 20. Documentation Equipment Requirements 1. Personal Protective Equipment 2. NP/OP Airways 3. BVM 4. Stethoscope 5. Supplemental oxygen 6. Magill forceps 7. Laryngoscope(s) 8. Laryngoscope blades (multiple sizes) 9. Appropriate size ET tubes 10. Stylet(s) 11. Pulse oximeter 12. Waveform capnography 13. Suction device 14. Cardiac monitor 15. Difficult Airway Kit/Rescue Airway Kit (including just in time training aids) Instructor Resource Materials 1. Prehospital Trauma Life Support 2. AHA CPR and BLS Provider Manual 3. AHA ACLS Provider Manual 4. AHA PALS Provider Manual 5. Current AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care 6. NHTSA EMS Educational Instructor Guidelines for EMT and Paramedic Adult Orotracheal Intubation Validation PERFORMANCE CRITERIA: 100% accuracy required on all items with an * Before performing orotracheal intubation, the paramedic must: Points Score Performance Steps Additional Information successful unsuccessful 1 Take or verbalize body substance Selection: gloves, goggles, mask, gown, booties, N95 PRN isolation. Determine BLS airway adjuncts No or inadequate rise and fall of chest, no improvement are inadequate for effective in patient’s color or condition. positive pressure ventilation (PPV) and confirm the need for Endotracheal Intubation (ETI). * 1 Recognize signs of a difficult • A difficult airway is defined as the presence of airway and select, prepare, and anatomic conditions which preclude direct employ the appropriate alternative visualization of the patient’s glottic opening. tools and techniques (e.g., ET • Signs of a difficult airway include, but are not limited to: Introducing Stylet, Rescue 1. Airway edema Airway). * 2. Arthritis or scoliosis of the spine 3. Significant overbite 4. Small mandible 5. Short neck 6. Morbid obesity 7. C-spine immobilization 8. Face or neck trauma 1 Correctly assemble all equipment ETT, stylet, laryngoscope with functioning bulb, Magill required for ETI within 60 seconds. forceps, suction, suction catheters (flexible and rigid), 10 * mL syringe, stethoscope, Rescue Airways (i-Gel), Toomey Syringe, waveform capnography, pulse oximeter, BVM. Provide optimal ventilation and oxygenation to the patient while ETI equipment is prepared. * 1 Test the cuff of the ET Tube by inflating it with air, and ensuring that there is not a leak in the cuff. * Select an appropriate size ET tube • Adult women will typically require will take a 6.5 – 7.5 ETT; • aAdult men will typically require take a 7.5 – 8.0 ETT While performing orotracheal intubation, the paramedic must: 1 Consider having a team member Apply gentle pressure to the patient’s cricoid cartilage to apply cricoid pressure during occlude the esophagus and reduce the patient’s chances of intubation attempts. aspirating gastric contents. Properly position the patient for intubation. * 1 Visualize anatomical structures including the glottic opening (vocal cords) during direct laryngoscopy. * 1 Minimize oral trauma during Do not use the patient’s teeth as a fulcrum. laryngoscopy by utilizing correct technique. * 1 Place the appropriately sized ETT • Adult women typically will take a 6.5 – 7.5 ETT; adult securely in the trachea at the men will typically take 7.5 – 8.0 ETT correct depth within 30 seconds. • Appropriate depth is ½ -- 1 inch beyond the vocal * cords, usually 21 – 23 cm marking at the teeth dependent on tube size 1 Inflate the cuff with enough air to seal the trachea;trachea, estimating inflation pressure by palpation of the pilot balloon. * 1 Immediately re-establish PPV with the appropriate rate, tidal volume and oxygen at 10 – 15 LPM following ETT placement. * 1 Confirm ETT is in the trachea * • Direct visualization of the tube passing through the vocal cords • IMMEDIATELY attach waveform capnography and commence gentle bagging while confirming proper airway placement. o Confirm appropriate rectangular waveform is present or that the colorimetric detector shows yellow on exhalation • Auscultate over lung fields for confirmation of airflow with PPV o If only right lung sounds heard, carefully adjust ETT as necessary by slowly withdrawing ETT and listening for onset of left lung sounds. • Auscultate over the epigastrium for the lack of airflow with PPV. • Print strip of capnogram and retain for documentation. • Observe for appropriate chest rise and fall. • Remove ETT immediately if esophageal placement is suspected. Immediately re-establish PPV at the clinically required rate and tidal volume (minute volume) and oxygen at 10 – 15 LPM following ETT placement. * 1 Secure the ETT in the trachea at • Stabilize the patient’s airway and prevent tube migration the correct depth with tape or a by using a device to prevent rotation, flexion, or extension commercial device and prevent tube of patient’s head. migration by securing the patientspatient’s head. * 1 Efficiently employ post-ETI • Symmetrical rise and fall of the chest with PPV diagnostic tools to thoroughly • Monitor pulse oximetry – the target SpO2 is greater assess overall effectiveness of than or equal to 94% if spontaneous circulation is ventilatory support throughout present the duration of respiratory o In patients with COPD/pulmonary disease, it management efforts. * may not be possible or desirable to attain a SpO2 of 94%. • Monitor ETCO2 for appropriate waveform morphology and target CO2 levels. o The target range for ETCO2 level is between 30 – 45 mmHg if spontaneous circulation is present. o In cardiac arrest, metabolic derangement will significantly alter ETCO2 values and waveform morphology. Target range for ETCO2 levels is between 15 mmHg – 45 mmHg during CPR. o Recognize that in a patient with traumatic brain injury, ETCO2 less than 35 mmHg due to hyperventilation may actually causecause harm. Minute volume should be adjusted accordingly while maintaining optimal oxygenation. • Monitor ECG for dysrhythmia due to vagal simulation or other treatable causes. • Frequent auscultation of lung fields and epigastrium. • Constant evaluation of ventilatory compliance and resistance during PPV. Critical Failure Criteria Failure to take or verbalize BSI appropriate to the skill prior to performing the skill Failure to initiate ventilations within 30 seconds after applying gloves or interrupts ventilations for greater than 30 seconds Failure to ventilate patient at a rate appropriate to patient age Failure to provide adequate tidal volume per breath Failure to pre-oxygenate patient prior to intubation attempt Failure to successfully intubate within 2 attempts Failure to disconnect syringe immediately after inflating cuff of ET tube Uses teeth as a fulcrum Failure to assure proper tube placement by auscultation over lung fields and epigastrium Failure to use either a colorimetric end tidal CO2 cap or waveform capnography If used, stylet extends beyond end of tube Failure to recognize an esophageal intubation Any procedure that would have harmed the patient Supraglottic Airway 6091B Effective Expires 7/1/2023 6/30/2026 Approval: Medical Director Signed Low Frequency John Beuerle, MD Supraglottic Airway Applies To: Approval: EMS Director Signed Paramedics Teresa Rios Performance Objective Secure placement of a supraglottic airway to facilitate positive pressure ventilation. Before performing insertion of a supraglottic airway, paramedics must: 1. Determine that BLS airway adjuncts are inadequate for effective positive pressure ventilation (PPV) and confirm the need for alternate means of airway managementALS airway placement. 2. Assess the patient for Recognize signs of a difficult airway. 2. and select, prepare and employ the appropriate supraglottic airway and techniques. a. A difficult airway is defined as the presence of anatomic conditions thatwhich preclude direct visualization of the patient’s glottic opening (e.g., airway edema, arthritis, kyphosisscoliosis of the spine, significant overbite, small mandible, short neck, morbid obesity, cervical spine immobilization, face or neck trauma). 3. Select and prepare the appropriate supraglottic airway. 4. Within 60 seconds, Ccorrectly assemble all equipment required for supraglottic airway insertion within 60 seconds. a. Ensure aAppropriate size iGel: 1) Size 3: For patients 30-60 kg 2) Size 4: For patients 50-90 kg 3) Size 5: For patients > 90 kg b. lLubricant c. Bag-/Valve device d. Stethoscope e. Suction f. Monitoring equipment 4.5. Ensure optimal ventilation and oxygenation of the patient while the supraglottic airway and equipment isare being assembled and prepared. While performing insertion of a supraglottic airway, paramedics must: 1. Minimize oral trauma during insertion by utilizing correct technique. 2. Place the appropriately sized supraglottic airway securely (per the manufacturer’s instructions) in the hypopharynx at the correct depth within 30 seconds. 3. Following supraglottic airway placement, iImmediately re-establish Positive Pressure Ventilation (PPV) with the appropriate rate and tidal volume (minute volume) with and supplemental oxygen at 10 – 15 LPM following supraglottic airway placement. 4. Confirm correct placement: a. IMMEDIATELY attach waveform capnography and commence gentle bagging while confirming proper airway placement. b. Confirm appropriate rectangular waveform is present. c. Auscultate lung fields and epigastrium. d. Print capnography strip of capnogram and retain for documentation. e. Observe patient for appropriate chest rise and fall. 5. Secure the supraglottic airway at the correct depth (per the manufacturer’s instructionsdirections). 6. Stabilize the patient’s airway and prevent tube migration by using a device to prevent rotation, flexion, or extension of patient’s head. 7. Efficiently employ post supraglottic airway diagnostic tools to thoroughly assess overall effectiveness of ventilatory support throughout the duration of respiratory management efforts, including: a. Visualization of symmetrical rise and fall of the chest with PPV. b. Monitor pulse oximetry. - tThe target Sp02 is greater than 95% if spontaneous circulation is present. c.b. d.c. Monitor ETC02 for appropriate waveform morphology and target C02 levels. 1) The target range for ETC02 level is between 30 – 45 mmHg if spontaneous circulation is present. 2) In cardiac arrest, metabolic derangements will significantly alter ETC02 values and waveform morphology. Target range for ETC02 level is between 15 mmHg – 45 mmHg during CPR. 3) Recognize that in a patient with traumatic brain injury, ETC02 less than 35 mmHg due to hyperventilation may actually causecause harm to the patient. Minute volume should be adjusted accordingly while maintaining optimal oxygenation, reserving hyperventilation for those patients showing signs of cerebral herniation only.1 e.d. Monitor ECG for dysrhythmias due to vagal stimulation or other treatable causes. f.e. Frequent aPeriodically auscultateion of lung fields and epigastrium . g.f. Constant eContinuously evaluateion of ventilatory lung compliance and airway resistance and resistance during PPV. Changes in lung compliance or airway resistance may indicate an airway obstruction, pneumothorax, or poor positioning of the supraglottic airway. 8. Re-implement effective PPV within 10 seconds following unsuccessful supraglottic airway placement attempts. a. Rapidly transport patients to the closest Emergency Department when supraglottic airway placement is unsuccessful and airway patency is not secure. 9. Immediately identify malfunctioning equipment, ineffective techniques, or changes in post placement PPV compliance and employ alternative measures to achieve effective ventilations. 10. Reassess supraglottic airway placement each time the patient is moved and before transfer of care to hospital staff. a. Record and print the waveform ETC02 strip prior to transfer of care to the hospital staff and attach the strip to the completed PCR. 11. Provide direction to personnel that have been delegated managementperforming PPV following of post-placement of a supraglottic airway PPV. 12. Maintain effective ventilation and oxygenation throughout the entire prehospital treatment period. 13. Maintain calm, and effectively lead a team-based approach to resuscitation under all conditions. 14. Accurately document all assessment findings, therapeutic treatments, and the patient’s response to therapy. Critical Success Targets for use of a Supraglottic Airway 1. Supraglottic airway securely placed in the patient’s hypopharynx followed by effective PPV 2. Chest rise and fall with each ventilation cycle 3. Ventilatory rate and tidal volume (minute volume) appropriate for patient condition and response 4. Sp02 of greater than 95% in patients with spontaneous circulation 5. Limited interruption of PPV (30 seconds maximum) 6. Evaluation and dDocumentation of ETC02 morphology and values. System Benchmark Supraglottic airway securely placed in patient’s airway within 2 attempts in 98% of the indicated patients. Core Competency Requirements to be covered during education/ training on Supraglottic Airway 1 The Brain Trauma Foundation’s Guidelines for Prehospital Management of Severe Traumatic Brain Injury, Fourth Edition, Section V 1. Respiratory anatomy, physiology, A&P and pathophysiology 2. Assessment of airway and breathing 3. Techniques for PPV 4. Airway pressure secondary to PPV (– mean versus peak airway pressure) 5. Possible complications of PPV (- gastric, pulmonary, cerebral, and cardiovascular complications of over-inflation and over-ventilation) 6. Determination of PPV adequacy and efficacy. Note that greater tidal volume may be necessary due to greater dead space in use of supraglottic airways. 7. Differentiation between effective and ineffective patient response to PPV via BLS measures 8. Indications for use of a supraglottic airway 9. Selection of correct equipment required for insertion of a supraglottic airway 10. Identification of the difficult airway and employment of alternative techniques for airway management 11. Supraglottic airway placement techniques 12. Post-placement airway monitoring 13. Auscultation and diagnostic differentiation of lung sounds 14. Use of diagnostic tools, (e.g., capnography) 15. Recognition of complications (Dislodgement, Obstruction, Pneumothorax, Equipment Failure, or DOPE) 16. Team Leadership and patient safety 17. Documentation Equipment Requirements 1. Personal protective equipment 2. Adult airway mannequin 3. NPA / OPA airways 4. BVM 5. Supraglottic airway(s) 6. Stethoscope 7. Supplemental oxygen 8. Pulse oximeter 9. Waveform capnography 10. Suction device (both rigid and flexible catheters) 11. Cardiac monitor Instructor Resource Materials 1. Prehospital Trauma Life Support, 8th Edition 2. AHA CPR and BLS Provider Manual 3. AHA ACLS Provider Manual 4. AHA PALS Provider Manual 5. Current AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care 6. NHTSA EMS Educational Instructor Guidelines for EMT and Paramedic 7. Adjunct specific manufacturer guidelines for use Supraglottic Airway Successful (y/n) Performance Steps Additional Information Take or verbalize appropriate Selection: gloves, goggles, mask, gown, booties, P100 body substance isolation PRN precautions Assess Determinewhether BLS airway adjuncts are inadequate for effective positive pressure ventilation (PPV). Identify and confirm the need for ALS airway placement. Recognize signs of a difficult airway. • A difficult airway is defined as the presence of and sSelect and, prepare and employ anatomic conditions thatwhich preclude direct the appropriate supraglottic airway visualization of the patient’s glottic opening. and techniques. * • Signs of a difficult airway include, but are not limited to: o Airway edema o Arthritis or kyphosisscoliosis of the spine o Significant overbite o Small mandible o Short neck o Morbid obesity o Cervical spine immobilization o Face or neck trauma Correctly assemble all Suction, suction catheters (flexible and rigid), stethoscope, equipment required for supraglottic airways, waveform capnography, pulse supraglottic airway insertion oximeter, BVM within 60 seconds. * Ensure optimal ventilation and oxygenation of the patient while supraglottic airway equipment is prepared. * While performing insertion of a supraglottic airway, the paramedic must: Minimize oral trauma during insertion by utilizing correct technique. * Place the appropriately sized supraglottic airway securely (per the manufacturer’s instructions) in the hypopharynx at the correct depth within 30 seconds. * Immediately re-establish PPV with the appropriate rate, and tidal volume (minute volume) with, and supplemental oxygen at 10 – 15 LPM following supraglottic airway placement. * Confirm correct placement. * • IMMEDIATELY attach waveform capnography and commence gentle bagging while confirming proper airway placement. • Confirm appropriate rectangular waveform is present • Auscultate lung fields and epigastrium • Print capnography strip of capnogram and retain for documentation • Observe the patient for appropriate chest rise and fall Secure the supraglottic airway at the Per manufacturer’s instructions correct depth. * Stabilize the patient’s head to avoid Stabilize patient’s airway and prevent tube migration by using movement and possible supraglottic a device to prevent rotation, flexion, or extension of patient’s airway dislodgement. head. Efficiently employ post-supraglottic • Visualize symmetrical rise and fall of the chest with PPV airway diagnostic tools to • Monitor pulse oximetry. - t The target is greater than thoroughly assess overall 95% if spontaneous circulation is present. effectiveness of ventilator support o The target range is ETC02 level is between 30 – 45 throughout the duration of mmHg if spontaneous circulation is present. respiratory management efforts. * o In cardiac arrest, metabolic derangements will significantly alter ETC02 values and waveform morphology. Target range for ETC02 level is between 15 mmHg – 45 mmHg during CPR. o Recognize that in a patient with traumatic brain injury, ETC02 less than 35 mmHg due to hyperventilation may actually causecause harm to the patient. Minute volume should be adjusted accordingly while maintaining optimal oxygenation, reserving hyperventilation for those patients showing signs of cerebral herniation only. • Monitor ECG for dysrhythmia due to vagal stimulation or other treatable causes. • Frequent auscultation of lung fields and epigastrium. • Constant evaluation of ventilator compliance and airway resistance during PPV. Re-implement effective PPV within Rapidly transport patients to the closest most appropriate 10 seconds following unsuccessful hospital when supraglottic airway placement is unsuccessful placement attempts. * and airway patency is not secure. Immediately identify malfunctioning equipment, ineffective techniques, or changes in post-placement PPV compliance/ resistance and employ alternative measures to achieve effective ventilations. * Reassess supraglottic airway Record and print the waveform ETC02 strip prior to transfer of placement each time the patient is care to the hospital staff. and aAttach the recording strip to moved and before transfer of care the completed PCR. to hospital staff. * Maintain effective ventilation and Target Sp02 is greater than 95%. ; tTarget ETC02 is 30 – 45 oxygenation throughout the entire mmHg in a patient with spontaneous circulation. pre-hospital treatment period. * Maintain calm, and effectively lead a team-based approach to resuscitation under all conditions Accurately document all assessment findings, therapeutic treatments, and the patient’s response to therapy. Critical Failure Criteria Failure to take or verbalize BSI appropriate to the skill prior to performing the skill Failure to initiate ventilations within 30 seconds after applying gloves or interrupts ventilations for greater than 30 seconds. Failure to ventilate patient at a rate appropriate to patient age Failure to provide adequate tidal volume per breath Failure to pre-oxygenate patient prior to placement of supraglottic airway Failure to successfully place supraglottic airway within 2 attempts Failure to disconnect syringe immediately after inflating cuff of supraglottic airway Failure to assure proper placement by auscultation over lung fields and epigastrium Failure to use waveform capnography Failure to re-check placement after each patient movement and before transfer of care to hospital staff Any procedure that would have harmed the patient Synchronized Cardioversion 6091-E Effective Expires 7/1/2023 6/30/2026 Approval: Medical Director Signed Low Frequency/High Risk: John Beuerle, M.D. Synchronized Cardioversion Applies To: Approval: EMS Director Signed Paramedics Teresa Rios Performance Objective Termination of hemodynamically significant tachycardia resulting in restoration of adequate cardiac output and tissue perfusion. Before performing synchronized cardioversion, paramedics must: 1. Methodically assess the patient’s ABC’s within 30 seconds. 2. Determine the patient is hemodynamically unstable due to idiopathic (non-compensatory) tachycardia and is a candidate for immediate cardioversion: a. Confirm the patient is exhibiting signs and symptoms of systemic poor perfusion (including but not limited to hypotension, altered mental status, chest pain, dyspnea/tachypnea, diaphoresis, pale/cool skin). b. Confirm tachycardia (HR greater than 150 in adults, greater than 180 in children, greater than 220 in infants) is present on the ECG. c. Confirm underlying causes of the dysrhythmia have been considered and reversible causes have been treated. 3. Provide supplemental oxygen in high concentration (10 – 15 LPM). 4. Confirm the ECG monitor leads have been placed appropriately. 5. Differentiate between wide and narrow complex tachycardia. a. Print Lead II strip prior to performing any medical treatment as this could appear to be a wide complex rhythm when in fact it is a paced rhythm (some monitors do not show pacer spikes). b. Consider performing a 12 Lead ECG prior to cardioversion if such delay does not cause harm to the patient. 6. Strongly consider midazolam for sedation/amnesic affect for alert patients while preparing cardioversion equipment, but do not delay cardioversion in an unstable patient presenting with signs and symptoms of poor perfusion (hypotension, decreased LOC, chest pain, dyspnea/tachypnea, diaphoresis, pale/cool skin). a. If IV access is delayed, consider faster alternate routes of administration for midazolam (IN/IM). 7. Explain to patient/family what they can expect to feel and to see while avoiding delays in treatment. While performing synchronized cardioversion, paramedics must: 1. Select and prepare the appropriate sites for application of the ECG monitor/defibrillator multifunction pads. a. Proper pad placement on cleaned, dry skin is essential to minimize pain (heat generated from passage of current through the skin) and maximize current conduction. The better the contact, the more effective attempts at cardioversion will be. 2. Apply the ECG monitor/defibrillator multifunction pads (MFP) firmly to the patient’s clean, bare skin in the correct anatomical locations for maximum electrical current flow through the heart. 3. Identify a patient with a pacemaker or automatic internal cardiac defibrillator (AICD) and place the MFP(s) in alternate position(s) to minimize damage to the device(s) and to avoid disruption of current flow through the heart. 4. Place the ECG monitor/defibrillator in synchronize mode. 5. Confirm the monitor is tracking the R wave for delivery of synchronized current. 6. Select the correct energy setting on the ECG monitor/defibrillator per the Monterey County EMS agency protocols 7. Assure everyone is clear from the patient and all possible energy conducting surfaces/contacts. 8. Discharge the defibrillator for synchronized delivery of electrical current. 9. Immediately re-assess the patient. 10. Perform and print a 12 Lead ECG and attach to PCR. 11. Provide treatment based upon re-assessment findings. Critical Success Targets for Synchronized Cardioversion 1. Improvement in patient level of consciousness 2. Improved signs of perfusion 3. Resolution of patient’s tachycardia-related signs and symptoms (chest pain) 4. ECG return to normal sinus rhythm or sinus tachycardia 5. Proficient use of the ECG monitor/defibrillator including lead and MFP placement System Benchmark Percentage of patients receiving cardioversion with restoration of a stable perfusing rhythm Core Competency Requirements to be covered during education/training on synchronized cardioversion 1. Cardiovascular A & P 2. Cardiology – Pathophysiology of tachycardias 3. Assessment of circulation and recognition of hemodynamic instability 4. Identification and contraindications for synchronized cardioversion 5. Proper placement of ECG electrodes on patient 6. Proper placement of multi-function pads on patient 7. Patient communication techniques 8. Pre-cardioversion midazolam for sedation and amnesic effect 9. Demonstrates proper technique for use of the ECG monitor/defibrillator for cardioversion 10. Post-cardioversion cardiac monitoring/ rhythm recognition and treatment 11. Reassessment of patient Equipment Requirements 1. PPE 2. CPR mannequin(s) 3. Stethoscope 4. Cardiac monitor/ECG/Defibrillator 5. ECG Rhythm Generator 6. ECG electrodes 7. Defibrillation/ Multifunction pads 8. Midazolam 9. Pre-medication equipment (IV access, IN equipment, IM equipment) Instructor Resource Materials 1. AHA ACLS Provider Manual 2. AHA PALS Provider Manual 3. Current AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care 4. NHTSA EMS Educational Instructor Guidelines for EMT and Paramedic Synchronized Cardioversion Validation Synchronized Cardioversion Successful (y/n) Performance Steps Additional Information Take or verbalize appropriate Selection: gloves, goggles, mask, gown, booties, P100 body substance PRN isolation. Methodically assess the patient’s ABC’s within 30 seconds. * Determine the patient is • Confirm the patient is exhibiting signs and hemodynamically unstable due symptoms of systemic poor perfusion: to idiopathic (non- o Hypotension compensatory) tachycardia and o Altered mental status is a candidate for immediate o Chest pain cardioversion. * o Dyspnea/tachypnea o Diaphoresis o Pale/cool skin • Confirm tachycardia is present on the ECG o Heart rate greater than 150 in adults o Heart rate greater than 180 in children o Heart rate greater than 220 in infants • Confirm underlying causes of the dysrhythmia have been considered and reversible causes have been treated. Provide supplemental oxygen Confirm the ECG monitor leads have been placed appropriately. Differentiate between wide and • Print a Lead II strip prior to performing any narrow complex tachycardia. medical treatment as this could appear to be wide complex rhythm when in fact it is a paced rhythm (some monitors do not show pacer spikes) • Consider performing a 12 Lead ECG prior to cardioversion if such delay does not cause harm to the patient. Consider midazolam for • Do not delay cardioversion in an unstable sedation/amnesic effect while patient presenting with signs and symptoms preparing cardioversion of poor perfusion. equipment. • Use IN/IM route midazolam for sedation/amnesic effect if IV access is poor. Explain to the patient/family Do not delay immediately needed treatment. what they can expect to feel and to see. Apply the ECG • Anterior-posterior placement is monitor/defibrillator recommended, if possible. multifunction pads (MFP) firmly • Proper pad placement on cleaned, dry skin is to the patient’s clean, bare skin essential to minimize pain (heat generated from in the correct anatomical passage of current through the skin) and locations for maximum maximize current conduction. The better the electrical current flow through contact, the more effective conduction will be. the heart. * • Identify if patient with a pacemaker or automatic internal cardiac defibrillator (AICD) and place the MFP(s) in alternate position(s) to minimize damage to the device(s) and to avoid disruption of current flow through the heart 1 Correctly place the ECG monitor/defibrillator in synchronize mode. * 1 Confirm the monitor is tracking the R wave for delivery of synchronized current * 1 Select the correct energy setting on the ECG monitor/defibrillator. Assure everyone is clear from the patient and all possible energy conducting surfaces/contacts. * 1 Discharge the defibrillator for synchronized delivery of electrical current. * Immediately reassess the patient. Perform a 12 Lead ECG and print Attach the rhythm strip to your PCR. a rhythm strip Provide treatment based upon reassessment findings. Critical Failure Criteria Failure to take or verbalize BSI appropriate to the skill prior to performing the skill Failure to identify indications for procedure Failure to ensure the functionality of cardiac monitor and availability of equipment ____Failure to ensure the cardiac monitor/defibrillator is in synch mode, resulting in and provideddelivery of a non- synchronized defibrillation shock Failure to assure that everyone is clear from the patient and all possible energy conducting surfaces/contacts. Failure to confirm efficacy of intervention Any procedure that would have harmed the patient Monterey CountyCounty of Monterey EMS System Policy Policy Number: 6170 Effective Date: 7/1/20263 Review Date: 6/30/20296 PILOT PROGRAMS I. PURPOSE A. To define the process by which the Monterey County County of Monterey EMS Agency plans, develops, implements, and monitors Pilot Programs. II. POLICY A. The EMS Agency Director and EMS Medical Director must review and approve all Pilot Programs prior to implementation. B. Pilot Program studies are typically small scale and short term for the purpose of evaluating quality indicators and/or operational improvements for local EMS policies and/or protocols. C. Projects involving any of the following will be considered as research and require approval according to the Monterey CountyCounty of Monterey EMS System Policy #6160 (Research StudiesPolicy): 1. Changes in the State EMS Authority Paramedic EMT-P Scope of Practice or an untested intervention. 2. The goal of the project is to test a hypothesis. 3. The investigators intend to submit the results for publication in a professional journal. 4. When questions arise as whether a project is quality improvement versus research, the investigator will consult with the Institutional Review Board. D. The Pilot Program Investigator(s) shall submit a Pilot Program Proposal to the EMS Agency at least three (3) months prior to the planned implementation date in order to allow time for the Pilot Program Review Process. 1. The EMS Agency shall review the Pilot Program Proposal and solicit EMS Stakeholder input through the most appropriate EMS aAdvisory subcCommittee, either the Medical Advisory SubcommitteeClinical Care Committee (MACCCC) or the Operations Subcommittee Working Group (OPS), or both. Recommendations from the EMS Agency and the EMS aAdvisory subcCommittee(s) and/or working group(s) shall be presented to the Emergency Medical Care Committee (EMCC) for review, discussion, and recommendations. 2. The Pilot Program Proposal shall include the following: Monterey County of Monterey EMS System Policy 6170 a) Background/Significance: Describe the rationale for the Pilot Program, citing relevant research. Identify what questions remain and how the proposed Pilot Program will address these questions. Specify how the Pilot Program may improve the quality of care in the EMS System. b) Objectives: List the objectives upon which the outcome of the Pilot Program will be based. Identify the predictor and outcome variables and the expected outcome of the Pilot Program. c) Design/Methods: Identify the type of study, the outcome variables to be measured, and how each outcome variable is an indicator of quality of care. Describe the methods used to collect the data and avoid bias. d) Evaluation: Describe the data management and statistical methods that will be used to evaluate the data. Include methods used to minimize bias and evaluate and standards or benchmarks proposed to accept the conclusions. e) Conflicts of Interest: Identify and describe any proprietary, personal, familial, social, professional, or financial (e.g., salary, consultant payments, honoraria, royalty payments, dividends, loans, or any other payments or remunerations) conflicts of interest. f) References: Provide copies of references cited in the proposaltocol. III. PILOT PROGRAM REVIEW PROCESS A. The EMS Agency Director and EMS Medical Director shall review the Pilot Program Proposal and will present the Pilot Program to the most appropriate subEMS Advisory cCommittee(s) and/or working group(s) (MAC CCC and/or OPS) for review and discussion. B. Feedback from the reviewing subcommittee body will be incorporated into the EMS Agency’s presentation of the Pilot Program to EMCC, which shall review the proposaltocol, provide feedback, and vote to recommend approval, modifications, or disapproval of the proposed Pilot Program. Recommendations from EMCC and the reviewing subcommittee body shall be considered by the EMS Agency Medical Director, who will make the final determination on whether to approve or deny the implementation of the Pilot Program. C. If approved, the data collection period is one (1) year or as determined by the EMS Medical Director. IV. REPORTING PROCESS A. Monthly Reports: The Pilot Program Investigator(s) shall submit monthly reports to the EMS Agency on the 15th day of the following each month for the duration of the Pilot Program. These reports must summarize the progress of the program and evaluate available outcome data from the previous month. The need for quarterly reports in addition to or instead of monthly reports will be determined by the EMS Agency Medical Director. Monterey County of Monterey EMS System Policy 6170 B. Final Report: At the end of the data-collection period, the Investigator(s) must submit a final report to the EMS Agency Medical Director. The final report must include a summary of the Pilot Program including the objectives, methods, data analysis of the outcome variables, limitations of the study, and conclusions. The final report is due no later than the 15th day of the 3rd month following completion of the data-collection period. V. EARLY DISCONTINUATION A. If, under the judgment of the EMS Medical Director, patient safety concerns or preliminary data demonstrate compelling evidence warranting suspension or early discontinuation of the Pilot Program, the EMS Agency Medical Director may suspend or discontinue the Pilot Program at any time. VI. COMPLETION OF THE PILOT PROGRAM A. The EMS Agency will present the results of the Pilot Program to EMCC and the most appropriate subEMS Advisory cCommittee(s) or working group(s) (MAC CCC and/or OPS). Members may offer recommendations pertaining to continuation, modification, or discontinuation of the program. B. The EMS Medical Director will assign one of the following designations to the Pilot Program: 1. Approved – The Pilot Program demonstrates improved quality of care or benefits the EMS System and its patients, as determined by the EMS Medical Director. The program may be modified or continued under a Local Optional Scope of Practice or revision to EMS policies and/or treatment protocols, pursuant to Monterey County EMS System Policy #1000 (Policy and Protocolcedure Development Process). 2. Extended (up to one year) – There is insufficient data to evaluate the impact of the Pilot Program on quality of care or the EMS System. The data-collection period shall be extended for a defined period of time not to exceed an additional one year from completion of the initial data-collection period. 3. Discontinued – The Pilot Program does not demonstrate improved quality of care or benefit the EMS System and its patients, as determined by the EMS Medical Director. The Pilot Program will be discontinued. END OF POLICY Monterey County of Monterey EMS System Policy Policy Number: 6190 Effective Date: 7/1/2023 Review Date: 6/30/2026 COLLECTION AND SUBMISSION OF EMS DATA I. PURPOSE To establish requirements for the collection and submission of data to the Monterey County of Monterey EMS Data System by EMS provider agencies. by EMS providers using either the Monterey County EMS Data system or their own system as required by state regulations and Monterey County EMS policy. II. POLICY A. All Monterey County of Monterey EMS provider organizationsagencies, including all Basic Life Support (BLS) and Advanced Life Support (ALS) first responder agenciess and non-EOA ambulance transport EMS Pproviders, shall utilize either the designated electronic patient care report (ePCR)EMS ePCR reporting system provided by the Monterey County of Monterey EMSS Agency or an an ePCRelectronic PCR system capable of integrating seamlessly with the EMS Agency’s data Monterey County EMS Data Systemreporting system. Said All data will conformshall meet to California Emergency Medical Services Information System (CEMSIS) and National Emergency Medical Services Information System (NEMSIS) standards. B. The designated Monterey County EMS Data System is the primary system for the collection and submission of EMS data in Monterey County and is the only authorized data system for the submission of data to CEMSIS and NEMSIS. III. EMS PROVIDER AGENCIES UTILIZING COUNTY ePCR SYSTEM A. EMS Provider provider organizations agencies shall use the designated ePCR system to document all EMS responses/calls/patient information as required bystipulated in EMS Agency EMS System Ppolicies, Protocols, and Pprocedures. B. EMS Provider provider organizations agencies shall maintain hardware/software as identified in manufacturers manufacturers' and vendors’ recommendations, including all system and program updates, including security updates. C. EMS Provider organizations provider agencies are responsible for all costs of modules not related to the designated EMS Data System, such as fire reporting, staffing, scheduling, and inventory management. D. EMS Provider organizationsprovider agencies will shall use the designated County of Monterey County EMS Data System to collect, analyze, and report provider Monterey County of Monterey EMS System Policy 6190 specificprovider-specific data as required by EMS System Agency pPoliciesy, system quality improvement efforts, and applicable state requirements such as CEMSIS. E. EMS Provider organizationsprovider agencies will shall have access to their organization’s data and other data, as provided by the EMS Agency for system quality improvement efforts. F. In the event of an incident where an EMS Provider organizationsprovider agency notices that the reporting system is not operating properly, that agency shall file a support claim to the vendor. Afterwards, they shall will alert notify the EMS Agency with and the vendor to system issues or outages.a copy of the submitted support claim. G. EMS Provider organizationsprovider will agencies shall participate in the Continuous Quality Improvement Technical Advisory Group (CQI TAG), where toall EMS system participants will work collaboratively on system-wide issues and changes. EMS Pprovider agenciesorganizations shallwill not be able to change the EMS data component of the designated County system without going through a collaborative county-wide process.Guidance from these meetings shall be adhered to by all relevant system participants. .In the event, that an agency has concerns with the group’s recommendations, it should be brought up during CQI TAG meetings. This does not relinquish the agency’s responsibility to adhere to the guidance from CQI TAG. H. EMS Provider organizationsprovider agencies will enter a data sharing agreement(s) with Monterey Countythe EMS Agency and will only utilize the system once that agreement(s) has been finalized between the provider agency and the EMS Agency. I. EMS Provider organizationsprovider agencies will develop internal policies and procedures, provide training, and take other necessary steps to assure contract compliance and compliance with all data security and patient privacy laws, including Health Insurance Portability, and Accountability Act, Health Information Technology for Economic and Clinical Health Act, and California Confidentiality of Medical Information Act. J. EMS Pprovider agencies and hospitals will collaborate with the EMS Agency and hospitals to integrate system efforts with HIE/HDE as appropriateto institute and maintain a Health DataInformation Exchange (HDIE) program. IV. EMS PROVIDER AGENCIES NOT UTILIZING COUNTY ePCR SYSTEM A. EMS pProvider organizations agencies and their vendor not using the designated Monterey County of Monterey EMS DataEMS DataePCR System and their vendors must maintain a data system that: 1. Exports data to the designated Monterey County of Monterey’s Data sSystem in a format compliant with the Monterey County EMS Data System, EMS Agency’s guidelines, and is compliant withincluding CEMSIS and NEMSIS standards. This transfer of data must be seamless and require little to no effort on the part of the County EMS Agency to integrate the exported data. 2. Includes all data elements required by the designated Monterey County EMS Data System. Monterey County of Monterey EMS System Policy 6190 3. Attaches all pertinent records and documents and attachments to the ePCR shall be included in submissions. This includes, but is not limited to, and documents to the attachments and documents related to patient care, such as electrocardiograms (ECG/EKGs), capnography waveforms, Physician Certification Statement (PCS) forms, face sheets, and PDF copies of the electronic patient care report. 4. Contains provisions for the electronic transfer of patient care information between EMS providers and hospitals at the time of transfer of care or within timeframes specified in EMS System Policies and Procedures. This transfer ofAll shared information must be compatible with the overall CountyEMS Agency’s Ddata Ssystem. 5. Integrate real time Search, Alert, File and Reconcile capabilities consistent with the Monterey County EMS Data System. 6. Bi-directionally moves data in real time into and from the designated Monterey County EMS Data System 7. Provides bi-directional data movement and real time Search, Alert, File and Reconcile capabilities that is automatic and in real time and does not require any effort on the part of the EMS Agency to seamlessly integrate data with the rest of the Monterey County EMS Data System. 8. Continues seamless integration and operation with the designated Monterey County EMS Data System, even if material changes are made to the Monterey County EMS Data System. B. EMS Provider organizations utilizing their own system must notify the EMS Agency (via the EMS Duty Officer after hours) of any system outages lasting over sixty minutes in their system. C. EMS Provider organizations utilizing their own system must provide the EMS agency with a list of or description of their PCR, including all data elements and field values currently active in their system. This documentation must show the relationship between data elements and field values in the provider’s system and the EMS Agency’s Data SystemCounty system.gency shall also be responsible for all system updates required for compatibility. D. EMS Provider organizations utilizing their own system are responsible for making any changes or updates to their system required to keep their system compatible with the EMS Agency’sCounty system and are responsible for the costs of those changes/updates. Non-users of the County EMS Agency’s system are also responsible for the costs to the County of processing, testing, or and ensuring compatibility between the provider’s system and the County EMS Agency’s system. E. EMS Provider organizationsprovider agencies will shall develop internal policies and procedures, provide training, and take engage in allother necessary steps to asensure compliance with all data security and patient privacy laws. This would includes, but is not limited to, , including Health Insurance Portability, and Accountability Act, Health Information Technology for Economic and Clinical Health Act, and California Confidentiality of Medical Information Act. Monterey County of Monterey EMS System Policy 6190 F. EMS provider agencies and hospitals will collaborate with the EMS Agency and hospitals to institute and maintain a HDIE program.Provider agencies will collaborate with the EMS Agency and hospitals to integrate system efforts with HIE/HDE as appropriate. V. HOSPITAL ROLES/RESPONSIBILITIES A. Hospitals will shall be responsible for working with EMS providers and the EMS Agency to ensure the integration of prehospital and hospital patient records as specified in EMS System Policies and Procedures. B. Hospitals will provide outcome data to the EMS data system. At a minimum, that data will include Emergency Department and hospital discharge diagnosis information as well as other data points required by the EMS Agency. C. Hospitals will shall participate in the CQI TAG to and work collaboratively on system- wide issues. and changes. D. Hospital data submission will shall be consistent with CEMSIS and NEMSIS hospital data elements. E. Hospitals will collaborate with the EMS Agency and EMS Provider organizations in the HIE/HDE as appropriate. F. Hospitals will shall enter into a data sharing agreement with the Monterey County of Monterey EMS Agency and will only utilize the system once that agreement has been finalized. between the hospital and the County. F. VI. EMS AGENCY ROLES/RESPONSIBILITIES A. The EMS Agency will coordinate the designated ePCR/Data System including implementation, training, and issue resolution. The Agency will work with the ePCR vendor on system coordination. B. The EMS Agency will pay for the initial implementation and ongoing costs related to the EMS Data system as specified in the agreement(s) between provider agencies and the EMS Agency. C. The EMS Agency will promulgate EMS System Policies and Procedures to prescribe use of the designated Monterey County EMS Data System. D. The EMS Agency will have access to provider-specific and system-wide data. Some operational data from EMS provider organizations, such as response times, may be shared as a part of the public record. Clinically oriented data may be shared in appropriate confidential quality improvement processes. E. The EMS Agency will analyze and report on system-wide data to EMS system stakeholders and other interested parties as appropriate and in concert with system-wide quality improvement efforts. The Agency may also work with individual provider agencies on provider specific quality improvement efforts as requested and appropriate. Monterey County of Monterey EMS System Policy 6190 F. The EMS Agency will be responsible for the submission of data to the CEMSIS database. This will include the submission of Core Measures and any other data as required by the state. G. The EMS Agency will enter a data sharing agreement(s) with provider agencies and hospitals and will only utilize the system once that agreement(s) has been finalized between the Agency, provider agencies, and hospitals. H. The EMS Agency will work in good faith to resolve problems with individual provider agencies and hospitals as they arise and will strive for a collaborative relationship with all system stakeholders. VII.VI. DISPATCH CENTERS USING COMPUTER AIDEDCOMPUTER-AIDED DISPATCH (CAD) ROLES/RESPONSIBILITIES A. Any dispatch center dispatching EMS providers in the Monterey County of MontereyEMS System must work with the EMS Agency, system providers, and the vendor(s) to ensure CAD data can populate the appropriate fields in of the ePCR and that this same data can be integrated into the designated County EMS Agency’s Data System. B. This All data must be consistent with current CEMSIS and NEMSIS data standards, and with the County EMS Agency’s Data System. C. EMS Dispatch Centers will shall participate in the CQI TAG to work collaboratively on system-wide issues and changes. D. As appropriate and deemed necessary by the EMS Agency, Dispatch dispatch Centers centers will shall enter a data sharing agreement with Monterey Countythe EMS Agency. E. Dispatch Centers will play an active roleshall particiapte in system-wide quality improvementQI efforts based on CAD and Medical Priority Dispatch System (MPDS) data obtained as a result of the County data system. VIII.VII. VENDOR RESPONSIBILITIES A. Vendor responsibilities are will be described in detail in the an agreement between the vendor and the County of Monterey. That agreement is a public document and will be shared with system stakeholders upon request. IX.VIII. TECHNICAL PROBLEMS/OUTAGES A. Device Failure – In the event of a device failure (e.g.i.e. iPad, tablet, laptop, etc...), provider agencies should contact their internal support person, document all pertinent PCR information on paper, and enter the ePCR information into the electronic system as soon as possible. Electronic device failure is not an exception for completing an electronic patient care reportePCR. and entering it into the system. B. Connectivity Failure – In the event of connectivity failure, the provider shall attempt to find another appropriate means to submit ePCR data. In the event the provider can not they shall document all patient information either on paper or on the device being used and save it until connectivity is restored. Patient information should be uploaded into the Monterey County of Monterey EMS System Policy 6190 system as soon as possible. Connectivity failure may be local or system-wide. Local support personnel should be contacted for local issues. The EMS Agency will work with the vendor to resolve system-wide connectivity issues. C. System failure – In the event of system-wide failure, document all patient care information on paper or on youra device and savefor future submission. Patient information should be uploaded into the system as soon as the system is back up. The EMS Agency will work with the vendor to resolve system failure issues as quickly as possible and will communicate with system stakeholders when the system is back up. D. The EMS Agency should shall be notified of downtime or transmission difficulties lasting more than 1 hour. The EMS Duty Officer can shall be contacted for issues arising after normal business hours. E. Any system upgrades or system maintenance must shall be reviewed and approved in writing by the EMS Agency prior to implementation. Any planned issue, such as system maintenance, that could cause a delay in data transmission will shall be reported to the EMS Agency at least 24 hours in advance. X.IX. PRIVACY AND PROTECTION OF HEALTH INFORMATION A. Maintaining confidentiality is an essential part of all health care, including prehospital care. The confidentiality of protected health information (PHI) and protected personal information (PPI) is covered by numerous state and federal statutes. These include: Health Insurance Portability and Accountability Act (HIPPAA) of 1996; California Confidentiality of Medical Information Act (CCMIA) including California Civil Code Section 56.36, Division 109, Section 130200; and California Health and Safety Code Sections 1280.1, 1280.15, and 1280.3 1. Providing ePCR information to receiving hospitals and other providers giving care in an EMS response system and to the EMS Agency for quality improvement efforts does not constitute a violation of the above regulations. 2. Provider agencies and hospitals are responsible for training their employees on the initiation, completion, and distribution of patient care records, and on all applicable state and federal information privacy statutes, regulations, and policies and procedures. This is a priority as the unintended (or intentional) release of protected information can have serious consequences for the provider agency or hospital and may violate HIPPA and other applicable laws. EMS and provider agency and facility staff must protect the security, confidentiality, and privacy of all patient medical records in their custody at all times. 3. Detailed requirements for the sharing of data within the EMS system and for the protection of personal health information is contained in the agreements between individual provider agencies, hospitals, and the county. 4. The above referenced statutes and regulations also allow for the sharing of information in HIEs/HDEs. All the entities involved in an HIE/HDE are responsible for maintaining patient confidentiality. That includes the vendor of Monterey County of Monterey EMS System Policy 6190 the various electronic patient care reporting systems and the HIE/HDE entity itself. 5. The EMS Agency will facilitate and coordinate, as appropriate and deemed necessary, training opportunities on protecting confidential patient care information. 6. All patient records containing protected health and personal information must be kept secure at all times. These records must not be visible to the public. This includes appropriate security measures, such as user identification and login passwords, for computer workstations. Workstations must be locked when unattended. END OF POLICY County of Monterey EMS System Policy Policy Number: 7020 Effective Date: 7/1/2023 Review Date: 6/30/2026 NALOXONE LEAVE BEHIND PROGRAM I. PURPOSE A. To establish a policy to allow EMS personnel to provide an intra-nasalintranasal naloxone delivery device to patients who are at high risk for fatal opioid overdose. B. To help mitigate the impact of the opioid crisis by increasing the availability of naloxone to the public. II. POLICY A Naloxone Leave Behind Kit may be offered to an at-risk person, friend, or family member in the event of a suspected overdose following treatment of the patient. Kits may be provided to patients or bystanders regardless of whether the patient is transported to the hospital. All EMS providers, under the direction of the Monterey County EMS Medical Director, are authorized to leave behind an intra-nasal naloxone delivery device with the for patients or a responsible adult who are believed to be at high risk of an opioid overdose and refuse transport.: A. Decline transport to the hospital after a suspected opioid overdose event. B. Meets criteria of EMS Policy 4030, Pre-Hospital Consent and Refusal of Service/Care- Supplemental Checklist. C. EMS personnel deem to be at risk of an unintentional overdose. III. PROCEDURE A. EMS units may be stocked with naloxone intra-nasal delivery devices intended for layperson utilization in the event of an opioid overdose. EMS shall not distribute naloxone to patients or bystanders from the regular EMS patient care supply. B. Administration of naloxone by EMS providers at the scene of an incident will be performed in accordance with existing Monterey County of Monterey EMS protocols. C. Patients at-risk for opioid overdose may include: 1. Opioid overdose requiring naloxone administration or supportive care and monitoring. 2. History or physical exam with evidence of illicit substance use or paraphernalia (e.g. history of intravenous drug use, needle marks, abscesses at injection sites, needles present in belongings). 3. History or physical exam with prescription opioid use (prescribed or recreational). County of Monterey County EMS System Policy 7020 4. Physical environment with multiple or high-dose prescription opioids present. 5. Self-reported dependence on opioids. D. A Naloxone Leave Behind Kit may be distributed on each call where there is a primary impression of overdose or reasonable provider suspicion of opioid abuse. C. EMS personnel should recommend immediate transport to an emergency department for any patient who requires resuscitation with naloxone or is suspected to have experienced an opioid overdose. D. If a patient declines transport, EMS providers will: 1. Assess the patient using EMS Policy 4030, Pre-Hospital Consent and Refusal of Service/Care- Supplemental Checklist. E. Patients who do not have adequate decision-making capacity to decline transport will be transported to the closest appropriate emergency department. F. Patients who decline transport and are deemed to have adequate decision-making capacity will be asked to sign an AMA form declining further care and transport. G. For patients who decline transport and are deemed to have adequate decision-making capacity, EMS personnel may leave an intra-nasal naloxone delivery device and opioid addiction resource form with the patient or other responsible adult at the scene of the incident. E. If a nNaloxone Leave Behind Kit delivery device is left with the patient or other responsible adult, EMS personnel will instruct the recipient on the proper indications and technique for usage of the device and shall leave an instructional pamphlet. F. EMS personnel shall document in the patient care report (PCR) that a Naloxone Leave Behind Kit was distributed. If a Kit is left with a friend or family member and not the patient, EMS personnel do not need to create an additional PCR as it is related to the emergency scene of the initial response. In addition to the standard requirements, documentation shall include: 1. A description of the instructions given to the recipient. H.2. The administration of naloxone in the Medication section of the Flow Chart with “Other/miscellaneous” as the Route, the Lot Number of the Kit, and “Leave Behind” in the Comments. I. If a naloxone delivery device is left with the patient or other responsible adult, EMS personnel will record the lot number of the device on the EMS Policy 4030, Pre-Hospital Consent and Refusal of Service/Care)- Supplemental Checklist form. J. PCR documentation shall include patient capacity, distribution of an intra-nasal naloxone delivery device to the patient, naloxone delivery device lot number, and a description of the instructions given to the patient. K.G. EMS personnel may, at their discretion, leave a Naloxone Leave Behind Kit n intra-nasal naloxone delivery device with other individuals whom EMS personnel deem County of Monterey County EMS System Policy 7020 to be at risk for unintentional opioid overdose (e.g., patients whose medication regimen includes high doses of narcotics or at-risk family and bystanders), even if the call to which EMS personnel are responding does not specifically involve an opioid overdose. In such cases, EMS personnel will document on the initial patient’s PCR, that naloxone a Kit was provided to a separate individual, and include the naloxone lot number. No demographic information pertaining toof the individual shall be recorded on the patient’s PCR. The EMS personnel will instruct the recipient or a responsible adult on the proper indications and technique for usage of the device and leave an instructional pamphlet. L. When utilized on the scene of a call, the completed EMS Policy 4030, Pre-Hospital Consent and Refusal of Service/Care- Supplemental Checklist form is to be uploaded electronically and attached to the electronic Patient Care Report. The physical copy of the completed form is to be submitted to the supervisor in charge of that jurisdictional agency’s Leave Behind Naloxone Program. END OF POLICY Monterey CountyCounty of Monterey EMS System Policy Policy Number: 8080 Effective Date: 7/1/20263 Review Date: 6/30/20296 MONTEREY COUNTYCOUNT OF MONTEREY MHOAC NOTIFICATION/ACTIVATION I. PURPOSE To provide guidance to the EMS Duty Officer, Medical /Health Operational Area Coordinator (MHOAC) program, and operational lead and/or supporting agencies responsible for ensuring that medical and health preparedness and response activities are completed. Within the Operational Area (OA) various departments and programs may be responsible for one or more of the 17 MHOAC program functions outlined in Health and Safety Code §1797.153. II. POLICY The Board of Supervisors has designated the EMS Director as the Monterey CountyCounty of Monterey MHOAC. The MHOAC program will be facilitated through a collaborative effort between the Monterey CountyCounty of Monterey EMS Agency, the Monterey County County of Monterey Health Officer, and the Monterey CountyCounty of Monterey Health Department. III. PROCEDURE A. Notification 1. Any agency that is impacted by a trigger event or situation (as outlined below) shall contact the EMS Duty Officer by calling the Monterey CountyCounty of Monterey EMS Communications Center at 831-796-6444. 2. The Monterey CountyCounty of Monterey EMS Communications Center will contact the EMS Duty Officer, based upon internal notification policies. 3. If the Monterey CountyCounty of Monterey EMS Communications Center becomes aware of or identifies an event or situation that meets the notification/activation triggers they shall notify the EMS Duty Officer. 4. The EMS Duty Officer will notify the MHOAC, as appropriate. B. Triggers for Notification of the MHOAC Any of the following conditions may trigger the notification of the MHOAC: 1. An incident that significantly impacts or is anticipated to significantly impact public health, the medical/health system, behavioral health, environmental health, or emergency medical services; 2. An incident where resources are needed or are anticipated to be needed beyond the capabilities of the OA, including those resources available through existing County of Monterey County EMS System Policy 8080 agreements; 3. An incident that leads to a regional or state request for information or mutual aid; and/or 4. An incident in which increased information flow from the OA to the region and the state will assist in the management or mitigation of the incident’s impact. C. Role of the EMS Duty Officer 1. Day to day EMS system operational issues will be managed by the EMS Duty Officer. 2. If the situation/event meets a notification/activation trigger as described above, the EMS Duty Officer shall contact the MHOAC. D. Role of the MHOAC 1. Identify resources and coordinate the procurement and allocation of public and private medical, health and other resources required to support disaster medical and health operations in affected areas. 2. Request and respond to situation status reporting and resource requests generated by OA hospitals, Health Care Facilities and medical care entities and providers. 3. Communicate the medical and health status and needs to local, regional, and state governmental agencies and officials inside and outside of the OA. 4. Coordinate with the Regional Disaster Medical Coordinator/Specialist (RDMHC/S) program for medical and/or health mutual aid support from outside the OA as needed. 5. Coordinate with OA Supporting Agencies, and with regional and state entities as appropriate. 6. Ensure the completion and submission of a Situation Status Report inclusive of all Medical and /Health awareness information within the OA as per guidance in the California Public Health and Medical Emergency Operations Manual. 7. Coordination and support of the specific MHOAC Program functions with the Operational Area Lead and/or Support Agencies. E. The Operational Area Lead and/or Support Agency is responsible for: 1. Coordination of notifications within their respective agency, with the MHOAC, other OA agencies and with regional and state entities. 2. Ensuring situational awareness information is shared with the MHOAC for inclusion in any notifications and/or situation status reports. 3. Coordination and support of the specific MHOAC Program functions in which they are participating. County of Monterey County EMS System Policy 8080 F. MHOAC Program Function Matrix MHOAC Program Response Operational Operational Function Area Lead Support Agency 1. Assessment of immediate medical EMS PH needs 2. Coordination of disaster medical and health resources a. Medical HO, and PH, and b. Health MHOAC BH c. Mental Health 3. Coordination of patient distribution and medical EMS PH evaluations 4. Coordination with inpatient and emergency care EMS PH providers EMS and PH (Outpatient Clinics, Skilled 5. Coordination of non- Nursing, Long Term Care, out-of- hospital Dialysis Centers, Urgent medical care Care Centers & providers MHOAC Surgeryand Surgery Centers ) Centers 6. Coordination and integration with fire agenciesy personnel, resources, and emergency EMS OES fire pre-hospital medical services 7. Coordination of providers of non-fire based prehospital emergency EMS OES medical services 8. Coordination of the establishment of temporary EMS PH and OES fField tTreatment sSites 9. Health surveillance and epidemiological analyses of community health CDU PH status County of Monterey County EMS System Policy 8080 MHOAC Program Response Operational Operational Function Area Lead Support Agency 10. Assurance of food safety EH HO 11. Management of exposure HO/Regional EH to hazardous agents HazMat Team 12. Provision or coordination BH PH of mental health services 13. Provision of medical and HO and OES PIO health public information HO and PH PIO protective action recommendations 14. Provision or coordination EH HO / PH of vector control services 15. Assurance of drinking EH HO / PH water safety 16. Assurance of the safe management of liquid, solid EH PH and hazardous wastes 17. Investigation and control CDU PH of communicable disease Matrix Key: AG Agriculture Commissioner BH Behavioral Health CDU Communicable Disease Unit EH Environmental Health EMS EMS Agency HO Health Officer MHOAC Medical Health Operational Area Coordinator OES Office of Emergency Services PH Public Health PIO Public Information Officer (Health Department) G. Sustaining the MHOAC program in a long-term event The MHOAC Program will be sustained through a collaborative effort among the Monterey CountyCounty of Monterey EMS Agency, the Monterey CountyCounty of Monterey Health Officer, and the Monterey CountyCounty of Monterey Public Health Bureau for the duration of the event and through the recovery process. For sustained events requiring substantial expansion of the ICS/MAC structure, mutual aid may be necessary. 1. The Public Health Bureau and EMS Agency will ensure that they can adequately supply qualified staff to perform as the MHOAC designee. 2. The Public Health Bureau and EMS Agency will create a MHOAC staffing schedule to be utilized in the event of a long-term event, to include the activation of the DOC or the Operational Area EOC in order to fill the Medical/ County of Monterey County EMS System Policy 8080 Health Branch. 3. The Public Health Bureau and EMS Agency will identify the Lead Agency referencing the MHOAC Program Function Matrix H. Triggers to sustain the MHOAC program in a long-term event include: 4. Event lasting longer than 48 hours; or 5. Operational Area EOC activation; or 6. Public Health Officer directive; or 7. Activation of Public Health DOC IV. REFERENCES Health & Safety Code §1797.153 (MHOAC) & §1797.152 (RDMHC) California Health and Medical Emergency Operations Manual, July 2011 END OF POLICY Monterey County of Monterey EMS System Policy Protocol Number: E-1 Effective Date: 7/1/2023 Review Date: 6/30/2026 ACUTE VENOMOUS SNAKEBITE BLS CARE Routine medical care. Assess for oozing at the site of the bite. Notify next caregiver of the presence or absence of oozing. Record the time of the bite. Remove potentially constricting clothing or jewelry. Document the progression of swelling, including the time of each notation. Attempt to note progression every 15-30 minutes. Do not apply ice or restrict blood or lymph flow with a tourniquet or constricting band. Keep the site of the bite lower than the heart and restrict patient activity. Attempt to identify the snake. Do not attempt to capture a live snake. Gather antivenom if available at the scene. Bring antivenom with the patient to the hospital. ALS CARE Routine medical care. Pain control – refer to Protocol #M-2 (Pain Control) NOTES: The only native venomous snake in the area is the Northern Pacific Rattlesnake. All local hospitals have access to anti-venom for this snake. If a patient is bitten by a venomous snake that is believed to be non-native, attempt to identify the snake (do not capture), notify Animal Control, and transport the patient to the closest appropriate hospital. Consider contacting Base Hospital and Poison Control (1-800-222-1222) for additional guidance. If antivenom is available on scene, it should be transported along with the patient. Oozing at the site of the bite often indicatesmay indicate envenomation. This should be noted in the documentation and relayed to the receiving caregiver. Monterey County of Monterey EMS System Policy Protocol Number: E-1 Effective Date: 7/1/2023 Review Date: 6/30/2026 Notify the receiving hospital as early as possible. Mixing of antivenom can take 30 minutes. Northern Pacific Rattlesnake Monterey County EMS System Policy Protocol Number: EP-1 Effective Date: 7/1/2023 Review Date: 6/30/2026 ACUTE VENOMOUS SNAKEBITE - PEDIATRIC BLS CARE Routine Medical Care. Assess for oozing at the site of the bite. Notify the next caregiver of the presence or absence of oozing. Record the time of the bite. Remove potentially constricting clothing or jewelry. Document the progression of swelling, including the time of each notation. Attempt to note progression every 15-30 minutes. Do not apply ice or restrict blood or lymph flow with a tourniquet or constricting band. Keep the site of the bite lower than the heart and restrict patient activity. Attempt to identify the snake. Do not attempt to capture a live snake. Gather antivenom if available at the scene. Bring antivenom with the patient to the hospital. ALS CARE Routine Medical Care. Pain Control-refer to Protocol MP-2 (Pain Control-Pediatric) NOTES: The only native venomous snake in the area is the Northern Pacific Rattlesnake. All local hospitals have access to anti-venom for this snake. If a patient is bitten by a venomous snake that is believed to be non-native, attempt to identify the snake (do not capture), notify Animal Control, and transport the patient to the closest appropriate hospital. Consider contacting Base Hospital and Poison Control (1-800-222-1222) for additional guidance. If antivenom is available on scene, it should be transported along with the patient. Oozing at the site of the bite may indicate envenomation. This should be noted in the documentation and relayed to the receiving caregiver. Monterey County EMS System Policy Protocol Number: EP-1 Effective Date: 7/1/2023 Review Date: 6/30/2026 Notify the receiving hospital as early as possible. Mixing of antivenom can take 30 minutes.Oozing at the site of the bite often indicates envenomation. Notify the receiving hospital as early as possible. Mixing of antivenom can take 30 minutes. Northern Pacific Rattlesnake Monterey County EMS System Policy Protocol Number: MP-3 Effective Date: 7/1/2024 Review Date: 6/30/2027 PAIN CONTROL - PEDIATRIC BLS CARE Routine medical care. Positioning Splinting as indicated Ice packs as indicated ALS Care Routine Medical Care Morphine Sulfate 0.1 mg/kg IV/IO/IM (0.05 mg/kg if less than 6 months old). Max single dose 5 mg. May repeat every 10 minutes to a maximum total dose of 10 mg. OR Fentanyl 2 mcg/kg IN/IM. Max single dose 100 mcg. May repeat every 10 minutes to a maximum total dose of 200 mcg. OR Fentanyl 2 mcg/kg slow IV/IO (over 1 minute). Max single dose 100 mcg. May repeat every 10 minutes to a maximum total dose of 200 mcg. Fentanyl requires dilution for administration to patients weighing less than 25 kg: 1. Expel and discard 2 ml of Normal Saline (NS) from a 10-ml prefilled syringe, leaving 8 ml of NS in the syringe. 2. Using a 2nd syringe, withdraw 2 ml of Fentanyl 50 mcg/ml (100 mcg) and add it to the 8ml of NS left in the prefilled syringe. This results in a concentration of 10 mcg/ml. 3. Label the syringe. 4. Use a 1 ml or 3 ml syringe to draw up and administer doses. Increments are 1 mcg/0.1 ml. 5. Do not dilute medication if administering doses via the intranasal (IN) route. Base Hospital Contact required to administer more than one dose of morphine or fentanyl, or to switch pain medications for subsequent dosing. NOTEote: A. Attempt pain management through measures such as a cold pack, coaching, splinting, or other methods as indicated by the patient’s condition. B. The use of narcotics for pain management should be reserved for patients in moderate to severe pain. C. The patient’s respiratory status is to be monitored closely when narcotics are administered. D. Titration of medications can be done to achieve a desired outcome or prevent unwanted side effects. E. Document the patient’s pain level before and after pain management efforts. The method of evaluation must be consistent each time pain is evaluated. Patient response, if any, is to be recorded. F. Follow the appropriate protocol for specific conditions. G. Switching between analgesic medications to achieve pain control requires base physician direction.The use of multiple pain medications to achieve control of pain is discouraged and requires base physician direction. UNDILUTED Pediatric Fentanyl Dose Chart (2 mcg/kg) 50 mcg/ml Weight Dose Volume 5 kg 10 mcg 0.2 ml 10 kg 20 mcg 0.4 ml 20 kg 40 mcg 0.8 ml 30 kg 60 mcg 1.2 ml 40 kg 80 mcg 1.6 ml >50 kg 100 mcg 2 ml DILUTED Pediatric Fentanyl Dose Chart (2 mcg/kg) 10 mcg/ml Weight Dose Volume 5 kg 10 mcg 1 ml 10 kg 20 mcg 2 ml 20 kg 40 mcg 4 ml 30 kg 60 mcg 6 ml 40 kg 80 mcg 8 ml >50 kg 100 mcg 10 ml Document level of pain prior to and after administration of pain medications: ➢ <3 years old – Behavioral tool or Wong-Baker FACES scale ➢ 3-7 years old – Wong-Baker FACES scale or visual analog scale ➢ 8-14 years old – visual analog scale BEHAVIORAL TOOL 0 1 2 No particular Occasional grimace or Frequent to constant Face expression or smile frown, withdrawn, frown. Clenched jaw, disinterested quivering chin 0 1 2 Legs Normal or relaxed Uneasy, restless, tense Kicking, or legs drawn position up 0 1 2 Activity Lying quietly, normal Squirming, tense, shifting Arched, rigid or jerking position, moves easily back and forth 0 1 2 No cry (awake or Moans or whimpers; Cries steadily, screams, Cry asleep) occasional complaint sobs, frequent complaints 0 1 2 Consolability Content, relaxed Reassured by talking to, Difficult to console hugging, distractible Brief initial instructions: Point to each face using the words to describe the pain intensity. Ask the child to choose the face that best describes their own pain and record the appropriate number. Original instructions Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain. As the person to choose the face that best describes how he/she is feeling. ➢ Face 0 is very happy because he doesn’t hurt at all ➢ Face 2 hurts just a little bit ➢ Face 4 hurts a little more ➢ Face 6 hurts even more ➢ Face 8 hurts a whole lot ➢ Face 10 hurts as much as you can imagine, although you don’t have to be crying to feel this bad. VISUAL ANALOG SCALE Monterey CountyCounty of Monterey EMS System Policy Protocol Number: NP-2 Effective Date: 7/1/20263 Review Date: 6/30/20296 SUSPECTED HYPOGLYCEMIA - PEDIATRIC ALS and BLS CARE Routine Medical Care (Protocol MP-2) If hypoglycemia still most likely cause of the patient s condition despite normal reading on glucometer, NO BGL < 70 mg/dL OR known diabetic administer glucose regardless, while with altered mental status? considering other causes of altered mental status YES Can the patient YES Administer Glucose Paste 15 gm (½ safely tolerate oral tube) PO or other oral glucose glucose? containing solution NO Consider Glucagon: • < 20 kg = 0.5 mg IM NO YES Can IV access be established? Is the patient still symptomatic? • kg = 1 mg IM OR establish IO access for Dextrose YES Administer Dextrose: • Neonates = 10% at 2 cc/kg IV/IO • Pediatric = 25% at 2 cc/kg IV/IO Maximum dose of 50 cc Reassess Patient NO May repeat initial Dextrose dose NO Symptoms once if BGL remains below 70 mg/dL resolved? and altered mental status continues YES Consider other causes of altered Monitor Patient mental status Transport to the most appropriate ED If Dextrose 10% is not available due to supply chain shortages, Dextrose 12.5% may substituted at the same dose Monterey County EMS System Policy Protocol Number: R-4 Effective Date: 7/1/2023 Review Date: 6/30/2026 RESPIRATORY DISTRESS ALS and BLS CARE Protocol R-1 Airway No Management Airway Intact Yes • Oxygen-Titrate to > 94% Titrate to 92% with history of COPD • Capnography • Routine Medical Care Wheezing Present Go to Protocol R-3 Respiratory Distress Due Yes to Asthma/COPD No Signs of CHF: Crackles, Protocol R-2 Pedal Edema, and Yes Pulmonary Edema Hypertension No Consider most likely cause based on presentation Hyperventilation Pneumonia Croup Epiglottitis /Anxiety and Sepsis Supportive Care Consider Nebulized Position of comfort. Go to Protocol Consider Blood Saline Avoid unnecessary M-4 Sepsis Glucose check interventions. Transport to the nearest Emergency Department Monterey County EMS System Policy Protocol Number: RP-2 Effective Date: 7/1/2023 Review Date: 6/30/2026 RESPIRATORY DISTRESS – PEDIATRIC ALS and BLS CARE Go to RP-1 Airway No Airway Intact Management Yes • Oxygen-Titrate to >94% • Capnography • Routine Medical Care Go to EP-2 Allergic Anaphylaxis Yes Reactions/ Anaphylaxis No Bronchospasm Yes No or wheezing Position of comfort Albuterol 2.5 mg Epiglottitis? Yes Avoid unnecessary and Atrovent 0.5 mg interventions in 5.5 ml by nebulizer No Consider nebulized Croup? Yes saline Severe Distress includes: No Epinephrine 1:1,000 • ALOC • Establish IV/IO 0.01 mg/kg IM for • Severe fatigue access severe distress • Inability to speak • NS 20 mL/kg • O2 sat remains <90% Sepsis? Yes bolus • Cooling measures as needed No Hyperventilation Yes Reassurance /Anxiety? No Transport to closest Emergency Dept. Monterey County of Monterey EMS System Policy Protocol Number: T-1 Effective Date: 7/1/2023 Review Date: 6/30/2026 BURN CARE ALS and BLS CARE Stop the burning process: • Remove clothes or constricting items if not adhered to patient s skin. • For clinically stable patients with 1st or 2nd Types of Burns degree burns < 30% TBSA, remain on scene • Thermal – remove from environment, and irrigate burn with cool running water for put out fire. 20 minutes prior to transport. Do not use ice • Chemical – brush off or dilute chemical, water. consider HAZMAT team. • Electrical – make sure patient is de- Routine Medical Care (Protocol M-3) energized and suspect internal injuries. • Oxygen NRB 15 Lpm. • Assume CO if enclosed space. • CO2 End Tidal Monitoring • Albuterol 5 mg via nebulizer for Respiratory distress, signs or symptoms of Yes hoarseness, or stridor? bronchospasm. May repeat once. • Manage airway and assist ventilations as needed. *Critical Burns No • Consider CO exposure. Do not include 1st degree burns in this Evaluate degree and body surface determination area (BSA) involved • 2nd degree burns > 10% BSA. • 3rd degree burns > 5% BSA. • Burns involving the face, hands, feet, genitalia, • For clinically stable patients (no perineum, or major joints. trauma or airway involvement), • Electrical burns, including lightning injury. consider transporting directly to a Critical • Chemical burns. Yes Burn Center. Burns?* • Burn with inhalation injury. • Start 2 large-bore IVs or an IO. • Patients with preexisting medical disorders that • Administer Lactated Ringers (LR) could complicate management, prolong recovery, at 500 mL/hr. No or affect mortality. IV NS TKO Patients with burns and concomitant trauma should be transported to the closest Trauma Center for stabilization. Patients with inhalation injury or burns to the • Dress burns with dry sterile airway should be transported to the closest dressings or burn sheets. Emergency Department for stabilization. • Treat other injuries per protocols. • Cover patient to keep warm. Burn Centers Consider Pain Control (Protocol M-2) • San Jose – Santa Clara Valley Medical Center Regional Burn Center • Fresno – Community Regional Medical Center Leon S. Peters Burn Center Transport to closest • San Francisco – Bothin Burn Center at Emergency Department Saint Francis Memorial Hospital Monterey County of Monterey EMS System Policy Protocol Number: TP-1 Effective Date: 7/1/2023 Review Date: 6/30/2026 BURNS - PEDIATRIC ALS and BLS Stop the burning process: • Remove clothes or constricting items if not adhered to patient s skin. Types of Burns • For clinically stable patients with 1st or 2nd degree • Thermal – remove from environment, burns < 30% TBSA, remain on scene and irrigate put out fire. burn with cool running water for 20 minutes prior • Chemical – brush off or dilute chemical, to transport. Do not use ice water. consider HAZMAT team. • Electrical – make sure patient is de- energized and suspect internal injuries. Routine Medical Care (Protocol M-3) • Assume CO if enclosed space. • Oxygen NRB 15 Lpm. • CO2 End Tidal Monitoring • Albuterol 2.5 mg via nebulizer for Respiratory distress, signs or symptoms of Yes *Critical Burns hoarseness, or stridor? bronchospasm. May repeat once. Do not include 1st degree burns in determining • Manage airway and assist • 2nd degree burns > 10% BSA. ventilations as needed. No • 3rd and 4th degree burns. • Consider CO exposure. • Burns involving the face, hands, feet, Evaluate degree and body surface genitalia, perineum, or major joints. area (BSA) involved • Electrical burns, including lightning injury. • Chemical burns. • For clinically stable patients (no • Burn injury with inhalation injury. trauma or airway involvement), consider transporting directly to a Burn Center. Critical • For patients with > 20% BSA 2nd & Destination Considerations Burns?* 3rd degree burns: For patients with burns and concomitant Yes - Start a large-bore IV or IO trauma: - Initiate fluid resuscitation with • If the burn injury poses the greatest risk of Lactated Ringers (LR) morbidity or mortality, consider transporting No directly to a Burn Center. Fluid Resuscitation Rates: • If the trauma poses the greater immediate IV NS TKO • yrs old – mL LR per hour risk, transport to the closest Trauma Center. • 6-13 yrs old – mL LR per hour Patients with inhalation injury or burns to the airway should be transported to the closest Emergency Department for stabilization. • Dress burns with dry sterile dressings or burn sheets. • Treat other injuries per protocols. Burn Centers • Cover patient to keep warm. • San Jose – Santa Clara Valley Medical Center Regional Burn Center • Fresno – Community Regional Medical Center Leon S. Peters Burn Center Consider Pain Control (Protocol MP-2) • San Francisco – Bothin Burn Center at Saint Francis Memorial Hospital Transport to closest Emergency Department PEDIATRIC RULE OF 9’S Relative percentage of total body surface area (TBSA) affected by growth AREA NEONATE 1 YEAR 5 YEARS 10 YEARS 15 YEARS A/D = 1/2 OF HEAD 9 ½ % TBSA 8 ½% TBSA 6 ½% TBSA 5 ½% TBSA 4 ½% TBSA B/E = 1/2 OF ONE THIGH 2 ¾% TBSA 3 ¼% TBSA 4% TBSA 4 ½% TBSA 4 ½% TBSA C/F = 1/2 OF ONE LEG 2 ½% TBSA 2 ½% TBSA 2 ¾% TBSA 3% TBSA 3 1/4% TBSA County of Monterey Monterey County EMS System Policy Protocol Number: TP-2 Effective Date: 7/1/20263 Review Date: 6/30/20296 ISOLATED EXTREMITY INJURY - PEDIATRIC ALS and BLS CARE Routine Medical Care (Protocol MP-2) Hemorrhage Control • Apply direct pressure • Apply a tourniquet if bleeding is not controlled with direct pressure • If a tourniquet cannot be placed, consider wound packing with hemostatic dressings & apply a pressure dressing Evaluate for Field Trauma Triage Criteria (Policy 4040) and consider Rapid Transport to most appropriate Trauma Center Remove potentially constricting items Stabilize impaled objects Hypothermia Prevention Consider IV/IO Access 20 cc/kg Normal Saline bolus Repeat bolus as needed for signs of shock Consider Pain Control (Protocol MP-3) Consider condition- specific treatments Amputations Decreased/Absent CSM Femur Fractures Dislocations • Wrap body part or tissue in sterile • Manually reposition extremity into • If isolated mid-shaft femur fracture • Splint in position found gauze moistened with sterile saline anatomical position suspected, use traction splint • Re-Evaluate CSM – expedite • Place into a plastic bag or container transport if no change • Place bag or container into another • Splint in anatomical position container filled with ice water • Cover open wounds with sterile • Do not allow body part or tissue to dressings directly contact ice • All tissue or body parts should be transported with the patient to the hospital, but do not delay transport of patient for prolonged extrication of body parts or tissue. Transport separately if needed. Splint all other fractures as patient condition and time permits Transport to appropriate Emergency Department