ems policies and procedures

EMS POLICIES AND PROCEDURES

POLICY #: 2

EFFECT DATE: xx/01/06 PAGE: 1 of 2

SUBJECT: PARAMEDIC ACCREDITATION

APPROVED BY: Art Lathrop, EMS Director Joseph A. Barger, MD, EMS Medical Director

I. PURPOSE

To identify the process for paramedic accreditation in Contra Costa County.

II. ACCREDITATION

A. All candidates shall meet the following accreditation requirements: 1) Possess a current California paramedic license. 2) Be employed as a paramedic with a designated ALS service provider or the EMS Agency 3) Attend a Contra Costa EMS Orientation provided by the provider agency and approved by the

EMS Agency or provided by the EMS Agency. 4) Successfully complete the Contra Costa County EMS Optional Scope Skills Session provided

by the provider agency. 5) Complete an application form, available on line or at the provider agency or the EMS Agency.

B. Documentation that the accreditation requirements have been met must be submitted to the EMS Agency, by the applicant’s employer, with the candidate’s application and accreditation fee.

The EMS Agency shall notify individuals applying for accreditation of the decision to accredit within thirty (30) days of application.

III. MAINTAINING ACCREDITATION

A. Accreditation to practice shall be continuous as long as:

1) State licensure is maintained, 2) Employment as a paramedic with a designated Contra Costa ALS service provider or the EMS

Agency is maintained, 3) A current and valid ACLS card, according to the standards of the American Heart

Association, is maintained.

4) Verification of skills competency is completed every two years, and,

5) Any other local requirements are met.

B. Documentation that the above requirements to maintain accreditation have been met must be submitted by the applicant’s employer prior to expiration of the paramedic’s license.

Revised: 01/01/02, xx/01/06

Instructions for Completion of the Paramedic Skills Verification Form 1 Name of License Holder

Provide the complete name of the paramedic who is demonstrating skills competency.

2 License Number Provide the paramedic license number of the paramedic who is demonstrating skills competency.

3 Signature Signature of the paramedic who is demonstrating competency.

By signing this section the paramedic is verifying that the information contained on this form is accurate and that he/she has demonstrated competency in the skills listed to a qualified instructor.

4 Date Date of signature verifying that the information contained on this form is accurate. Verification of Competency 1 Affiliation Provide the name of the training program or EMS service provider that the qualified

individual who is verifying competency is affiliated with. 2 Date Enter the date that the individual demonstrates competency for the skill that is being

evaluated. 3 Signature of Person Verifying Competency Signature of the individual verifying competency of the skill once the competency has been

demonstrated by direct observation of an actual or simulated patient contact. Individuals qualified to verify skills competency shall be a currently licensed 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 by 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 Print Name Print the name of the individual verifying competency of the skill. 5. Certification/License Number: Provide the profession and license number of the individual verifying competency.

(e.g. RN/262614)

Verification of skills competency shall be valid for a maximum of two years from the date of verification to maintain paramedic accreditation. All skills listed must be verified during the individual’s two year licensure period and verification of skills competency shall be forwarded to the EMS Agency prior to the end of the licensure period in order to maintain accreditation. (See Policy 2 – Accreditation)

Paramedic Skills Verification Form

Name License Number Signature Date I certify, under the penalty of perjury, that the information contained on this form is accurate.

Skill Verification of Competency Cricothyrotomy:

Affiliation: Date:

Print Name:

Signature of Person Verifying Competency:

Certification/License Number:

Pleural Decompression: Affiliation: Date: Print Name:

Signature of Person Verifying Competency: Certification/License Number:

Pediatric Endotraceal Intubation: Affiliation: Date:

Print Name:

Signature of Person Verifying Competency: Certification/License Number:

ETDLA (Combitube): Affiliation: Date:

Print Name:



Intraosseous Infusion: Affiliation: Date: Print Name:



External Cardiac Pacing: Affiliation: Date: Print Name:



Pulse Oximetry: Affiliation: Date: Print Name:



Emergency Medical Services Agency

Paramedic Skills Verification Skills Sheets

January 2006

NEEDLE CRICOTHYROTOMY SKILLS DEMONSTRATION NAME_________________________________________ DATE________________ EVALUATOR_____________________________________

Skill Demonstration SKILL COMPLETION CRITERIA _ Patient Assessment - Checks airway and breathing

· identifies indications for procedure · confirms obstructed airway

Assembles Equipment - Attaches 30cc syringe to 10 - 13g. angiocath. · assembles O2 delivery system · connects to high flow O2 source (15 L/m)

Prepares Patient - States anatomical landmarks · identifies cricothyroid space · preps site

Explains and Demonstrates Procedure - Demonstrates proper technique in locating landmarks · states would make midline puncture with scalpel (optional) or

· demonstrates insertion angle of syringe and needle (60° downward angle) to puncture using steady pressure

· states feels "give" when penetrates cricoid membrane

states would remove needle · aspirates with syringe to obtain free air

· states would advance catheter until hub is against skin

Maintenance of Site - Attaches O2 delivery system and demonstrates ventilation of patient · places thumb over the open end of the "Y"

connector and ventilates for 1 second, release for 4 seconds

· states would observe for chest rise, and would auscultate chest to assess adequate ventilation

· states would apply occlusive sterile dressing to site and secure catheter

Reassesses Patient - Discusses circumstances when reassessment is essential · after moving patient · upon loading/unloading · states potential complications with field

ramifications: subcutaneous air

Station Completion Criteria: Student correctly performs, in proper sequence, all identified critical performance steps.

NEEDLE THORACOSTOMY SKILLS DEMONSTRATION NAME_________________________________________ DATE________________ EVALUATOR_____________________________________

SKILL DEMONSTRATION SKILL COMPLETION CRITERIA _ Patient Assessment - Checks airway and breathing

· states insures adequate BLS measures/oxygen delivery · identifies indications for procedure - Checks for findings of: · dyspnea or difficulty ventilating · absence of breath sounds on affected side · jugular vein distention · possible tracheal shift away from affected side · hyperresonance to percussion on the affected side · possible alterations in VS and LOC

Assembles Equipment - Attaches 30cc syringe to 12 – 14g. angiocath. Prepares Patient - States anatomical landmarks for both sites

· identifies 2nd intercostal space in the midclavicular line on same side as identified tension pneumothorax, or

· 4th or 5th ICS in mid-axillary line · preps site

Explains and Demonstrates Procedure

- Demonstrates proper technique in locating landmarks · states insert catheter on top of lower rib at 90° angle

· states would advance slightly superior to clear rib, then back to 90° angle, to complete "Z" track puncture

· states feels "give" when penetrates pleural space, and that air or blood should push the syringe plunger back

· states would advance catheter superiorly and remove needle to allow pressure to escape

Maintenance of Site - Attaches one-way valve to catheter · states would apply sterile occlusive (vaseline gauze)

dressing to site and secure catheter · tape one-way valve in dependent position

Reassesses Patient - States would expect immediate improvement in patient condition

- Discusses circumstances when essential to reassess condition

· after moving patient · upon loading/unloading

· states potential complications of concern to field personnel: other viscera or vessels punctured


PEDIATRIC ENDOTRACHEAL INTUBATION SKILLS DEMONSTRATION NAME_________________________________________ DATE________________ EVALUATOR_____________________________________

SKILL DEMONSTRATION SKILL COMPLETION CRITERIA Patient Assessment -Identifies patient meets criteria for endotraceal intubation Initiates Treatment -Ensures oxygen delivery equipment is connected to oxygen source

-Position patient -Assure patient is oxygenated and ventilated with bag-valve-mask

Assembles Equipment -Selects appropriate ET tube -Tests equipment (checks cuff in cuffed tube, check light) -Inserts stylet -Lubricates tip of ET tube -Assures suction functioning

Prepares Patient -Position patient – Medical patient sniffing position, Trauma patient in neutral position with in-line manual stabilization

-Has partner oxygenate patient 5 – 6 time with bag-valve-mask and 100% oxygen

Insert Endotracheal Tube -Opens mouth by applying thumb pressure on chin -Inserts laryngoscope into mouth -Visualizes vocal cords -Suctions if necessary

cheal tube tip past the vocal cords -Removes stylet -Advances the ET tube until the cuff is just beyond the vocal cords; inflates cuff. For uncuffed tubes, advances tube no more than 2.5 cm beyond vocal cords.

Assess /Monitor Patient -Confirms tube placement using Colorimetric end-tidal CO2 indicator or capnography

-Continues confirmation of tube with auscultation of lungs, epigastruim and observation of bilateral chest rise

-Secure tube with tape or ET holder and ventilate -Marks tube at the level of the lips. Record tube position. -Continues to monitor patient and tube placement


ESOPHAGEAL/TRACHEAL DOUBLE LUMEN AIRWAY (ETDLA) SKILLS DEMONSTRATION

NAME_________________________________________ DATE________________ EVALUATOR_____________________________________

SKILL DEMONSTRATION SKILL COMPLETION CRITERIA Patient Assessment -States or demonstrates the use of PPE

-Checks airway and breathing · looks, listens, and feels · assures adequate BLS airway

Insert Oropharyngeal Airway -Demonstrates proper sizing technique · angle of jaw to the corner of mouth, or angle of jaw to central incisor

-Demonstrates proper insertion technique

Insert Nasopharyngeal Airway

-Demonstrates proper sizing technique · angle of jaw to nares · states lubrication

-Demonstrates proper insertion technique

Bag-Valve-Mask w/ O2 Reservoir

-Demonstrates proper technique · obtains good seal · proper head position · ventilates at appropriate rate

ETDA Insertion

-States indications and contraindication -States how tube size is determined and chooses appropriate

size tube -Checks equipment· inflates and checks both cuffs -States would lubricate tube -Attaches “fluid deflector” elbow to tube #2 -Positions mannequin properly (neutral or slightly flexed) -Demonstrates hyperventilation of patient with BVM device-Lifts tongue and jaw upward with one hand -Inserts ETDA into mouth, keeping tube midline – advance the tube until double black line on the tube matches up to teeth or alveolar ridge

Assesses Placement of ETDA

-Inflates #1 pilot balloon with 100 cc of air -Inflates #2 pilot balloon with 15 cc of air -Ventilates through #1 tube (blue) -Auscultates for breath sounds bilaterally, if present

continues to ventilate -Ventilates tube #2 (clear) if breath sounds absent -Auscultates for breath sounds bilaterally, if present continues to ventilate

Secures ETDA - Demonstrates using tape Reassesses Patient - Discusses circumstances when reassessment is essential

(suctioning, instillation of medications, after moving patient, upon loading/unloading) and method used

- Discusses drug administration (which drug, volume, when)


INTRAOSSEOUS INFUSION SKILLS DEMONSTRATION NAME_________________________________________ DATE________________ EVALUATOR_____________________________________

SKILL DEMONSTRATION SKILL COMPLETION CRITERIA Patient Assessment -Identifies patient meets criteria for intraosseous infusion Initiates Treatment -Evaluates patient for potential IV sites Assembles Equipment -Assures IO equipment ready and available

-Assures IV set up is ready for use with volutrol or 100cc bag

Prepares Patient -Positions patient supine with a rolled towel under the knee -Restrains patient if necessary. -Finds the flat surface of the proximal tibia tubercle. -Puts on gloves and preps the area with the antiseptic solution

Insert Intraosseous Infusion -Introduces the Intraosseous needle slightly angled from perpendicular at a 60 degree angle, directed toward the foot

-Pierces the bony cortex using a firm rotary or drilling motion (a distinct change in resistance will be felt upon entry into the medullary space)

-Removes the stylet -Confirms intramedullary placement by injecting, without resistance, 10cc of normal saline

-Attaches IV tubing to the Intraosseous hub

Assess /Monitor Patient -Secures needle to overlying skin with tape -Monitors pulses distal to area of placement. -Monitors leg for swelling or cooling temperature.


PULSE OXIMETRY SKILLS DEMONSTRATION NAME_________________________________________ DATE________________ EVALUATOR_____________________________________

SKILL DEMONSTRATION SKILL COMPLETION CRITERIA Patient Assessment -Identifies patient meets criteria for use of pulse oximetry Assembles Equipment -Choose appropriate sensor for patient

-Assure monitoring cable attached to pulse oximetry monitoring device

Prepares Patient -Explains procedure to patient -Cleans and dries site prior to sensor placement

Placement of Sensor -Applies appropriate sensor to patient Pulse Oximetry -Connect the sensor to the monitoring cable

-Note oxygen saturation (SpO2) and document -Place patient on oxygen, as appropriate

Assess /Monitor Patient -Monitor SpO2 with vital signs -Continue to assess the patient’s respiratory status (include rate and tidal volume)


EXTERNAL CARDIAC PACING SKILLS DEMONSTRATION NAME_________________________________________ DATE________________ EVALUATOR_____________________________________

SKILL DEMONSTRATION SKILL COMPLETION CRITERIA Patient Assessment -Identifies cardiac rhythms and patient symptoms that may

require pacing

Initiates Treatment of Symptomatic Brady

-Ensures airway, high flow oxygen -Position of comfort -Establishes IV access TKO -Administers Atropine 0.5 mg IV

Assembles Equipment -Prepares AP patches -Assures EKG electrodes are away from pacing electrode site -Confirms and records EKG

Prepares Patient -Explains procedure to patient -Considers/outlines sedation options -Bares patient’s chest -Wipes electrode sites clean and dry (Does not use alcohol, benzoin or antiperspirant on pacing electrode sites)

-Describes additional preparation to patient with excessive hair, damp or oily skin

Pacing -Applies pacing electrodes (describes and demonstrates anterior-posterior placement and anterior-lateral placement)

-Attaches pacing cable to pacing device/manufacturer’s recommendation

st prominent QRS display nd mode, rate at 80 and current to 0mA -Activates pacer -Increases current in 10mA increments until capture is achieved

Reassess /Monitor Patient -Confirms efficacy of pacing (evaluates pulse, VS, skin signs, LOC, symptoms)

-Continues to monitor patient -Discusses other options available for treatment (dopamine, repeat atropine, rapid transport)


POLICY #: 7

EFFECT DATE: xx/01/06 PAGE: 1 of 2

SUBJECT: COUNTY PARAMEDIC EVALUATOR

APPROVED BY: Art Lathrop, EMS Director Joseph A. Barger, MD, EMS Medical Director

I. PURPOSE

To ensure that individuals working in an ALS Program have the ability to function as a single paramedic in a safe, competent and consistent manner.

II. DEFINITION A county paramedic evaluator is a paramedic currently employed in Contra Costa County, approved by the Emergency Medical Services Agency to provide supervision and evaluation of California state licensed paramedics in Contra Costa County.

III. REQUIREMENTS/QUALIFICATIONS

A. EMS PROGRAM REQUIREMENTS

1. Paramedic for a third service EMS provider has a minimum of two (2) years full-time experience as a paramedic

2. A paramedic for a fire based ALS service has a minimum of four (4) years full-time experience as a paramedic in a fire based ALS service or two (2) years full-time experience as a paramedic for a third service EMS provider.

3. Minimum of six (6) months current field experience in Contra Costa County Paramedic licensure/accreditation current and in good standing.

4. Absence of QI issues6. 5. Demonstrated professional attitude, appearance and manner of dealing with people.

IV. SELECTION PROCESS

A. APPLICATION

1. Complete an application (available from employer) and return it to employer. 2. The employer shall send a letter of recommendation to the EMS Agency, along with the

completed application. This letter must include statements on the qualifications listed in section III, above.

B. EMS REVIEW AND NOTIFICATION

The EMS Agency shall review the application and the employer recommendations along with licensure/accreditation status and determine whether or not the qualifications have been met. The paramedic and the paramedic provider agency shall be notified of the EMS Agency's decision in writing, within two weeks of receipt of the application and all supporting documentation.

SUBJECT: PREHOSPITAL CREDENTIAL REVIEW PROCESS POLICY 7

EFFECTIVE: xx/01/06 PAGE: 2 of 2

C. ORIENTATION The paramedic evaluator shall be required to complete a Contra Costa County Paramedic Evaluator Orientation provided by the EMS Agency.

V. MAINTENANCE

A. To maintain County Evaluator status through the EMS program requirements, all evaluators shall: 1. Maintain current state paramedic licensure and Contra Costa County accreditation in good

standing 2. Have no patient care/operational issues requiring remediation. 3. Attend scheduled bi-annual evaluator updates.

Issued: 09/01/02 Revised: 11/8/05, xx/01/06

EMS POLICIES AND PROCEDURES CONTRA COSTA EMERGENCY

MEDICAL SERVICES 50 Glacier Drive

Martinez, California 94553-1631

EFFECTIVE DATE: 1/1/98 REVISED: POLICY #: 8 PAGE: 1 of 1 SUBJECT: PARAMEDIC STUDENT PRECEPTOR PROGRAM APPROVED BY: ____________________________ _____________________________ Art Lathrop, EMS Director Joseph Barger, MD, EMS Medical Director I.PURPOSE To assure a consistent training experience to paramedic students during their internship in Contra Costa County. II. REQUIREMENTS Each paramedic provider agency that wishes to provide field internships for paramedic students in Contra Costa County must have a paramedic student preceptor program approved by the EMS Agency that: A. provides specific criteria for the selection of paramedic student preceptors, and, B. provides initial and on-going training for, and evaluation of, paramedic student preceptors,

and, C. provides criteria for maintaining designation as a paramedic student preceptor.

EMS POLICIES AND PROCEDURES POLICY #: 9

EFFECT DATE: 02/01/06 PAGE: 1 of 4

SUBJECT: PATIENT DESTINATION DETERMINATION

APPROVED BY: Art Lathrop, EMS Director Joseph A. Barger, MD, EMS Medical Director I. PURPOSE

To determine the appropriate receiving facility for patients transported by ground ambulance.

II. RELEVANT STATUTES

Title 13 of the California Code of Regulations 1105 (C) "In the absence of decisive factors to the contrary, an ambulance driver shall transport emergency patients to the most accessible emergency medical facility equipped, staffed, and prepared to administer care appropriate to the needs of the patients."

III. DEFINITION OF AMBULANCE RECEIVING FACILITY

Title 22 (70411) requires that a Basic Emergency Service, Physician on Duty, be staffed and equipped at all times to provide prompt care for any patient presenting urgent medical problems.

IV. METHOD

While assessing the patient, field personnel collect data that assists them in determining whether a patient is unstable or stable. This information must be considered along with a number of additional factors in making destination and transport code decisions. These additional factors include the consideration of:

A. the patient's/family's choice of receiving hospital and ETA to that facility B. recommendations from a physician familiar with the patient’s current condition (consider on-

scene physician communication with base physician in case of conflict) C. the patient's regular source of hospitalization or health care D. the ability of field personnel to provide field stabilization or emergency intervention E. ETA to the closest basic emergency department F. traffic conditions G. hospitals with special resources

V. UNSTABLE PATIENTS

Generally, unstable patients should be transported to the closest appropriate basic emergency department regardless of county. If the patient or family requests or if other factors exist which indicate that another facility be considered, field personnel are to present their findings, including ETA’s to both facilities, to the base hospital. Base personnel will weigh the benefits of each destination and may direct field personnel to a facility other than the closest. Trauma patients should be transported in accordance with County trauma protocols. Field personnel make transport code decisions. Generally, unstable patients should be transported Code 3 unless contraindicated for medical reasons.

SUBJECT: PATIENT DESTINATION DETERMINATION POLICY #: 9

EFFECTIVE: 02/01/06 PAGE: 2 of 4

VI. STABLE PATIENTS:

In determining the destination for stable patients, the patient's/family's preference is to be given primary consideration without regard to county. Stable patients shall be transported to hospitals with Basic Emergency departments or to other facilities approved by the EMS Agency to receive ambulance patients. If the patient does not express a preference, the hospital where the patient normally receives health care or the closest basic ED are to be considered without respect to County lines. Ambulances transporting patients in response to emergency calls must consult with the base hospital regarding patient stability to transport a patient greater than 45 minutes if there are closer basic emergency departments. Such approval shall be based upon medical consideration, taking into account patient's need for specialized service at the requested hospital and patient's stability for an extended transport prior to medical evaluation. Stable patients are transported Code 2 unless their status deteriorates enroute.

VII. PATIENTS ON 5150 HOLDS:

Police or other designated individuals may place a person who, as a result of a mental disorder, is a danger to self, to others, or is gravely disabled on a "5150" involuntary hold. This involuntary hold is an application for detention for up to 72 hours for the purpose of psychiatric evaluation and treatment. Contra Costa Regional Medical Center is the designated facility appropriate for receiving patients on 5150 holds.

All patients placed on 5150 holds in the field should be assessed for the presence of a medical emergency. Based upon the history and physical examination of the patient, field personnel shall determine whether the patient is stable or unstable.

A. Medically Unstable Patients on 5150 holds

Unstable patients shall be transported to the closest basic emergency department. A patient with a current history of overdose of medications is to be considered unstable. A patient with history of ingestion of alcohol or illicit street drugs is considered unstable if he or she has significant alteration in mental status (e.g., decreased level of consciousness or extremely agitated), significantly abnormal vital signs, or has any other history or physical findings that suggest instability (e.g. chest pain, shortness of breath, hypotension, diaphoresis).

B. Medically Stable Patients on 5150 holds

Stable patients, including those with alcohol or illicit drug usage, who are stable, are to be transported to Contra Costa Regional Medical Center. After radio or phone contact with the Emergency Department, hospital staff will make a destination decision (either the medical Emergency Department or Mental Health Crisis Service).

VIII. OBSTETRICAL PATIENTS

A. Patients should be considered “Obstetric” if pregnancy is estimated to be of 20 weeks duration or more.

B. Obstetric patients should be transported to receiving facilities with in-patient obstetrical services in the following circumstances:

1. Patients in labor;

2. Patients whose chief complaint appears to be related to the pregnancy, or who potentially have complications related to the pregnancy;

3. Injured patients who do not meet trauma criteria or guidelines.



C. In-patient obstetrical services are provided at all acute care hospitals in Contra Costa County

with the exception of Kaiser Medical Center in Richmond and Mt. Diablo Medical Center in Concord.

D. Obstetric patients meeting trauma criteria should be transported to an adult trauma center.

E. Obstetric patients should be transported to the nearest basic emergency department under the following circumstances:

1. Life threatening situations such as cardiac or respiratory arrest, acute respiratory distress, or shock, in which immediate treatment appears necessary in order to preserve the mother’s life;

2. Patients with imminent delivery that precludes transport to a facility with obstetric services.

F. Stable obstetric patients should be transported to the emergency departments of choice if their complaints are clearly unrelated to pregnancy.

G. The base hospital may provide guidance in situations in which the appropriate choice of receiving facility is unclear to transport personnel.

IX. BURN PATIENTS

A. Burn patients with unmanageable airways should be transported to the closest basic ED.

B. Adult and pediatric burn patients with significant trauma should be transported to

the closest most appropriate designated trauma center.

C. The closest available Burn Centers are:

Doctor’s San Pablo- Adults > 14 years old

UC Davis Medical Center, Sacramento (UCDMC) – Pediatric < 14 years old (via helicopter)

D. Patient Selection

1. Most minor burn patients can be cared for at any of the receiving facilities. However, patients with more extensive or complex burns may be appropriate for initial transport to a burn center.

2. The following patients may be appropriate for initial transport to a burn center:

a. Partial thickness (2nd degree) > 10% TBSA

b. Significant burns to the face, hands, feet, genitalia, perineum, or circumferential burns of the torso or extremities

c. 3rd degree burns in any age group

d. Chemical or high voltage electrical burns

e. Smoke inhalation with external burns

E. Consult Base hospital for any questions regarding destination decision.



Rule of Nines

Revised: 8/1/00, 7/1/01, 10/29/01, 3/1/02, 12/5/03, 02/01/06

EMS POLICIES AND PROCEDURES

POLICY #: 16

EFFECT DATE: 02/01/06 PAGE: 1 of 2

SUBJECT: TRANSFER OF CARE IN THE FIELD

APPROVED BY: Art Lathrop, EMS Director Joseph A. Barger, MD, EMS Medical Director I. PURPOSE

A. To provide guidelines for the transfer of care from non-transport to transport personnel. B. To provide guidelines for the transfer of care from an on-scene paramedic to an EMT-I

staffed transport ambulance. II. SCOPE OF DIRECTION AND OVERSIGHT

A. Patient Care Authority

1. The most medically qualified pre-hospital personnel first on-scene at a medical emergency shall have patient care management authority.

2. The individual with patient care authority is responsible for the patient until care is

turned over to another appropriate prehospital care provider or responsible receiving facility staff.

B. Turn Over of Patient Care Authority

1. BLS First Responders

a. BLS first responders initiating patient care shall transfer care upon the

arrival of either an EMT-I or paramedic transport crew. BLS first responder personnel shall maintain patient care authority and accompany a BLS transport unit when an AED has been used as specified by the First Responder Defibrillation treatment guideline.

2. First Responder Paramedics

a. First Responder paramedics, when first on-scene, should transfer patient

care authority and provide a verbal report to the transport paramedics as soon as feasible. In those cases where the first responder paramedic believes continuity of his/her care will be in the patient's best interest, he/she should maintain patient care authority and accompany the patient during transport.

SUBJECT: TRANSFER OF CARE IN THE FIELD POLICY 16


3. Paramedic to EMT-I Transport Crew

a. A paramedic may transfer patient care authority to a BLS ambulance crew for transport, when all of the following circumstances exist:

(1) The BLS unit is available within a reasonable time, and (2) ALS care has not been initiated, and (3) It does not appear that ALS care is likely to be required during

transport.

b. A paramedic shall maintain patient care authority and shall accompany the patient in a BLS transport ambulance to the appropriate receiving facility if either of the following circumstances exist:

(1) ALS care has been started, or (2) A reasonable likelihood exists that the patient may require ALS care

enroute.

C. Responsibility for Patients Who Decline Care

1. First-responders who determine that patients are declining care or transport are responsible for appropriate documentation of those situations.

2. If patient care has been transferred and a patient subsequently declines further treatment or transport, the transport crew is responsible for appropriate documentation.

D. Documentation

1. Documentation of transfer of care shall be made by both transferring and receiving

crews, e.g., "Patient care transferred to AMR paramedic 56 at 0900", and "Patient care accepted from CCC Fire paramedic 115 at 0900".

E. Turn-over Procedures

Those emergency medical response agencies providing enhanced levels of care are responsible for creating and implementing internal operational procedures regarding transfer of patient care. These procedures shall be consistent with the EMS Agency's policies, and shall interface with the procedures of other emergency medical response agencies which might be represented at the scene of an emergency.

Revised: 02/01/06

12/20052006 Contra Costa County Prehospital Care Manual

► Continuous Positive Airway Pressure (CPAP)

The purpose of CPAP is to improve ventilation and oxygenation and avoid intubation in patients with Congestive Heart Failure (CHF) with Acute Pulmonary Edema. CPAP is generally indicated for a patient in moderate to severe respiratory distress who is completely alert and able to maintain his airway.

Indications

Patients 8 years and older in severe respiratory distress and:

History of CHF with pulmonary edema and one or more of the following: o Peripheral edema o Current medications such as digoxin, or lasix o Orthopnea o Anxious o Rales or course wheezes o Diaphoresis

OR

Near drowning

Absolute Contraindications: (Do NOT Use)

Age < 8 Respiratory or cardiac arrest Agonal respirations Severely decreased level of consciousness Systolic BP < 90 Signs and symptoms of pneumothorax Inability to maintain patent airway Major trauma, especially head trauma with increased ICP or significant chest trauma Facial anomalies or trauma (e.g. burns, fractures)

Relative Contraindications: (Use with CAUTION)

History of Asthma/COPD History of Pulmonary Fibrosis Decreased LOC Claustrophobia/unable to tolerate mask (after 1-2 minute trial)

** Consider ventilation with bag-valve-mask or endotracheal intubation for any patient who exhibits one or more of the above contraindications.

Procedure

1. Place patient in a seated position with legs dependent

2. Monitor ECG, Vital signs (BP, HR, RR, SPO2)

Contra Costa County Prehospital Care Manual 12/2005 6 Page 37

3. Set up the CPAP system (per manufacturers recommendation)

4. Explain what you will be doing to the patient

5. Apply mask while reassuring patient

6. Reevaluate the patient every 5 minutes – normally the patient will improve in the first 5 minutes with CPAP as evidenced by:

7. Decreased heart rate

8. Decreased respiratory rate

9. Decreased blood pressure

10. Increased SPO2

*Failure to improve: should the patient fail to show signs of improvement with CPAP remove the CPAP device and assist ventilations with BVM as needed.

Documentation:

· All PCR’s will be reviewed by the EMS Medical Director for appropriate use of CPAP and required documentation

· The use of CPAP must be documented on the PCR

· Vital Signs (BP, HR, RR, SPO2) must be documented every 5 minutes

· Documentation regarding the patient’s response to CPAP should be included in the narrative section of the PCR

Additional Notes:

If you are using a portable tank, it is important to conserve your oxygen. For example: at 100% FIO2 and at full flow, a full tank will last approximately:

- “D” cylinder = 3.5-4 minutes - “E” cylinder = 5.5-6 minutes - “M” cylinder = 28 minutes

at 28% FIO2, a full tank will last approximately:

- “D” cylinder = 30 minutes - “E” cylinder = 45-50 minutes - “M” cylinder = 236 minutes

2. Continuous pulse oximetry must be used to monitor patients oxygen saturation

Correct CPAP pressure must be delivered at all times. The flow from the generator should always be in excess of the patients demand.

ems policies and procedures

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