Protocols

1. Patients with burns > 50% BSA

2. Airway compromise

3. Hypotension with systolic BP < 90 or for children 0-12 years of age a systolic BP < 70 + twice the years in age (hemodynamically unstable)

4. History of significant inhalation

5. High-energy electrical injury (non-residential)

• When arriving in ED Triage, the Stroke Nurse will bring the rtPA BOX (tpabox) from the ED.

• Three rtPA Boxes will be kept in the ED and supplied by Pharmacy and restocked within 30 minutes of use.

• The ED Charge Nurse will count the tpaboxes each shift and call the Pharmacy about the number and condition of the tpabox

• The ED tpabox will contain supplies such as gauze, tape, syringes, needles, tubing, rtPA, and other supplies determined by Jen and Jamie and provided to the Pharmacist on Tuesday October 15, and updated by Jen and Jamie as needed.

• After ED physician determines that the patient is hemodynamically stable in the ED Holding Bay, the patient will be transported to CT Scanner for STAT non-contrast CT Head.

• When the CT scan begins, the ED physician will call the Neurologist on call to discuss the patient’s signs and symptoms as well as describing the just completed CT Head with attention to bleed and infarction stroke.

• The Neurologist, over the phone, will agree that rtPA is indicated, or state that it is not.

• If the ED physician and Neurologist agree, over the phone, that rtPA is indicated, the ED physician will tell the Stroke Nurse to mix the rtPA. After the non-contrast CT Head is completed, the patient will be taken or backed out of the CT scanner and IV lines inserted if necessary, using the tpabox. Additional rtPA vials will be kept in the CT Scanner Pyxis.

• The Stroke Nurse will administer the rtPA bolus in the CT scanner room after the Radiologist reports to the ED physician that there is no intracranial hemorrhage and no infarction.

• The CTP will be completed after the rtPA bolus has been given.

• The remainder of the rtPA drip will be started after the CTP.

• The Stroke nurse will notify the Pharmacist that a tpabox has been used and that it needs restocking within 30 minutes.

Patient presents as symptomatic wake-up ischemic stroke ≤ 4.5 hrs since awakening

Use of rTPA recommended:

• If last known well time ≤ 9 hrs after going to sleep (all must be true)

  1. • CTA demonstrates no LVO

     • Patient NOT going to attempted thrombectomy

     • CTP mismatch ratio > 1.2

     • Ischemic/infarcted core ≤ 30 mL

• If last known well time > 9 hrs after going to sleep (all must be true)

• CTA demonstrates no LVO

• Patient NOT going to attempted thrombectomy

• CTP mismatch ratio > 1.8

• Ischemic/infarcted core ≤ 30 mL

• MRI demonstrates < 5 chronic microbleeds

• MRI flair is NEGATIVE

Wake-up ischemic strokes must be differentiated from extended time ischemic strokes.

• True wake-up ischemic strokes usually result of small vessel disease but can be large vessel disease.

• Most individuals, on average, sleep 8 hours.

• Most wake-up strokes occur near time of waking up.

• The WAKE UP and EXTEND Trials demonstrate significant efficacy of treating wake-up strokes with rtPA.

  1. • Average time of treatment in WAKE UP is 10.3 hours and EXTEND is 9.9 hours.

• However, both WAKE UP and EXTEND demonstrate near significant increased risk of ICH with treating patients with rtPA (due to core infarct).

• Patients in WAKE UP trial self-report increased health related quality of life when given rtPA for wake-up stroke compared to not receiving rtPA.

• Wake-up strokes are at risk of hemorrhage if brain cell death has occurred. We use the same criteria as ischemic strokes presenting less than or equal to 4.5 hours. Therefore, if it has been greater than 4.5 hours since the person has awakened, the risk increases similarly.

EKG obtained and read within 10 min

Consider STEMI If

• CP suggestive of MI < 12 hrs AND ST elevation (≥ 1mm) in 2 contiguous leads

• Or otherwise determined by practitioner

Contact Operator to activate code STEMI

• Operator activates STEMI team 

• On-call Interventional Cardiologist will contact ED Physician

• On-call STEMI team will report directly to Cardiac Cath lab within 30 min

• STEMI team will contact ED when ready to receive

• ED RN assists w/ prep & transport to Cath Lab for Primary PCI

• Goal of door-to-device ≤ 90 min

Considerations for STEMI Activation/ Transfer

• STEMI team unavailable within 30 min of activation 

• Fibrinolytic therapy administered after discussion with cardiology

INLAND COUNTIES EMERGENCY MEDICAL AGENCY

POLICY AND PROTOCOL MANUAL Reference No. 9010

Effective Date:  04/01/23

Supersedes:  04/01/22 Page 1 of 3

CONTINUATION OF CARE 

I.  PURPOSE

To develop a system that ensures the rapid transport of patients upon arrival at a receiving hospital that requires urgent transfer to a higher level of care.

This policy shall only be used for:

• Rapid transport of STEMI, stroke and trauma patients from referral hospitals to the appropriate Specialty Care Center.

• Specialty Care Center to Specialty Care Center when higher level of care is required.

• EMS providers that are transporting unstable patients to a STEMI, Stroke or Trauma Center but need to stop at the closest receiving hospital for stabilization before continuing to a Specialty Care Center.

It is not to be used for interfacility transfer of patients.

II.  INCLUSION CRITERIA

• Patients meeting ICEMA Reference #9040 - Trauma Triage Criteria, who arrive at a nontrauma hospital. 

• Upon recognition of any critically injured patient that require urgent transfer from one trauma receiving center to a higher level of care trauma receiving center.

• Patients requiring subspecialty services that are not a requirement for trauma center designation (i.e., reimplantation, hand surgery, burn, etc.) are not covered by this policy and must be managed through the normal interfacility transfer process compliant with all applicable regulations.

• Any patient with a positive STEMI requiring EMS transport to a STEMI Receiving Center (refer to ICEMA Reference #4040 - ST Elevation Myocardial Infarction Critical Care System Designation).

• Any patient with a positive mLAPSS requiring EMS transport to a Stroke Receiving Center, (refer to ICEMA Reference #4070 - Stroke Critical Care System Designation). 

• Any stroke patient identified with a Large Vessel Occlusion (LVO) requiring rapid EMS transport to higher level of care for Endovascular Stroke Treatment.

III.  INITIAL TREATMENT GOALS AT REFERRAL HOSPITAL

• Initiate resuscitative measures within the capabilities of the facility.

• Ensure patient stabilization is adequate for subsequent transport.

• Do not delay transport by initiating any diagnostic procedures that do not have direct impact on immediate resuscitative measures.

  GOAL FOR USE OF CONTINUATION OF CARE POLICY

• Less than 30 minutes at referral hospital (door-in/door-out).

• Less than 30 minutes to complete ALS continuation of care transport.

• Less than 30 minutes door-to-intervention at Specialty Care Center.

• Less than 60 minutes for rapid identification of a LVO at a primary stroke center.  

• Referral hospital shall contact the appropriate Specialty Care Center ED physician directly without calling for an inpatient bed assignment.  

• Specialty Care Centers should route requests directly to the ED physician and bypass their transfer center triage process.

• EMS providers shall make contact with Specialty Care Centers to notify of the estimated time of arrival.

• Specialty Care Centers shall accept all referred STEMI, stroke and trauma patients meeting criteria in this policy unless they are on Internal Disaster as defined in ICEMA Reference #8050 - Requests for Ambulance Redirection and Hospital Diversion (San Bernardino County Only).

• The ED physician is the accepting physician at the Specialty Care Center and will activate the STEMI, Stroke or Trauma Team according to internal policies or protocols.

• The referral hospital ED physician will determine the appropriate mode of transportation for the patient. 

• Simultaneously call 9-1-1 and utilize the following script to dispatch:

“This is a continuation of care from ____ hospital to ____ STEMI, Stroke or Trauma Center”

Fire departments will not be dispatched for 9-1-1 continuation of care calls, the dispatchers will only dispatch transporting ALS ambulances.

• Referral hospital ED physician will provide a verbal report to the ED physician at the Specialty Care Center. 

• Referral hospital will send all medical records, test results, radiologic evaluations to the Specialty Care Center.  DO NOT DELAY TRANSPORT - these documents may be electronically submitted or faxed to the Specialty Care Center.

 IV.  SPECIAL CONSIDERATIONS FOR REFERRAL HOSPITALS

• If a patient arrives to a referral hospital via EMS field personnel, a physician may request that the transporting team remain and immediately transport the patient once minimal stabilization is completed. 

• If a suspected stroke patient presenting to a non-designated stroke center is outside of the tPA administration window (greater than 4.5 hours from “last seen normal”), consider contacting nearest thrombectomy capable or comprehensive stroke center to determine the best destination.  Then follow the 9-1-1 script.

• Unless medically necessary, avoid using medications or IV drips that are outside of the EMT-P scope of practice to avoid delays in transferring of patients. 

• The referral hospital may consider sending one of its nurses or physician with the transporting ALS ambulance if deemed necessary due to the patient’s condition or scope of practice limitations per ICEMA Reference #8010 - Interfacility Transfer Guidelines.

• Do not call 9-1-1 dispatch if the patient requires Critical Care Transport (CCT) or Specialty Care Transport (SCT). The referral hospital must make direct contact with the EMS Providers Dispatch Center.

• Diversion is not permitted except for Internal Disaster. However, to avoid prolonged doorto-intervention times when STEMI, Stroke and Trauma Centers are over capacity, base hospitals may facilitate alternative STEMI, Stroke or Trauma Centers as the best destination for the patient.  Base hospitals must ensure physician to physician contact when facilitating the use of an alternate destination. 

 V.  REFERENCES

Number Name

4040 ST Elevation Myocardial Infarction Critical Care System Designation (San Bernardino County Only)

4070 Stroke Critical Care System Designation (San Bernardino County Only)

8010 Interfacility Transfer Guidelines

8050 Requests for Ambulance Redirection and Hospital Diversion (San Bernardino County Only)

9040 Trauma Triage Criteria

1. Ejection from automobile

2. Death in same passenger compartment

3. Extrication time > 20 minutes

4. Falls > 20 feet

5. Rollover with significant injury

6. Auto-pedestrian/auto-bike injury with significant (5 mph) impact 

7. Pedestrian thrown or run over 

8. Motorcycle/Off-highway vehicle crash > 20 mph or with separation of rider from bike 

9. Age > 65 

   • With blunt injury to the torso (chest and/or abdominal injury)  

   • Fall from any height within last 72 hours on anticoagulants (excluding aspirin)

10. Children < 5 years old

    • Involved in motor vehicle collision

    • Fall > three times height

    • Suspected non-accidental trauma

    • Mechanism with potential for injury

11. Two long bone fractures (femur, humerus, tibia)

12. Pregnancy 23 weeks gestation or greater

    • Involved in motor vehicle collision

    • Fall

    • Physical abuse

    • Mechanism with potential for injury

13. Suspicion of drowning or hanging

14. Blunt abdominal injury

    • With firm or distended abdomen

    • With abdominal seatbelt sign

1. GCS < 13

2. Airway Compromise

   • Intubated patients transferred from the scene, or

   • Patients with respiratory compromise or obstruction - includes intubated patients who have been transferred from another facility, with ongoing respiratory compromise (does not include patients intubated at another facility and who have been stabilized from a respiratory and hemodynamic standpoint)

3. Respiratory Rate < 10 or > 29 per minute

4. Confirmed blood pressure < 90 at any time in adults and age-specific hypotension in children

5. Heart rate >140

6. Penetrating injuries to head, neck, or torso

7. Penetrating injuries to extremities proximal to elbow or knee without a distal pulse

8. Chest wall trauma with flail or open chest  wound

9. Traumatic full arrest

10. Paralysis or suspected spinal cord injury

11. Amputation proximal to wrist and ankle 

12. Bone injuries: 

    • Pelvic Fracture

    • Open and depressed skull fracture

13. Patients transferred in receiving blood products to maintain vital signs

14. Crushed, degloved, or mangled extremity

15. Emergency physician's discretion

• Low Titer O Whole Blood (LTOWB) will be used if all the following criteria are met:

  • • For Trauma patients admitted in the Trauma department and is documented as an active trauma in Epic

    • For all patients over 57 years of age

    • Used during a massive transfusion protocol while waiting for the MTP pack from Blood Bank. LTOWB will be issued one unit at a time followed by a MTP pack.

    • Trauma patients admitted in the Trauma department whose ABO group is not known or has not been confirmed.

• LTOWB will not be available to patients admitted in any other department.

FDA-approved HBO therapy treatments:

• Air or gas embolism

• Carbon monoxide poisoning

• Enhancement of healing in diabetically derived illness such as diabetic foot, diabetic retinopathy, diabetic nephropathy

• Exceptional blood loss (anemia)

• Intracranial abscess

• Clostridial myositis and myonecrosis (gas gangrene)

• Crush injury, compartment syndrome, and other acute traumatic ischemias

• Decompression sickness

• Necrotizing soft tissue infections (necrotizing fasciitis)

• Osteomyelitis (refractory)

• Delayed radiation injury (soft tissue and bony necrosis)

• Skin grafts and flaps (compromised)

• Thermal burns

• Actinomycosis

• Cyanide poisoning

• Central Retinal Artery Occlusion

• Delayed radiation injury (soft tissue and bony necrosis)

Process for handling 5150 patients under arrest

• Approved by West Valley Detention Center (WVDC),  BHU, and ARMC ED - Jan 28, 2020 

• WVDC is NOT a designated LPS (5150 receiving) facility

  • • Patients on 5150 should be transferred to WVDC

    • Patients on 5150 need psych eval to determine whether patient is to be admitted or 5150 lifted before transfer to WVDC 

• If 5150 cannot be lifted by psych

  • • Patient needs to be admitted to inpatient hospital unit (preferably jail unit 5N) 

    • Patient will be followed by ARMC psych consultant

• If patient not on 5150 is being discharged to WVDC but there is still concern for patient safety

  • • “Suicide  watch” can be requested as appropriate

    • However, WVDC does not have capacity requiring 1:1 observation

    • There may be delay from patient’s arrival to WVDC until patient actually  placed on “suicide watch”

• Patient sent from WVDC psychiatrist on 5150 has been determined to be too ill to be managed within prison system

  • • Need ARMC inpatient admission

    • DO NOT SEND THEM BACK 

• When BHU or inpatient service is ready to d/c patient who is under custody, appropriate law enforcement officials will need to be contacted

  • • Includes patients with 5150 forms with request to contact law enforcement upon release (check box at bottom of form)

• In general, all 5150 patients transferred to WVDC from ARMC should have psych eval (preferably in BH triage area)

• For questions, WVDC jail charge nurse can be contacted at extension 35086

• WVDC also has psychiatric liaison officer who can assist with patient navigation

  • • Sergeant Aaron Vandenburg, Cell: 909-531-3385 / Desk: 35037

If a title 17 communicable disease condition is suspected and testing is required, send an Epic message/email or call ARMC epidemiology so they can assist with testing coordination and timely communication with Public Health.

Clinician Recommendations

• Report to San Bernardino County Department of Public Health (SBCDPH)

  • lung injury of unclear etiology

  • initial diagnosis of pneumonia or bronchitis that did not respond to antibiotics, or vaping product use within the past 90 days

• Ask all patients who report e-cigarette or vaping product use within the last 90 days about signs and symptoms of respiratory illness

• If e-cigarette or vaping product use is suspected as a possible cause for a patient’s lung injury, a detailed history of the substances used, the sources, and the devices used should be obtained for laboratory analysis by the SBCDPH laboratory

Wash your hands

• before touching patient

• after touching patient

• before clean/aseptic procedures

• after body fluid exposure

• after touching patient's surroundings

If a patient presents to the ARMC ED with a condition that requires an urgent referral to one of our specialty clinics, and the patient has IEHP direct assigned to one of our Family Medicine (FM) clinics, there will be no need for the patient to be seen in person by the primary physician solely to generate the urgent referral request to IEHP. Rather, the ED practitioner can call the referral center phone number, 855-422-8029 and communicate either via direct conversation during the business hours or via a voicemail after the hours that include patient information, name of the FM clinic that the patient is assigned to (not the name of the practitioner but the clinic), condition/diagnosis, and the type of specialty clinic referral needed. Hospital specialty clinic and registration teams will sort out the referrals, forward them to the appropriate FM clinics, then the responsible parties there will send over to IEHP the necessary pre-authorization paperwork.

Anesthesia/Pain Management

• Indirect Supervision: 3

• Conditional Independence: 20

Arterial Line

• Indirect Supervision: 3

• Conditional Independence: 10

Bedside US

• Indirect Supervision: 10

• Conditional Independence: 150

Cardiac Pacing

• Indirect Supervision: 3

• Conditional Independence: 6

Cardioversion/Defibrillation

• Indirect Supervision: 3

• Conditional Independence: 10

Central Venous Access

• Indirect Supervision: 5

• Conditional Independence: 20

Chest Tube Insertion

• Indirect Supervision: 5

• Conditional Independence: 10

Cricothyroidotomy

• Indirect Supervision: 1

• Conditional Independence: 3

Dislocation Reduction

• Indirect Supervision: 5

• Conditional Independence: 10

EFAST Scan

• Indirect Supervision: 3

• Conditional Independence: 5

Intraosseous Line Placement

• Indirect Supervision: 3

• Conditional Independence: 5

Intubation

• Indirect Supervision: 5

• Conditional Independence: 35

Lumbar Puncture

• Indirect Supervision: 3

• Conditional Independence: 15

Paracentesis

• Indirect Supervision: 3

• Conditional Independence: 5

Pericardiocentesis

• Indirect Supervision: 1

• Conditional Independence: 3

Peritonsillar Abscess Drainage

• Indirect Supervision: 2

• Conditional Independence: 6

Priapism Reduction

• Indirect Supervision: 5

• Conditional Independence: 10

Procedural Sedation

• Indirect Supervision: 5

• Conditional Independence: 10

Regional Nerve Block

• Indirect Supervision: 3

• Conditional Independence: 9

Resuscitation, Adult Medical

• Indirect Supervision: 10

• Conditional Independence: 45

Resuscitation, Adult Trauma

• Indirect Supervision: 10

• Conditional Independence: 35

Resuscitation, Pediatric Medical

• Indirect Supervision: 5

• Conditional Independence: 15

Resuscitation, Pediatric Trauma

• Indirect Supervision: 5

• Conditional Independence: 10

Splinting

• Indirect Supervision: 5

• Conditional Independence: 10

Thoracentesis

• Indirect Supervision: 3

• Conditional Independence: 5

Thoracotomy

• Indirect Supervision: 1

• Conditional Independence: 5

US Guided Deep Brachial IV Line

• Indirect Supervision: 3

• Conditional Independence: 5

Vaginal Deliveries

• Indirect Supervision: 5

• Conditional Independence: 10

Wound Management

• Indirect Supervision: 5

• Conditional Independence: 10

Department of Internal Medicine

• Admit patients with any of the following:

  • 1. Acute chest pain, dyspnea, or signs and symptoms of pulmonary edema

    2. Prior h/o cardiovascular or cerebrovascular event within last 6 months

    3. Uncontrolled arrhythmia or new arrhythmia with heart rate > 110

    4. New onset atrial fib with pacemaker or AICD

    5. Decompensated DM defined as BS > 250 on admission

    6. Albumin < 2.5; T bili > 20

    7. Severe valvular heart disease

    8. EF <30% on ECHO

    9. Any active infection

    10. Chronic or acute renal failure

    11. Any acute LOC / syncopal episode

    12. SBP > 180 or DBP > 100

    13. Hbg < 8 or evidence of active bleed

    14. Electrolyte imbalance: K > 5.5, Na < 130

    15. On home O2, room air PaO2 < 60, O2 sat < 90%, or PCO2 > 50

    16. Acute intoxication with ethanol level > 250 mg/dl

• Respond to Ortho c/s within 24 hrs of request, pre-op c/s for risk stratification within 24 hrs, and pre-op c/s within 4 hrs of admission

• Accept patients who were initially admitted to Ortho, and develop any of above

• When disagreements occur, determination regarding criteria will be made by respective resident, and if necessary by respective attending 

• Consult Ortho to reassess patient who they feel is medically stable to be transferred to Ortho

Department of Orthopedics

• Ortho resident will respond in timely manner when called by ED

• Admit all patients with MSK d/o except those with conditions listed above

• Obtain IM c/s on patient with whom they are  uncomfortable

• Obtain IM c/s on patient whose condition changes pre or post-op

• Coordinate surgical plan including, but not limited to NPO status, equipment, PT/OT, perioperative antibiotics, wound care, activity level, and anticoagulation for patients admitted to IM

• Accept transfers from IM in post-op period if initial indication for admission to IM has been resolved 

• Answer c/s from IM within 24 hrs of request, and continue to follow until Ortho no longer needed

• Disagreements regarding criteria determination will be made by respective resident, and if necessary by respective attending

Department of Emergency Medicine

• Review above criteria to determine which service patient will be admitted

• Request telemetry or ICU level of care, if indicated

Federal Law Enforcement Presence at County

Should federal law enforcement arrive at your County facility, please take the following actions: 

Staff

• Remain calm and professional

  • • Remain courteous and neutral at all times

    • Do not give permission to access private areas and advise the federal law enforcement personnel that leadership must be contacted before a response may be provided

    • Exception: This guidance does not apply in cases of emergency

    • Do not obstruct federal law enforcement when following the guidance below

• Notify leadership immediately

  • • Ask federal law enforcement to wait for a supervisor or designated leadership to arrive

    • Alert your direct supervisor, manager, or designated contact person right away

    • Follow the direction from your chain of command regarding access to non-public or secure areas and/or information in accordance with applicable law, county and department policy

Leadership

• Request identification

  • • Politely ask to see the federal law enforcement personnel’s official identification and credentials

    • Document the name, agency, badge number, and purpose of the visit (if provided)

• Warrant

  • • Limit any interaction to public areas only (e.g., public lobbies, waiting rooms)

    • If agents request access to non-public areas (offices, employee-only spaces, secured areas)

      • • Ask if they have a judicial warrant signed by a judge

        • If they do not have a judicial warrant: You are not required to allow entry into non-public areas

        • If they present a warrant: Make a copy or note the details and immediately contact Chief Assistant County Counsel Laura Feingold or Supervising Deputy County Counsel County Charles Phan

• Limit information sharing

  • • Do not share any private or confidential information (employee, student, or client records) without consulting a supervisor or County Counsel first

    • Some information may be protected by laws such as PII, HIPAA (for health information), FERPA (for education records), or state privacy laws

• County Counsel

  • • Do not attempt to interpret or negotiate legal matters yourself

    • Contact Chief Assistant County Counsel Laura Feingold or Supervising Deputy County Counsel County Charles Phan for legal advice

• Document the visit

  • • After the encounter, document

      • • Date, time, and location of the visit

        • Names and badge numbers of agents

        • Purpose of the visit

        • Any documents requested or presented

    • Submit this documentation to your leadership and department Designated Administrator