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.

Bloodless medicine and surgery (BMS) protocol for management of severe anemia in patients for whom blood transfusion is not an option at Englewood Hospital and Medical Center (version 900.03, dated Sept 26, 2017) 

Baseline hgb >7 g/dL

• Epoetin alfa (Procrit): 40 000 units subQ once per week (use IV only if subQ unsuitable, eg, edema)

• Iron sucrose (Venofer): 100 mg IV push once daily for up to10 days (no test dose required); or other appropriate iron preparations (eg, low molecular weight iron dextran)

• Folic acid (folate): 1 mg IVPB once daily

• Vitamin B12 (cyanocobalamin): 1000 mcg IM × 1 dose

• Supplemental O2

• Nutritional support

• Proper management of infection

• DVT prophylaxis: Sequential compression devices (SCDs), cautious use of any anticoagulants (eg, heparin, enoxaparin (Lovenox), direct oral anticoagulants (DOAC))

• GI stress ulcer prophylaxis: Proton pump inhibitor or H-2 blocker (IV or PO)

Baseline hgb 5-7 g/dL 

• Epoetin alfa (Procrit®): 20 000 units subQ once daily for 5 days (use IV only if subQ unsuitable, for example, edema)

• Iron sucrose (Venofer): 100 mg IV push once daily for up to10 days (no test dose required); or other appropriate iron preparations (eg, low molecular weight iron dextran) 

• Folic acid (folate): 1 mg IVPB once daily

• Vitamin B12 (cyanocobalamin): 1000 mcg IM × 1 dose

• If weekly corrected reticulocyte count <6% then redose Epoetin alfa (Procrit): 40000 units subQ once daily for 4 day

• Monitor for tissue dysoxia:

  • 1. Daily 12 lead ECG

    2. Baseline evaluation of mental status and frequent re-evaluation

    3. Periodic lactate determination

• Minimize oxygen utilization

  • 1. Strict bed rest

    2. Supplemental O2

• Nutritional support

• Proper management of infection

• DVT prophylaxis: Sequential compression devices (SCDs), no anticoagulants (eg, heparin or enoxaparin (Lovenox), direct oral anticoagulants (DOAC))

• GI stress ulcer prophylaxis: Proton pump inhibitor or H-2 blockers (IV or PO)

• Reduce intrapulmonary shunt

  • 1. Head of bed greater than 30

    2. “Standing order” bronchodilator therapy

    3. Chest PT and incentive spirometry (if not ventilated and patient able to perform)

• If signs of end organ dysoxia: 

  • 1. Intubation, sedation, ventilation with 100% oxygen (goal PaO2 no <200, but no >250)

    2. Remember to use PEEP to reduce intrapulmonary shunt, maintain FRC and increase PaO2 (make sure patient is euvolemic) c. Sedation to reduce oxygen consumption

    3. Keep euthermic, active cooling if elevated temperature (fever increases consumption and reduces SaO2)

    4. Neuromuscular blockers (NMBs) if necessary to facilitate ventilation, minimize oxygen consumption, and facilitate cooling by reducing subclinical shivering. NMB (“train-of-four”) monitoring as standard: Try to keep patient at 3/4.

Baseline hgb <5 g/dL 

• Epoetin alfa (Procrit): 20 000 units IV every 12 h for 5 days (use IV only if subQ unsuitable, eg, edema)

• Iron sucrose (Venofer): 100 mg IV push once daily for up to10 days (no test dose required); or other appropriate iron preparations (eg, low molecular weight iron dextran)

• Folic acid (folate): 1 mg IVPB once daily 

• Vitamin B12 (cyanocobalamin): 1000 mcg IM × 1 dose 

• If weekly corrected reticulocyte count <6% then redose Epoetin alfa (Procrit): 40 000 units IV every 12 h for 5 days 

• Maximize dissolved oxygen content: 100% oxygen therapy 

• Monitor for tissue dysoxia: 

  • 1. Daily 12 lead ECG 

    2. Baseline evaluation of mental status and frequent re-evaluation 

    3. Periodic lactate determination 

• Minimize oxygen utilization 

  • 1. Strict bed rest 

    2. Non-selective beta blocker: Propranolol (Inderal) 25 micrograms IV q4h starting dose to be increased by 25 μg to a total of no more than 150 μg (0.15 mg) IV q4h as tolerated by BP and pulse rate. Goal HR 90-100 bpm or reduction of HR by 10% but no more than 15% from baseline tachycardia. 

• Aggressive nutritional support 

• Proper management of infection 

• DVT prophylaxis: Sequential compression devices (SCDs), no anticoagulants [eg, heparin, enoxaparin (Lovenox), direct oral anticoagulants (DOAC)] 

• GI stress ulcer prophylaxis: Proton pump inhibitor or H2-blockers (IV or PO) 

• Reduce intrapulmonary shunt 

  • 1. Head of bed greater than 30  

    2. “Standing order” bronchodilator therapy 

    3. Chest PT and incentive spirometry (if not ventilated and patient able to perform) 

• If signs of end organ dysoxia: 

  • 1. Intubation, sedation, ventilation with 100% oxygen (goal PaO2 no <200, but no >250) 

    2. Remember to use PEEP to reduce intrapulmonary shunt, maintain FRC, and increase PaO2 (make sure patient is euvolemic) c. Sedation to reduce oxygen consumption 

    3. Keep euthermic, active cooling if elevated temperature (fever increases consumption and reduces SaO2) 

    4. Neuromuscular blockers (NMBs) if necessary to facilitate ventilation, minimize oxygen consumption, and facilitate cooling by reducing subclinical shivering. NMB (“train-of-four”) monitoring as standard: Try to keep patient at 3/4.

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)

Ordering Guidelines from Radiologists

Neuroradiology

BRAIN 

Headache 

• CT head without contrast for acute (“worst headache of life”). MRI  without contrast

Trauma 

• CT head without contrast (acute). Concussion/TBI: MRI without and  with contrast with DTI

Suspected intracranial hemorrhage 

• CT head without contrast

Acute neurological changes 

• CT head without contrast (only if concern for ICH) Subsequent study:  MRI with and without contrast

Acute stroke/TIA 

• CT head without contrast (if candidate for thrombolysis) Subsequent  studies: MRI brain with /without contrast ( with MR perfusion), MRA  brain and MRA neck without and with contrast as indicated

Hydrocephalus 

• If concern for shunt malfunction CT head without contrast. Alternative  for more acute processes: MRI with and without contrast

Seizure 

• First (New Onset) seizures: MRI Brain with and without contrast (CT  Head if patient unstable / concern for ICH).

Temporal lobe epilepsy 

• MRI without and with contrast with hippocampal volumes. Brain  SPECT as needed

Dementia / Memory loss 

• MRI brain with & without contrast (Hippocampal volumetrics  (Alzheimer’s disease), perfusion, aqueductal stroke volume  measurement (NPH)). PET can also be considered for Alzheimer’s  diagnosis

Normal pressure hydrocephalus, aqueductal  stenosis, Chiari I malformation

• Brain MRI without contrast & CSF flow study (Acqueductal stroke  volume measurement)

Mass 

• MRI without and with contrast. MRI contraindicated: CT without and  with contrast

Aneurysm or AVM 

• “Screening” MRA Head (non-contrast) @ 3T. CTA head with contrast for  definition of small aneurysms, patients who can’t get MRA. Follow-up  studies, MRA @ 3T

Infection 

• MRI without and with contrast. MRI contraindicated: CT without and  with contrast

CSF leak 

• CT Cisternogram (requires intrathecal contrast injection (i.e. identical  to myelogram)). Nuclear medicine CSF leak study

Cranial neuropathy 

• MRI without and with contrast (Cranial nerve protocol)

Pituitary dysfunction 

• MRI Brain with and without contrast (Pituitary protocol)

FACE 

Trauma 

• CT maxillofacial without contrast

Sinus disease 

• CT sinus without contrast. If suspected orbital/intracranial involvement:  MRI Brain and Orbits without and with contrast

Infection 

• CT maxillofacial with contrast. Suspected orbit or brain extension: MRI  Brain and Orbits without contrast (IAC protocol)

Hearing loss, vertigo 

• Developmental: CT temporal bones without contrast. Sensorineural:  MRI IAC without and with contrast

TMJ pain 

• MRI temporomandibular joints

Possible metal in orbits and patient needs an  MRI

• Orbits x-ray

NECK/SOFT TISSUE 

Carotid or vertebral artery stenosis 

• CTA neck with contrast. MRA neck without and with contrast. Carotid  Doppler ultrasound

Mass 

• CT neck with contrast. Thyroid nodule: neck ultrasound. Thyroid  cancer: MR neck without and with contrast

Infection 

• CT neck with contrast

Neurologic deficit in brachial plexus 

• MRI brachial plexus without and with contrast

Carotid or vertebral artery Dissection 

• MRA neck without and with contrast (Dissection protocol). CTA Neck  with contrast

THORACIC SPINE 

Indication 

Preferred Study

Trauma 

CT thoracic spine without contrast. Acute neurologic deficit and CT  negative: MRI without contrast

Pain, degenerative changes, radiculopathy 

MRI thoracic spine without contrast. Prior surgery: MRI cervical spine  without and with contrast. MRI contraindicated: CT without contrast  or CT myelogram. For pain localization in setting of prior surgery or  multiple degenerative findings: SPECT fusion with CT or MRI

Mass 

MRI without and with contrast

Infection 

MRI without and with contrast. MRI contraindicated: CT with contrast

LUMBAR SPINE 

Indication 

Preferred Study

Trauma 

CT lumbar spine without contrast. Acute neurologic deficit and CT  negative: MRI without contrast

Pain, degenerative changes, radiculopathy,  sciatica

MRI lumbar spine without contrast. Prior surgery: MRI without  and with contrast. MRI contraindicated: CT without contrast or CT  myelogram. For pain localization in setting of prior surgery or multiple  degenerative findings: SPECT fusion with CT or MRI

Pars stress injury 

MRI lumbar spine 3T pars protocol. 3T not available: SPECT bone scan.  Followup: CT without contrast

Mass 

MRI without and with contrast

Infection 

MRI without and with contrast. MRI contraindicated: CT with contrast

Lumbosacral plexus abnormality 

MRI lumbosacral plexus (pelvis) without contrast

Musculoskeletal Ordering Guidelines 

SHOULDER 

Indication 

Preferred Study

Trauma, surgical hardware 

X-ray first. CT for pre-operative planning of fractures. CT for occult  fracture in younger patients. MR for occult fracture in older  patients. CT arthrography without and with contrast for arthroplasty  complications

Masses 

X-ray first for bony lesions. Ultrasound for suspected lipoma. Otherwise  MRI without and with contrast

Infection 

MRI shoulder without and with contrast

General pain 

MRI shoulder without contrast. US for patients who cannot have an  MRI

Suspected rotator cuff tear 

MRI without contrast; some shoulder surgeons prefer MRI shoulder  arthrogram. CT arthrogram for patients who cannot have an MRI

Proximal biceps injury 

MRI shoulder without contrast. US for patients who cannot have an  MRI

Suspected labral tear 

MRI shoulder arthrogram

HUMERUS 

Indication 

Preferred Study

Trauma, surgical hardware 

X-ray first. CT for pre-operative planning of fractures. CT for occult  fracture in younger patients. MRI for occult fracture in older patients

Masses 

X-ray first for bony lesions. Ultrasound for suspected lipoma. Otherwise  MRI humerus without and with contrast

Infection 

MRI humerus without and with contrast

General pain, muscle injury 

MRI humerus without contrast

Post-traumatic radial nerve injury 

MRI humerus without contrast

ELBOW  

Indication 

Preferred Study

Trauma, surgical hardware 

X-ray first. CT for pre-operative planning of fractures. CT for occult  fracture in younger patients. CT for arthroplasty complications. MRI for  occult fracture in older patients

Masses 

X-ray first for bony lesions. Ultrasound for suspected lipoma. Otherwise  MRI without and with contrast

Infection 

MRI without and with contrast

General pain, epicondylitis 

MRI without contrast

Distal biceps injury 

MRI elbow without contrast

Ligament injury, especially in throwing  athletes

MRI elbow arthrogram

Osteochondral lesion 

MRI elbow without contrast

Nerve injury/entrapment syndrome 

MRI elbow without contrast

FOREARM  

Indication 

Preferred Study

Trauma, surgical hardware 

X-ray first. CT for pre-operative planning of fractures. CT for occult  fracture in younger patients. MRI for occult fracture in older patients

Masses 

X-ray first for bony lesions. Ultrasound for suspected lipoma. Otherwise  MRI without and with contrast

Infection 

MRI without and with contrast

General pain, muscle injury 

MRI without contrast

Nerve injury/entrapment 

MRI without contrast

WRIST 

Indication 

Preferred Study

Trauma, surgical hardware 

X-ray first. CT for pre-operative planning of fractures. MRI for occult  fracture (such as scaphoid and distal radius)

Masses 

X-ray first for bony lesions. Otherwise MRI without and with contrast

Infection 

MRI without and with contrast

General pain, tendinopathy 

MRI without contrast

Ligament injury 

MRI wrist arthrogram 

TFCC injury 

MRI wrist arthrogram

HAND 

Indication 

Preferred Study

Trauma, surgical hardware 

X-ray first. CT for pre-operative planning of fractures. MRI for occult  fracture

Masses 

X-ray first for bony lesions. Otherwise MRI without and with contrast

Infection 

MRI without and with contrast

General pain, muscle injury, rheumatologic  diseases

MRI without contrast

FINGER (AREA FROM MCP JOINT TO DISTAL TIP) 

Indication 

Preferred Study

Trauma, surgical hardware 

X-ray first. CT for pre-operative planning of fractures. 

Masses 

X-ray first for bony lesions. Otherwise MRI without and with contrast.

Infection 

MRI without and with contrast

General pain, ligament injury 

MRI without contrast

Tendon injury 

MRI without contrast first. US for dynamic abnormality

SACRUM 

Indication 

Preferred Study

Trauma, surgical hardware 

X-ray first. CT for pre-operative planning of fractures. MRI for occult  fracture

Masses 

X-ray first for bony lesions. Otherwise MRI without and with contrast

Infection, decubitus ulcer 

MRI without and with contrast

General pain, sacroiliitis 

MRI without contrast

Suspected sacral plexus nerve impingement 

MRI without contrast

Piriformis syndrome 

MRI without contrast

BONY PELVIS 

Indication 

Preferred Study

Trauma, surgical hardware 

X-ray first. CT for pre-operative planning of fractures. CT for occult  fracture in younger patients. MRI for occult fracture in older patients

Masses 

X-ray first for bony lesions. US for suspected lipoma. Otherwise MRI  without and with contrast

Infection, decubitus ulcer 

MRI without and with contrast

General pain, muscle injury 

MRI without contrast

“Groin pull,” sports hernia 

MRI without contrast

HIP 

Indication 

Preferred Study

Trauma, surgical hardware 

X-ray first. CT for pre-operative planning of fractures. CT for  arthroplasty complications. MRI for occult fracture

Masses 

X-ray first for bony lesions. US for suspected lipoma. Otherwise MRI  without and with contrast

Infection, decubitus ulcer 

MRI without and with contrast

General pain, muscle injury 

MRI without contrast

Arthritis 

MRI without contrast

Osteonecrosis 

MRI without contrast

Stress injury 

MRI without contrast

Labral tear, suspected femoroacetabular  impingement syndrome

MRI hip arthrogram

Assess iliopsoas tendon in snapping hip  syndrome

US

THIGH/FEMUR 

Indication 

Preferred Study

Trauma, surgical hardware 

X-ray first. CT for pre-operative planning of fractures. CT for hardware  complications. MRI for occult fracture

Masses 

X-ray first for bony lesions. US for suspected lipoma. Otherwise MRI  without and with contrast

Infection 

MRI without and with contrast

General pain, muscle injury, hamstring injury 

MRI without contrast

Nerve injury 

MRI without contrast

KNEE 

Indication 

Preferred Study

Trauma, surgical hardware 

X-ray first. CT for pre-operative planning of fractures. CT for  arthroplasty complications. MRI for occult fracture

Masses 

X-ray first for bony lesions. US for suspected lipoma or Baker’s cyst.  Otherwise MRI without and with contrast

Infection 

MRI without and with contrast

General pain, internal derangement (i.e.  ligament or meniscal tear)

MRI without contrast. CT arthrogram in patients who cannot have an  MRI

Meniscal tear in setting of prior partial  meniscectomy

MRI knee arthrogram

Arthritis 

MRI without contrast

Osteonecrosis 

MRI without contrast

Cartilage and Osteochondral Lesions 

MRI without contrast and with T2 mapping

CALF/TIBIA 

Indication 

Preferred Study

Trauma, surgical hardware 

X-ray first. CT for pre-operative planning of fractures. MRI for occult  fracture

Masses 

X-ray first for bony lesions. US for suspected lipoma. Otherwise MRI  without and with contrast

Infection 

MRI without and with contrast

General pain, muscle injury 

MRI without contrast

Stress injury, “shin splints” 

MRI without contrast

ANKLE/HINDFOOT 

Indication 

Preferred Study

Trauma, surgical hardware 

X-ray first. CT for pre-operative planning of fractures. CT for  arthroplasty complications. MRI for occult fracture

Masses 

X-ray first for bony lesions. Otherwise MRI without and with contrast

Infection, osteomyelitis, ulcer 

MRI without and with contrast

General pain, ligamentous injury 

MRI without contrast

Tendinopathy, Achilles injury 

MRI without contrast. US in patients who cannot have an MRI

Plantar fasciitis 

MRI without contrast. US in patients who cannot have an MRI

Tarsal coalition 

CT or MRI without contrast

Osnavicular syndrome 

MRI without contrast

Cartilage and Osteochondral Lesions 

MRI without contrast and with T2 mapping

Tarsal tunnel syndrome 

MRI without contrast

Chronic instability, lateral impingement  syndrome, adhesive capsulitis

MRI ankle arthrogram

MIDFOOT 

Indication 

Preferred Study

Trauma, surgical hardware 

X-ray first. CT for pre-operative planning of fractures. MRI for occult  fracture

Masses 

X-ray first for bony lesions. Otherwise MRI without and with contrast

Infection, osteomyelitis, ulcer 

MRI without and with contrast

General pain 

MRI without contrast. SPECT bone scan fusion study with either CT or  MRI if injection or joint surgery planned.

Metatarsal stress fracture 

MRI without contrast

Lis France ligament injury 

MRI without contrast

FOREFOOT/TOES (REGION FROM MTP JOINT TO DISTAL TIP) 

Indication 

Preferred Study

Trauma, surgical hardware 

X-ray first. CT for pre-operative planning of fractures

Masses 

X-ray first for bony lesions. Otherwise MRI without and with contrast

Infection, osteomyelitis, ulcer 

MRI without and with contrast

General pain 

MRI without contrast

Plantar plate injury, turf toe 

MRI without contrast

Morton’s neuroma 

MRI without and with contrast

OTHER 

Indication 

Preferred Study

Non-acute traumatic pain in scapula,  clavicle, sternoclavicular joints, sternum, ribs,  abdominal muscles, and back muscles

MRI without contrast

Skeletal metastases 

Bone scan for overview. MR without and with contrast for specific  lesions

DVT 

US

Foreign body localization 

US

Superficial abscess detection and drainage 

US

Pain injection or aspiration 

Depending on site, these are performed under x-ray or US

Thoracic Imaging Guidelines 

Indication 

Preferred Study

Chronic Dyspnea 

High resolution chest CT (HRCT)

Hemoptysis 

Chest CT with contrast. If contrast contraindicated then chest CT  without contrast may be ordered. 

Lung cancer-Noninvasive staging 

Chest CT with or without contrast if renal failure or PET/CT 

Screening for pulmonary metastases 

CT chest with or without for initial evaluation or surveillance. Chest  X-ray if performed as a baseline 

Pulmonary nodule > 1 cm 

Chest CT without contrast. Alternatively: PET/CT or transthoracic  needle biopsy are equally appropriate options to work up nodule. 

Pulmonary nodule < 1 cm 

Chest CT follow up without contrast. Consider transthoracic needle  biopsy if high suspicion for malignancy. 

Blunt chest trauma, suspect aortic injury 

CTA chest with contrast 

Acute chest pain suspect aortic dissection 

Chest x-ray most appropriate first imaging test only if readily available  and does not delay CT or MRA. Cannot definitively exclude dissection.  CTA chest and abdomen is the definitive test to rule out aortic  dissection. Alternative: MRA chest and abdomen if CT contrast is  contraindicated. 

Suspected pulmonary embolism 

CTA chest with contrast is current standard of care to exclude  pulmonary embolism. Alternative: When CT contrast contraindicated,  consider ventilation/perfusion scan and lower extremity venous  Doppler ultrasound to rule out deep venous thrombosis. 

Acute respiratory illness- immunocompetent  patient 

Chest X-ray. Chest CT without contrast when x-ray findings  inconclusive. 

Gastrointestinal Imaging Guidelines 

Indication 

Preferred Study

Acute abdominal pain, fever, R/O Abscess 

CT abdomen and pelvis with contrast. Alternative: MRI offers imaging  without non-ionizing radiation and can provide additional clinically  useful information regarding ovarian pathology, PID, ectopic  pregnancy and ovarian torsion. 

Pregnant patient with acute abdominal pain 

Ultrasound, if indeterminate then MRI Abdomen and pelvis without  contrast 

Pancreatitis 

Abdomen with contrast. Ultrasound to exclude gallstones 

Blunt trauma stable patient 

CT Chest/Abdomen/Pelvis with contrast 

Blunt trauma unstable patient 

X-ray chest/abdomen/pelvis with Ultrasound FAST scan. 

Colorectal cancer screening 

CT colonography every 5 years after negative screen. 

Crohn’s disease - adult 

CT enterography. Alternative: MRI enterography has shown similar  sensitivity and specificity to CT and avoids radiation risks. 

Crohn’s disease - child 

MRI or CT enterography initial presentation. MRI enterography for  known disease to avoid repetitive CT radiation exposure. 

Jaundice-painless 

CT pancreas protocol with contrast 

Jaundice with pain/fever 

Ultrasound abdomen 

Left lower quadrant pain 

CT abdomen/pelvis with contrast 

Liver lesion initially identified on U/S or CT 

MRI liver with contrast 

Palpable abdominal mass 

CT abdomen/pelvis with contrast most definitive.. Alternative: MRI with  contrast or ultrasound do not use ionizing radiation 

Right lower quadrant pain suspected  appendicitis 

CT abdomen/pelvis with contrast 

Right lower quadrant pain-pregnant 

Ultrasound, obtain MRI if inconclusive 

Right lower quadrant pain- children 

Ultrasound, obtain MRI if inconclusive 

Dysphagia-oropharyngeal with attributable  cause 

Modified barium swallow 

Dysphagia- unexplained or retrosternal 

Pharyngoesophagram 

Right upper quadrant pain 

Ultrasound limited. If only gallstones present and no fever or elevated  WBC then hepatobiliary scan. 

Suspected liver metastases 

CT or MRI with contrast. MRI should be first line study when  indeterminate liver lesions found on ultrasound or CT. 

Suspected small bowel obstruction 

CT with IV contrast only if high grade or complete obstruction.  Alternative: If partial or low grade obstruction suspected MRI  enterography may be considered. 

Perianal/Perirectal Fistula evaluation 

MRI Fistulogram with/without contrast

Urologic Imaging Guidelines 

Indication 

Preferred Study

Flank pain- suspected stone disease 

CT abdomen and pelvis without contrast (CTKUB). If recurrent  symptoms of stone disease then CTKUB or ultrasound.

Scrotal pain, mass, trauma 

Scrotal ultrasound 

Hematospermia 

MRI prostate with Gd 

Acute pyelonephritis 

CT abdomen and pelvis without and with contrast.. Alternative: Renal  ultrasound less sensitive an specific than CT 

Hematuria 

CT abdomen and pelvis without and with contrast. Order as CT-IVP  which includes high resolution excretory phase imaging of the renal  collecting systems and ureters

Bladder cancer follow up 

CT abdomen and pelvis without and with contrast CT-IVP 

Renal cell cancer follow up 

CT abdomen and pelvis with contrast. Alternative: MRI abdomen and  pelvis 

Incidental renal mass 

Either CT or MRI without and with contrast is appropriate 

Incidental adrenal mass 

CT without contrast. If indeterminate then CT without and with  contrast. Alternative: MRI without contrast if CT inconclusive also no  radiation risks

Prostate cancer post treatment, rising PSA  levels 

Bone scan. CT or MRI abdomen and pelvis with contrast for soft tissue  disease

Prostate cancer pretreatment staging 

Pelvis MRI with contrast and endorectal coil. Bone scan 

Recurrent urinary tract infections in women 

CT without and with contrast for bladder and kidneys evaluation. MRI  pelvis to exclude urethral diverticulum or pelvic prolapse 

Renal failure, rule out obstruction 

Ultrasound 

Renal trauma 

CT abdomen and pelvis with contrast 

Renovascular hypertension 

Renal artery MRA or CTA with contrast. Alternative: Renal Doppler  ultrasound when contrast is contraindicated

Suspect lower urinary tract trauma 

X-ray retrograde cystography or CT cystogram 

Womens Imaging Guidelines 

Indication 

Preferred Study

Abnormal vaginal bleeding 

Transvaginal/Transabdominal pelvic ultrasound

Acute pelvic pain-reproductive age 

gynecological etiology suspected 

Transvaginal/Transabdominal pelvic ultrasound. If positive pregnancy  test and ultrasound inconclusive then MRI pelvis has been beneficial in  providing additional diagnostic information. 

Gravid cervix assessment 

Pelvic ultrasound 

Clinically suspected adnexal mass 

Initial evaluation reproductive age or  postmenopausal. 

Transvaginal/Transabdominal pelvic ultrasound. Short term pelvic  ultrasound follow up often required based on initial findings. May  proceed to MR characterization based on size and composition of any  ovarian findings. 

Adnexal mass, reproductive age, not pregnant  that is persistent or getting larger 

MRI pelvis without and with Gd 

First trimester bleeding 

Transvaginal/Transabdominal pelvic ultrasound 

Second, third trimester uterine bleeding 

Transabdominal ultrasound 

Growth disturbances, IUGR 

OB Ultrasound 

Ovarian cancer screening 

Transvaginal/Transabdominal pelvic ultrasound. Note: Women with  a familial predisposition should be counseled that there is no proven  benefit to current screening methods 

Cervix/Endometrial cancer pretreatment  evaluation and staging 

MRI pelvis without and with Gd. Often followed by CT Chest/Abdomen/ Pelvis or PET/CT. 

Pelvic floor bulging, defecatory dysfunction 

MRI Pelvis with and without Gd Often followed by CT Chest/Abdomen/ Pelvis or PET/CT

Vesico-vaginal or recto-vaginal fistula  evaluation

MRI Pelvis Fistulography with/without contrast

Fecal incontinence-evaluate anal sphincter 

MRI Pelvis-anal sphincter without contrast (often done in conjunction  with Defecography if there is also fecal incontinence)

Abnormal fetal ultrasound (usually for better  evaluation of cranial abnormalities)

MRI Fetal exam without contrast

Fetal or Placental abnormality 

MRI abdomen/pelvis with contrast if ultrasound inconclusive

Vascular Imaging Guidelines 

Indication 

Preferred Study

Pulsatile abdominal mass, suspected aortic  aneurysm 

Ultrasound aorta/abdomen initial screening. May be limited by body  habitus or acoustic shadow. CT abdomen and pelvis preferred for  symptomatic patients when ultrasound not useful. 

Known aortic abdominal aortic aneurysm,  treatment planning 

CTA abdomen and pelvis with contrast 

Aortic injury suspected 

CTA chest with contrast 

Claudication-suspected vascular etiology 

Lower extremity arterial Doppler. Alternative: lower extremity MRA or  CTA runoff providing no contrast contraindication. 

Cold, painful leg-sudden onset 

Lower extremity arteriography. Alternative: CTA or MRA from distal  aorta through lower extremities if no contrast contraindications and  time allows. 

Deep venous thrombosis-lower or upper  extremity 

Ultrasound venous with Doppler

Pelvic vein or central chest vein thrombosis 

MR or CT venography with contrast.

Upper GI bleeding-negative endoscopy 

CT abdomen with contrast 

Pediatric Imaging Guidelines 

Indication 

Preferred Study

Headache, acute with or without positive  neurological signs and symptoms 

CT or MRI head without contrast 

Hematuria 

Renal and bladder ultrasound. If trauma or suspected stone disease  then CT 

Limping in child 0-5 years old 

X-ray of pelvis and lower extremity. 3 phase bone scan if limping  persists and negative x-rays 

Seizures non traumatic 

MRI without and with Gd 

Sinusitis-chronic or with orbital or intracranial  complications 

Sinus CT. MRI orbits/head 

Urinary tract infection 

Renal and bladder ultrasound. Voiding cystourography to exclude  reflux. 

Neck mass, lymphadenopathy 

Neck ultrasound. CT with contrast is complementary 

Right lower quadrant pain under 14  years old 

Ultrasound. MRI abdomen/pelvis with contrast if ultrasound  inconclusive

Suspected spine trauma, alert child no pain 

X-ray. If known cervical fracture then CT. No ACR consensus on  imaging fractures of the thoracic and lumbar spine on children. 

DDH (Developmental Dysplasia of the Hip),  including: abnormal finding on physical  or imaging exam of the hip, monitoring  of patients being treated for DDH, family  history of DDH, breech presentation,  oligohydramnios, neuromuscular condition

Ultrasound of the Hip

Stigmata associated with spinal dysraphism  such as mass, skin discoloration, tags, hair  tuft, hemangiomas, pinpoint midline dimple,  paramedian deep dimples, atypical dimples

Ultrasound of the Spine

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

1. Traumatic brain injury requiring care from multiple services

   • Brain death has not been declared

   • Admission to Trauma Service with neurosurgery consultation

2. Isolated brain injury

   • Brain death has not been declared

   • Admission to Trauma Service for first 24 hrs with immediate Neurosurgery consultation

     1. 1. If ongoing Intensive Care Unit needs per Neurosurgery, may transfer to Neurocritical Care Service after 24hrs with Neurosurgery following

        2. If deemed stable for downgrade by Neurosurgery, may be transferred to Internal Medicine Service with neurosurgery following

3. Traumatic brain injury with brain death declaration prior to admission

   • Patient has multiple traumatic injuries

     1. Admission to Trauma Service

   • Patient has isolated Traumatic brain injury with brain death declaration

     1. Admission to Medical Intensive Care Service

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