200 Questions
What is regulated under the Controlled Substances Act?
A drug or chemical substance
Who should be contacted for questions or concerns regarding controlled substances?
The Controlled Substance Manager
How often are medications stored in the storage area inventoried?
Monthly
Where are records pertaining to medication delivery, dispensing, and administration maintained?
In the storage area
What is the purpose of updating the box?
To include filled date, initials of person filling the box, and seal numbers
What is required for all staff members that have access to the storage area?
Training on proper record keeping
What is the name of the protocol that regulates controlled substances?
Controlled Substances Act
Who is responsible for maintaining up-to-date records?
The Controlled Substance Manager
What is the recommended dose of Fentanyl for RSI?
1-3mcg/kg IV
Which of the following is a contraindication for Succinylcholine?
Pseudocholinesterase deficiencies
What is the recommended dose of Etomidate for RSI?
0.3mg/kg
Why is Atropine used in RSI?
To manage symptomatic bradycardia
What is the recommended dose of Rocuronium for RSI in Tier 2 adults?
1.0mg/kg
What is the purpose of evaluating eyelash response and mandible tension?
To await flaccid paralysis or adequate relaxation
What should be done if oxygen saturation drops below 92% during RSI?
Stop the procedure and provide oxygenation and ventilation support
Who should perform the intubation if the first attempt by the second ALS provider is not successful?
The RSI paramedic
What is included in the narrative by the intubating medic during Endotracheal Intubation?
Landmarks visualized, use of bougie introducer, and verification
What is the purpose of transferring interventions and vital signs from the cardiac monitor/defibrillator?
To import them into the patient care report
What is included in the narrative by the RSI medic during Rapid Sequence Intubation?
Clinical course, procedure, and report to receiving physician
What is the purpose of the patient care report?
To reflect transfer of patient care to receiving personnel
What is included in the essential benchmark interventions?
12 Lead ECG, Waveform capnography, and Cardiac electrical therapies
What is the purpose of verifying placement and patency during Intraosseous vascular access?
To ensure safe and effective vascular access
What is included in the narrative by the provider during Cricothyroidotomy?
Clinical course, landmark identification, verification and report to physician
What is transferred from the first response units to transport units during patient care?
Patient status and transfer of care
What is a sign of inadequate sedation and/or pain control?
Tearing at eyes
What medication should be considered for extended transport or hypotensive patients?
Fentanyl
What is the recommended dose of Vecuronium for long-term paralysis?
0.1mg/kg IV
Why should the dose of Midazolam be reduced or avoided?
If systolic BP is less than 100mmHg
What should be recorded every five minutes during transport?
Vital signs and endotracheal tube placement
What should be considered if intubation is unsuccessful after 2-3 attempts?
Maintaining a BLS airway for the duration of the transport
Why is Ketamine used?
For rapid sedation if patient suddenly wakes and jeopardizes airway
What medication should be considered for hypotensive patients, asthmatics, and trauma?
Etomidate
What is the primary role of a Free-Standing Emergency Department?
To provide initial clinical evaluation and medical stabilization
What happens to patients who require hospital admission after being treated at a Free-Standing Emergency Department?
They are transferred to an appropriate full-service hospital
Which of the following patients should NOT be transported to a Free-Standing Emergency Department?
Patient with a suspected acute MI/STEMI
What is the primary reason why pediatric patients with complicated medical conditions should not be transported to a Free-Standing Emergency Department?
They require more advanced care than what a Free-Standing Emergency Department can provide
Which of the following patients can be transported to a Free-Standing Emergency Department?
Patient requiring a PEG tube replacement
Why are patients transported from a medical facility or nursing home usually not transported to a Free-Standing Emergency Department?
Because they are not seeking a specific service available at the Free-Standing Emergency Department
What is the typical mode of transportation for patients who require hospital admission after being treated at a Free-Standing Emergency Department?
EMS unit
What is the primary goal of a Free-Standing Emergency Department in relation to EMTALA guidelines?
To provide initial clinical evaluation and medical stabilization
What is the primary purpose of the EMS Report Quality Review and Quality Improvement process?
To assess patient care and documentation for compliance within standards
What is the responsibility of the reviewer and all involved personnel during the quality review process?
To maintain the security of patient protected health information and confidentiality
What should be done with any identified potential disciplinary or human resources issues during the quality review process?
They should be managed in accordance with Hanover County Human Resources Policy
What should the designated reviewer provide to the involved personnel at the conclusion of each quality review?
A summary of findings and recommendations
What should be documented and data collected for during the quality review process?
Each quality review
What is the purpose of submitting patient care and medical case reviews to the Operational Medical Director?
To identify areas of improvement and provide feedback to providers
What is the definition of a Quality Review?
The process of assessing patient care and documentation for compliance within standards
What is the primary goal of the quality review process?
To identify areas of improvement and provide feedback to providers
What triggers a general incident review?
High Risk/Significant Incident
Who is responsible for overseeing the department's EMS quality review and improvement?
Quality Improvement Officer
What is the role of the Operational Medical Director?
Reviews incidents and provides recommendations for improvement
Who forwards identified operational concerns to the appropriate officer?
Quality Improvement Officer
What is the purpose of the Assistant Chief of Operations?
Manages operations battalions and department response
Who is the highest level reviewer of clinical incidents?
Operational Medical Director
How can department personnel request incident review or post-incident analysis?
Through supervising officer or by making the appropriate selection within the EMS report
Who designates quality reviewers?
Quality Improvement Officer
What is the primary purpose of maintaining accurate records in the storage area?
To track medication usage and inventory
Where should patients with an uncontrolled airway or unstable vital signs be transported to?
A full-service hospital
Which of the following organizations regulates the possession and use of controlled substances?
United States Department of Justice, Drug Enforcement Administration
Who is responsible for updating the box and maintaining accurate records?
The Controlled Substance Manager
What is the primary function of Incident Quality Review and Quality Improvement?
To conduct quality improvement through continuous assessment and constructive feedback
What is the purpose of the Deployment Log?
To record deployment of personnel and equipment
What should be done if there is a question about the capabilities of the facility?
Contact the facility and speak to the ED Attending Physician
What is the purpose of the accountability logs?
To track personnel accountability and equipment usage
Why can patients with uncontrolled airways or unstable vital signs be transported to a full-service hospital near the free-standing Hanover Emergency Center?
Because the full-service hospital is close to the free-standing Hanover Emergency Center
What is the purpose of the Hanover Fire EMS Procedures-Guidelines Manual?
To establish hospital destination policies
What is the purpose of the narcotics count?
To ensure accurate counting and tracking of controlled substances
What is the role of the Controlled Substance Manager?
To ensure accurate recordkeeping and updating the box
What should be considered when deciding whether to transport a patient to a full-service hospital or a free-standing emergency department?
The patient's vital signs and medical condition
What is the benefit of having a full-service hospital near the free-standing Hanover Emergency Center?
It allows for the transport of unstable patients to the full-service hospital
What is the purpose of monthly inventory of medications in the storage area?
To detect and prevent diversion of controlled substances
What is the primary goal of the Incident Quality Review and Quality Improvement process?
To provide quality improvement through continuous assessment and constructive feedback
How do you remove the stylet from the needle?
Rotate the stylet counterclockwise and pull it out
What is the recommended amount of blood to aspirate to confirm placement?
2 cc of blood
How much sterile saline should be used to flush the needle?
10 cc of sterile saline
What should be attached to the needle after flushing with sterile saline?
I.V. tubing
Why should Lidocaine be considered for awake patients?
To reduce pain during the flush
What should be applied to the patient after the procedure is complete?
A yellow instructional wrist band
How long should the EZ-IO be left in place?
Up to 24 hours
How should the EZ-IO be removed?
By pulling the hub while rotating gently in a clockwise fashion
What is the primary method for documenting patient contacts?
Direct entry into the electronic reporting platform
What should be done with a paper patient care report after transferring data to the electronic report?
Destroy the paper patient care report
Why is it important to restrict access to paper patient care reports?
To prevent patient confidentiality breaches
What is the primary purpose of documenting patient refusals?
To fully document the decision not to treat or transport a patient
When is refusal documentation not indicated?
Stand-bys for fires, or hazardous materials incidents where no one is injured or exposed to hazardous material
What is included in the process of properly documenting a patient contact?
Both direct entry and using a paper patient care report
What is a prerequisite for a patient's decision to refuse care?
The patient must understand the consequences of the refusal
Why is it important to scan all parts of the paper patient care report?
To capture all information, including patient refusal signatures
Who has the right to refuse treatment and/or transportation?
Only competent adults
What is the purpose of documenting patient contacts?
To provide proper emergency medical care
What is the responsibility of Hanover Fire-EMS personnel?
Both to provide proper emergency medical care and to document patient contacts
What is the responsibility of the EMS provider when obtaining a patient's refusal?
To properly assess the patient for any possible illness or injuries and inform the patient of the findings
What is critical in handling patient documentation?
Proper handling
What is an example of an event that may indicate refusal documentation?
A medical call initiated by the patient or family member
Why is it important to document patient refusals?
To protect the EMS agency from liability
What is the purpose of assessing the patient for any possible illness or injuries?
To ensure that the patient is properly evaluated for any potential medical conditions
What is the purpose of updating the deployment log?
To ensure accountability of controlled substances
Which agency regulates the possession and use of controlled substances?
Drug Enforcement Administration
Who is responsible for maintaining accurate records of controlled substances?
Controlled Substance Manager
What is included in the inventory of medications stored in the storage area?
All medications, including narcotics
What is the purpose of training staff members on proper record keeping?
To ensure accurate maintenance of records
What is the frequency of inventorying medications stored in the storage area?
Monthly
What is the purpose of having a Controlled Substance Manager?
To manage the storage of controlled substances
What is the reference for the protocols used in Hanover Fire EMS?
Hanover County RSI Protocol
When must personnel obtain a receiving physician's signature?
For specific medications and procedures, including Field Cease Resuscitation and on-line medical control
What is required for a patient who is unable to sign due to incapacity or medical condition?
Two signatures, with the patient's family or legal power of attorney as the first choice
Who should sign for a minor patient?
The patient's parent or legal guardian and the receiving hospital medical staff
What is the purpose of obtaining patient authorization signatures for billing and HIPPA purposes?
To comply with billing and HIPPA regulations
When is a patient's original signature the only signature required?
When the patient is awake, alert, and oriented
What is the purpose of obtaining a receiving physician's signature for Field Cease Resuscitation?
To confirm that the patient's resuscitation efforts have been ceased
What is the purpose of obtaining a receiving physician's signature for Rapid-Sequence Intubation?
To confirm that the patient's intubation has been successfully performed
What is the purpose of obtaining a receiving physician's signature for on-line medical control?
To confirm that the patient's medical control has been performed under online medical direction
What is the primary role of a Free-Standing Emergency Department?
To provide initial clinical evaluation and medical stabilization
What happens to patients who require hospital admission after being treated at a Free-Standing Emergency Department?
They are transferred to an appropriate full-service hospital
Which of the following patients SHOULD be transported to a Free-Standing Emergency Department?
Patients with minor injuries
Why are patients transported from a medical facility or nursing home usually not transported to a Free-Standing Emergency Department?
Unless transported for a specific service available at the free standing ED
What is the typical mode of transportation for patients who require hospital admission after being treated at a Free-Standing Emergency Department?
EMS unit
What is the primary goal of a Free-Standing Emergency Department in relation to EMTALA guidelines?
To provide initial clinical evaluation and medical stabilization
Which of the following patients should NOT be transported to a Free-Standing Emergency Department?
Acute MI/STEMI suspected or identified by 12 lead ECG
What is the primary reason why pediatric patients with complicated medical conditions should not be transported to a Free-Standing Emergency Department?
Because the Free-Standing Emergency Department is not equipped to handle their conditions
What is the purpose of the SOG for patient refusals?
To define the process and expectations for obtaining and documenting patient refusals
Who has the right to refuse treatment and/or transportation?
Any competent adult
What is necessary for a patient's decision to refuse care to be considered informed?
The patient must understand the consequences of the refusal
What is an example of an event that may not indicate refusal documentation?
A patient who is an occupant of a minor crash or accident
What is the responsibility of the EMS provider in obtaining an informed decision from a patient?
To properly assess the patient for any possible illness or injuries
What is documented on the pre-hospital patient care report in the event of a patient refusal?
The refusal of care decision fully documented
What is an event that generally indicates refusal documentation?
A medical call initiated by the patient or family member
Why must a patient's decision to refuse care be an informed one?
So the patient understands the consequences of the refusal
What should be considered if intubation attempts are unsuccessful and BVM ventilation is ineffective in adults?
Consider surgical cricothyroidotomy
What is an important consideration when performing RSI on pediatric patients?
Ensuring the most experienced provider performs the intubation
Why may lower dosages of paralytics be appropriate for geriatric patients?
Due to decreased renal or hepatic function
What is a second-tier medication option for sedation per protocol in Tactical EMS Providers?
Approved through ODEMSA regional medication list
What is a consideration when performing RSI on pediatric patients?
Obtaining online medical control from an appropriate facility
What should be considered in geriatric patients regarding Succinylcholine?
Potential electrolyte imbalances
What is a consideration for Tactical EMS Providers when performing RSI?
Sedation per protocol
Why may Vecuronium metabolize faster in pediatric patients?
Due to faster pharmacokinetics in pediatric patients
Which of the following patients may be transported to a free-standing emergency department?
Patient with general illness/complaint without comorbid or complicating factors
What type of trauma is appropriate for transport to a free-standing emergency department?
MVC with minor or minimal complaints
Which of the following conditions is not suitable for transport to a free-standing emergency department?
Patient with airway involvement
What type of patient is suitable for transport to a free-standing emergency department for medical clearance?
Stable psychiatric patients in need of medical clearance
Which of the following patients may be transported to a free-standing emergency department for observation?
Patient with resolved chief complaint requiring observation
What type of complaint is suitable for transport to a free-standing emergency department?
General illness/complaint without comorbid or complicating factors
Which of the following patients may be transported to a free-standing emergency department for minor trauma?
Patient with minor trauma, such as laceration repair
What type of patient is suitable for transport to a free-standing emergency department for resolved hypoglycemia?
Patient with resolved hypoglycemia
What is the primary goal of the Quality Improvement process?
To achieve measurable improvement in documentation and patient care
What is the purpose of the Medication Storage and Recordkeeping procedure?
To ensure patient safety and health promotion
What is the scope of the Medication Storage and Recordkeeping procedure?
All Hanover Fire-EMS Personnel
What is the purpose of the Quality Review and Quality Improvement process?
To identify areas for improvement in patient care and documentation
What may occur based on the recommendations of the Quality Improvement Officer?
Remedial training or disciplinary action
What is the responsibility of all personnel in maintaining security of narcotics?
All personnel share the responsibility
What is the primary goal of the Quality Improvement process in relation to High Risk/Significant Incidents?
To minimize the risk of serious harm to patients and department personnel
What is the purpose of the EMS Report Quality Review and Quality Improvement process?
To identify areas for improvement in patient care and documentation
What should be done to patients who are hemodynamically unstable when administering sedation/induction medications?
Half dose them
What should be done to the RSI patient during transportation?
They should remain on the EMS cardiac monitor until physically transferred to the hospital stretcher
What should the RSI Paramedic do after RSI?
Present the case and circumstance to the attending emergency physician
Who should be notified if a conflict or complication develops during RSI?
The RSI Coordinator and OMD
Why should the Microstream EtCO2 adapter be transferred to the hospital?
It is compatible with most receiving hospital Capnography monitors
What should be verified before and after movement during RSI?
ET placement via waveform capnography
What should be included in the documentation of RSI in the electronic Patient Care Report?
RSI procedure details and medications used
What is the purpose of notification and documentation after RSI?
To create a recorded benchmark and CAD note
Who can refuse treatment and transport after appropriate assessment, treatment, and informed consent?
Patients with demonstrated mental capacity
What is required for patients under the age of 14 who refuse treatment?
Direct consent from the parent or legal guardian
What is the primary consideration when dealing with a patient who refuses care?
Respecting the patient's autonomy
What is the responsibility of every individual EMS provider?
To accurately assess patients and gather adequate information
What should EMS personnel do if a patient refuses care?
Respect the patient's decision and not attempt to treat or transport
What is required for patients with impaired mental capacity?
Appropriate medical power of attorney
What should be documented in accordance with ODEMSA Patient Care Protocol 12.6?
All patient refusals
What is the primary consideration for EMS personnel when dealing with a patient who refuses care?
Protecting themselves from potential harm
What should be done with patients who have an uncontrolled airway or unstable vital signs unless extenuating circumstances exist?
Transport them to a full service hospital
What is the location of the Hanover Emergency Center in relation to the Memorial Regional Medical Center?
In close proximity
Who should be contacted if there is a question about the capabilities of a facility?
The ED Attending Physician as Medical Control
What is the primary function of the Incident Quality Review and Quality Improvement process?
Conducting incident reviews and providing constructive feedback
What is the goal of the Incident Review and Quality Improvement process?
To identify opportunities for improved processes
What is the purpose of the EMS Report Quality Review and Quality Improvement process?
To identify opportunities for improved processes
What should be done with any identified potential disciplinary or human resources issues during the quality review process?
Document and refer them to the appropriate authority
What should be documented and data collected for during the quality review process?
Identified areas for improvement and corrective actions
What is the primary sedation agent in the Hanover Fire EMS RSI kit?
Etomidate
What is the initial paralytic medication in the Hanover Fire EMS RSI kit?
Succinylcholine
What is the long-term paralytic medication in the Hanover Fire EMS RSI kit?
Vecuronium
What is the purpose of Atropine in the Hanover Fire EMS RSI kit?
Rescue of vagal response
What type of airway device is included in the Hanover Fire EMS RSI kit?
Supraglottic device
What is the recommended dose of Etomidate in the Hanover Fire EMS RSI kit?
40mg
What is the purpose of the Hanover Fire EMS RSI kit?
To facilitate rapid sequence intubation
What is included in the Hanover Fire EMS RSI kit for syringes and needles?
10ml, 20cc, 5cc, and 18 gauge needles
What direction should the stylet be rotated to remove it?
Counterclockwise
How much blood should be aspirated to confirm placement?
2 cc
What should be used to flush the needle?
Sterile saline
What should be attached to the needle after flushing?
I.V. tubing
How long can the EZ-IO be left in place?
24 hours
How should the EZ-IO be removed?
By pulling the hub while rotating clockwise
What should be considered for awake patients prior to flushing the needle?
Lidocaine
What should be applied to the patient after attaching I.V. tubing?
Yellow instructional wrist band
What is the primary purpose of performing a detailed neurological exam before administration of neuromuscular blockade in RSI?
To document the patient's pre-intubation neurological status
What is the goal of pre-oxygenation in RSI?
To wash out nitrogen during the procedure
Which of the following is an indication for RSI?
All of the above
What should be done if oxygen saturation drops below 92% during RSI?
Abort the intubation procedure and call for assistance
What is an essential component of the patient assessment prior to RSI?
All of the above
Why is a thorough and detailed patient assessment essential prior to RSI?
To determine the need for RSI
What should be included in the patient assessment prior to RSI?
All of the above
What is the purpose of documenting assessment and impression prior to RSI?
To support medical decision-making and patient care
Study Notes
Endotracheal Intubation and Rapid Sequence Intubation
- Endotracheal Intubation requires a narrative by the intubating medic, describing landmarks visualized, use of bougie introducer, and verification.
- Rapid Sequence Intubation (RSI) requires a narrative by the RSI medic, outlining clinical course, procedure, and report to the receiving physician.
Interventions and Vital Signs
- Essential benchmark interventions include:
- 12 Lead ECG
- Waveform capnography
- RSI medications
- Cardiac medications
- Cardiac electrical therapies
- Interventions and vital signs shall be transferred from the cardiac monitor/defibrillator and imported into the patient care report prior to providing the report to the receiving facility.
Patient Care Report
- The PCR shall reflect the transfer of patient care to receiving personnel with a patient status.
- This includes transfer of care from first response units to transport units, as well as from transport units to hospital staff.
Free-Standing Emergency Departments
- Free-Standing Emergency Departments provide initial clinical evaluation and medical stabilization in accordance with Federal EMTALA guidelines.
- However, they do not provide admission on site.
- Patients requiring hospital admission will be transferred from the free-standing emergency department to an appropriate full-service hospital, most often by an EMS unit.
Patient Clinical Conditions
- The following patient clinical conditions should not be transported to a free-standing emergency department:
- Acute MI/STEMI suspected or identified by 12 lead ECG
- Patients in Cardiac Arrest
- Multiple System Trauma patients or patients who meet Trauma Triage criteria
- Open fractures/surgical orthopedic patients, long bone fractures
- Acute or suspected stroke patients/neurological deficits
- Intubated patients
- Pediatric patients with complicated medical conditions
- Patients transported from a medical facility or nursing home, unless transported for a specific service available at the free-standing ED
- Voluntary psychiatric patients seeking inpatient care
Medication Storage and Recordkeeping
- The box should be updated, including filled, dated, initials of the person filling the box, seal numbers, etc.
- All other records should be updated, including the Deployment Log, accountability logs, and a narcotics count if applicable.
Controlled Substances
- Controlled Substance: A drug or chemical substance whose possession and use are regulated under the Controlled Substances Act.
RSI Procedure
- Select and administer an induction agent before paralysis.
- Use of Fentanyl, Atropine, Etomidate, Rocuronium, Midazolam, Ketamine, and Vecuronium in RSI procedure.
- Evaluate eyelash response and mandible tension after administration.
- Intubate and place endotracheal tube per standard of practice, and confirm visually.
- Limit intubation attempts to avoid hypoxia.
- If first attempt by the second ALS provider is not successful, the RSI paramedic shall perform all subsequent attempts.
- Sedation and analgesia medications will be determined by the provider based on patient presentation and clinical course.
Long-Term Paralytics
- Consider only if succinylcholine is used as the initial paralytic and the patient is sedated.
- Clear communication of the time of the last paralytic to the receiving facility.
Record Keeping
- Record vital signs every five minutes and re-verify endotracheal tube placement with each movement.
Patient Destination
- Patients with uncontrolled airway or unstable vital signs should be transported to a full-service hospital unless extenuating circumstances exist.
- The Hanover Emergency Center is in close proximity to the full-service Memorial Regional Medical Center, making transport to the full ED a viable option for unstable patients.
EMS Report Quality Review and Quality Improvement
- The primary function of Incident Quality Review and Quality Improvement is to provide quality improvement through continuous assessment and constructive feedback.
- The goal of Incident Review and Quality Improvement is to understand how the department performs and identify opportunities for improved processes.
- General Incident Review Criteria include:
- Provider request for review
- Officer request for review
- High Risk/Significant Incident
- Deviation from protocol during patient care
- Delayed report completion
- Bi-annual provider review
- External or Internal complaint concerning patient care
- The Quality Improvement Officer is responsible for overseeing the department's EMS quality review and improvement.
- Designated Quality Reviewers assist with review and improvement of EMS reporting and care.
EMS Report Quality Review and Quality Improvement Process
- Statement of Facts and collected data
- Incident as applied to referenced standards
- Identify variance from standards
- Recommendations for process improvement and training
- Requests for improvement/completion of incident documentation
- Patient care and medical case reviews are submitted to the Operational Medical Director for review.
Medication Storage and Recordkeeping
- Medication storage boxes should be updated, including filled date, initials of person filling the box, seal numbers, etc.
- All other records should be updated, including the Deployment Log, accountability logs, and a narcotics count if applicable.
Definitions
- Quality Review: The process by which patient care and documentation are assessed for compliance within standards to identify areas of improvement and provide feedback to providers.
- Controlled Substance: A drug or chemical substance whose possession and use are regulated under the Controlled Substances Act.
Adults and Pediatrics EZ IO
- Rotate the stylet counterclockwise to remove it.
- Confirm placement by aspirating 2 cc of blood.
- Flush the needle with 10 cc of sterile saline.
- Attach I.V. tubing and cover with sterile dressing.
- Apply a yellow instructional wrist band to the patient.
- The EZ-IO should not be left in place for more than 24 hours.
Patient Care Documentation (SOG)
- Personnel must obtain receiving physician signature for specific medications and procedures, including Field Cease Resuscitation, Rapid-Sequence Intubation, administration of controlled substances, and on-line medical control for specific medications or procedures.
- Deviation from ODEMSA or Department Patient Care Guidelines also requires receiving physician signature.
- Patient authorization signatures for billing and HIPAA purposes are required for all transported patients.
Patient Refusals (SOG)
- Refusal of care decision must be fully documented on the pre-hospital patient care report.
- Events indicating refusal documentation include medical calls initiated by the patient or family member, and obvious injuries or medical conditions.
- Events that may not indicate refusal documentation include stand-bys for fires or hazardous materials incidents, routine blood pressure checks, and minor crashes or accidents.
Documentation Procedure
- All patient contacts should be properly documented, with direct entry into the electronic reporting platform as the primary method.
- In situations where a paper patient care report is used, it should be properly documented, restricted to ensure patient confidentiality, and then transferred to the electronic report.
Free-Standing Emergency Departments
- These departments provide initial clinical evaluation and medical stabilization in accordance with Federal EMTALA guidelines.
- Patients requiring hospital admission will be transferred to an appropriate full-service hospital, often by an EMS unit.
- Certain patient clinical conditions, such as acute MI/STEMI, cardiac arrest, multiple system trauma, and acute stroke patients, should not be transported to a free-standing emergency department.
Medication Storage and Recordkeeping (SOP)
- The medication storage box should be updated regularly, including the fill date, initials of the person filling the box, seal numbers, etc.
- All other records, including the Deployment Log, accountability logs, and narcotics count, should also be updated.
- The Controlled Substance Manager is responsible for addressing questions or concerns regarding medication storage and recordkeeping.
Patient Refusals (SOG)
- The purpose of this SOG is to define the process and expectations for obtaining and documenting patient refusals for any and all incidents.
- Refusal of care must be fully documented on the pre-hospital patient care report as required by 12VAC5-31-1090.
- Events that indicate refusal documentation include:
- Any medical call initiated by the patient or family member
- Reason to believe that the person has a medical condition that requires further treatment or transportation
- Obvious injury
- Events that may not indicate refusal documentation include:
- Stand-bys for fires or hazardous materials incidents with no injuries or exposure
- Routine blood pressure checks with normal findings and no other complaint
- Ambulatory person with minor crash or accident who does not wish to be evaluated
Patient Refusal Prerequisites
- Any competent adult has the right to refuse treatment and/or transportation offered by an EMS agency
- The decision to refuse care must be an informed one
- The patient must understand the consequences of the refusal
- The EMS provider is responsible for properly assessing the patient and informing them of the findings
Patient Destination (SOG)
- Patient clinical conditions that may be appropriate for transport to a free-standing emergency department include:
- General illness/complaint without comorbid or complicating factors
- Musculoskeletal pain
- Eyes, ears, nose, throat complaints without airway involvement
- Minor trauma
- Resolved hypoglycemia
- Improving, uncomplicated allergic reaction
- Stable psychiatric patients in need of medical clearance
Quality Improvement
- Consists of systematic and continuous actions that lead to measurable improvement in documentation and patient care
- May result in remedial training, disciplinary action, or revoked privileges
Medication Storage and Recordkeeping (SOP)
- The purpose of this policy is to train members of the department on the procedure for accurate record keeping and accountability for narcotics stored by Hanover Fire-EMS
- Applies to all Hanover Fire-EMS Personnel
- Ensures patient safety and health promotion related to impairment among healthcare providers
Rapid Sequence Intubation (RSI) (SOG)
- Considerations for RSI include:
- Pediatric patients: consider only if skill set of RSI Paramedic and crew matches the situation
- Geriatric patients: consider potential electrolyte imbalances and lower dosages of paralytics
- Tactical EMS Providers: consider sedation and pain management per protocol
- Transportation considerations:
- Patients should be transported to the most appropriate facility for the clinical problem
- Notify receiving facility of the need for ventilator and additional sedation
- RSI patients should remain on the EMS cardiac monitor until physically transferred to the hospital stretcher
- Verification of ET placement should occur before and after movement via waveform capnography
Patient Refusals
- Adults, emancipated minors (between 14 to 18 years old), and patients with demonstrated "mental capacity" can refuse treatment and transport after appropriate assessment, treatment, and informed consent.
- Patients with mental capacity are defined as being alert, oriented, and able to understand the circumstances surrounding their illness or impairment, and the risks associated with refusal.
- Patients under 14 years old cannot refuse treatment without direct consent from their parent or legal guardian.
- Patients with impaired mental capacity, such as those under the influence of mental illness, drugs, or physical/mental impairment, may have limited ability to refuse treatment and transport.
- EMS personnel should not put themselves in danger by attempting to treat and/or transport a patient who refuses care.
Procedures
- Patients with an uncontrolled airway or unstable vital signs should be transported to a full-service hospital unless extenuating circumstances exist.
- The location of the free-standing Hanover Emergency Center is in close proximity to the full-service Memorial Regional Medical Center, making transport to the full ED a viable option.
- Contact the facility and speak to the ED Attending Physician as Medical Control if there is a question about the capabilities of the facility.
Rapid Sequence Intubation (RSI)
- RSI is indicated for patients who have failed airway maintenance or protection, failed ventilation or oxygenation, or have an anticipated clinical course that will lead to deterioration.
- Contraindications for RSI include individual medication contraindications, such as those for succinylcholine.
- The procedure for RSI includes:
- Performing a thorough patient assessment and determining the need for RSI based on clinical findings and anticipated clinical course.
- Documenting assessment and impression.
- Initiating pre-oxygenation with 100% oxygen by NRB mask.
- Administering medications, such as sedation agents, paralytics, and ancillary agents.
- Using rescue airway devices, such as a supraglottic device or surgical airway equipment.
EZ IO
- The EZ IO is used for intraosseous infusion in adults and pediatrics.
- The procedure for EZ IO includes:
- Performing a thorough patient assessment and determining the need for EZ IO.
- Identifying the correct insertion site and preparing the equipment.
- Inserting the needle at a 90-degree angle and confirming placement by aspirating 2 cc of blood.
- Flushing the needle with 10 cc of sterile saline and attaching IV tubing and covering with a sterile dressing.
- Applying a yellow instructional wrist band to the patient.
This quiz covers various medical procedures performed in emergency situations, including endotracheal intubation and rapid sequence intubation.
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