Administrative.pdf

Winter Park Fire Department Our mission is to respond in a timely fashion to the urgent and emergent medical needs with skill and compassion to the residents and guests of the city of Winter Park. This manual and the included protocols are authorized by the medical director and is intended to be use...

Winter Park Fire Department Our mission is to respond in a timely fashion to the urgent and emergent medical needs with skill and compassion to the residents and guests of the city of Winter Park. This manual and the included protocols are authorized by the medical director and is intended to be used by trained personnel. This is limited to those employed by the Winter Park Fire Department as emergency medicine technicians/ paramedics. (EMT, EMT/P) These protocols are written to the level of performance of personnel credentialed and licensed to the paramedic (EMT-P) level scope of practice. Personnel who are credentialed and licensed at the technician (EMT) level are expected to perform within their scope of practice. Pediatric Evaluation Management Information will be noted by this icon. A Special Thanks to all the EMS personnel and local physicians who continue to offer suggestions in the development of these protocols. Mitchell Dean Maulfair, DO WPFD Medical Director Winter Park Fire Department 2020 PROTOCOLS Updated 04/20/2020 1 ADMINISTRATIVE POLICIES 1.00 INDEX 1.01 GENERAL MEASURES 1.02 RADIO REPORT FORMAT 1.03 REFUSAL OF SERVICE 1.04 PHYSICAN OR NURSE ON SCENE 1.05 TERMINATION OF RESUCITATION (TOR) 1.06 DETERMINATION OF DEATH (MEDICAL OR TRAUMA) 1.07 UNATTENDED DEATH OR CRIME SCENE 1.08a MEDICAL EVALUATION OF A PERSON IN POLICE CUSTODY 1.08b TASER PROBE EVALUATION 1.09a TRAUMA TRANSPORT PROTOCOLS-OVERVIEW 1.09b TRAUMA TRANSPORT PROTOCOLS-ADULTS 1.09c TRAUMA TRANSPORT PROTOCOLS-PEDIATRICS 1.09d TRAUMA TRANSPORT PROTOCOLS-DESTINATIONS 1.10 EMERGENCY TRANSPORT 1.11 CRITERIA FOR HELICOPTER TRANSPORT 1.12 MEDICAL PATIENT TRANSPORT DECISION 1.13 OBSTETRICAL PATIENT TRANSPORT DECISION 1.14 EMERGENCY INTERFACILITY TRANSPORT 1.15 EMS SATURATION DISASTER RESPONSE LEVELS 1.16 EMS OFFLOAD POLICY 1.17 EMT AND EMT-P CERTIFICATION PROCEDURES 1.18 EMS QUALITY IMPROVEMENT PROGRAM 1.19 HIV POST EXPOSURE PROPHYLAXIS 1.20 SCOPE OF PRACTICE 1.21 FREESTANDING ED TRANSPORT CRITERIA 1.22 BLANK (pending) 1.23 DOCUMENTATION GUIDANCE 1.24 BLANK (pending) 1.25a HOSPICE Winter Park Fire Department Updated 04/20/2020 1 ADMINISTRATIVE POLICIES 1.25b DO NOT RESUCITATE 1.26 FIREGROUND SUPPORT (pending) 1.27 PEDIATRIC TRANSPORT 1.28 RESPIRATORY COMMUNICABLE DISEASE EVALUATION AND TRANSPORT Winter Park Fire Department Updated 04/20/2020 1.01 GENERAL MEASURES INTRODUCTION The following guidelines shall be applied to help promote speed and efficiency when rendering emergency medical care to the sick, injured or infirm. These protocols were developed for the use of the paramedic (EMT-P) in the field. These protocols are a guideline and no guideline can accommodate every situation. They will be reviewed on a regular basis and updated as advancements in training, treatment and equipment become available. SAFETY The safety of Emergency Medical Service (EMS) personnel is paramount to quality patient care. Each scene should be properly evaluated for hazardous materials, fire, violent patients and circumstances as well as the need for additional support from emergency medical services, law enforcement and public service utilities. Proper Personal Protective Equipment (PPE) MUST be utilized according to WPFD Standard Operating Guidelines (SOG), and relevant protocols. 1.28 Respiratory Communicable Disease Evaluation and Management CONSENT Always try to obtain verbal consent prior to treatment. Courtesy, concern and common sense will assure the patient of the best possible care. Respect the patient's right to privacy and dignity. GENERAL TREATMENT MEASURES The paramedic should generally be able to decide expediently upon patient contact if Advanced Life Support (ALS) measures will be needed. These interventions should be instituted simultaneously with the initial assessment. A comprehensive, second survey exam is appropriate after the patient has been stabilized. TRAUMA PATIENTS Except for extensive extrication or other extenuating circumstances, the trauma patient should be en route to a receiving facility within 10 minutes. This is defined as the time from initial patient contact to the rescue vehicle leaving the scene. Continued assessment and treatment may continue until arrival at the receiving facility. Reasons causing a delay in transport should be noted in the patient record. For trauma situations, a patient is considered a pediatric patient if they appear to have the anatomical and physical characteristics of a person fifteen (15) years or younger. This applies to evaluation and management issues. Winter Park Fire Department Updated 04/20/2020 1.01 GENERAL MEASURES MEDICAL PATIENTS The medical patient should be en route to the receiving facility within 20 minutes. Continued assessment and treatment may continue until arrive at the receiving facility. This is defined as the time from initial patient contact to the rescue vehicle leaving the scene. Continued assessment and treatment may continue until arrival at the receiving facility. Reasons causing a delay in transport should be noted in the patient record. CONTINUITY OF CARE RESPONSIBILITIES The EMT-P is responsible for all patient care and is required to attend the patient(s) in the patient compartment of the rescue vehicle during transport. The EMT-P may designate an Emergency Medical Technician (EMT) to attend Basic Life Support (BLS) patients. Patients who have an intravenous line are NOT considered BLS patients and must be attended to by the EMT-P. An EMT may tend to patients with a Heparin-lock or saline-lock provided the patient's chief complaint or diagnosis is not ALS in nature. All patients who receive treatment are to be transported by ambulance to a receiving facility for further evaluation or be released by the medical control physician. MEDICATIONS Please note that all medication dosages listed are for adults, unless otherwise specified. For pediatric medication administration, the Handtevy SystemTM is utilized. An adult patient is one who is 14 years of age or over. A pediatric patient is under 13 years of age. MUTUAL AID RESPONSE In cases of out of county mutual aid response, the Winter Park Fire Department is directed to utilize these practice parameters in conducting patient care. PATIENT CARE RECORD A State Approved EMS Patient Care Report will be generated at the conclusion of each patient contact. Patient contact is defined as any time a person is evaluated for a potential injury or illness. This includes the patient assessment, vital signs if taken, and any procedure performed. Attach the patient’s name (either by handwriting or placing a patient sticker from the Emergency Department (ED) to the EKG monitor strips(s). Patient Care Reports or copies may not be discussed with anyone or distributed to anyone other than the receiving facility or the transporting unit. Any request for Personal Health Information (PHI) must go through the Agency’s Privacy Officer. Winter Park Fire Department Updated 04/20/2020 1.01 GENERAL MEASURES MEDICAL DIRECTION In the event that medical direction is required, personnel may contact the on-line physician at the receiving facility. If further medical direction is needed, contact the on call medical director directly or through the Communication Center. The medical director’s direct line is available on every Engine and Rescue vehicle assigned phone. For the purpose of these protocols, “Online Medical Control” is the physician at the receiving facility. If that physician is unavailable or the on-scene EMT-P or EMT requires additional guidance, the on-call medical director may be contacted. Winter Park Fire Department Updated 04/20/2020 1.02 RADIO REPORT FORMAT GENERAL RADIO ETIQUETTE & INFORMATION A unit requiring communications with a receiving facility will select the appropriate receiving facility talk group on the mobile or portable 800 MHz radio. The unit must listen before transmitting to determine if the talk group is in use. If there is other radio traffic on the talk group, units must wait until this traffic clears or they will hear an audible busy tone. The system does not allow for two radios to transmit on the same talk group at the same time. All receiving facilities in Orange and Seminole County have one (1) talk group except ORMC which has two (2). There may be times when ORMC will request the unit to select and transmit information on their second talk group. Since all communications will go directly to the receiving facility, the person taking the report must have a method of prioritizing the calls. To assist in this, a system of “Triage Categories & Levels” has been established. For all patients being transported to an initial receiving facility, the following should be transmitted, being as concise as possible. Information should be delivered at least three minutes prior to arrival. The unit calling the receiving facility must begin each transmission with the following: Unit Number CATEGORY TRIAGE LEVELS Estimated Time of Arrival CATEGORIES TRAUMA Indicates the patient has an injury Trauma Alert: Indicates a patient meets trauma alert criteria Trauma Red: Indicates a patient is a critical trauma patient, but does not meet trauma alert criteria MEDICAL Indicates patient has a medical problem CARDIAC Alert: Indicates patient meets EMS cardiac alert criteria STEMI Alert: Indicates patient meets STEMI criteria. Winter Park Fire Department Updated 04/20/2020 1.02 RADIO REPORT FORMAT STROKE Alert: Indicates patient meets stroke criteria SEPSIS Alert Indicates a patient who meets sepsis criteria CODE: Indicates patient is pulseless and/or apneic. Pediatric: Indicates patient is a child Haz-Mat: Indicates patient was involved in a hazardous materials incident. Doctor’s Orders: Indicates physician orders are needed. May be requested at any level. TRIAGE LEVELS RED YELLOW GREEN medical/trauma patient requiring critical airway, cardiovascular or surgical intervention or resuscitation. medical/trauma patient with a serious illness/injury and (potentially) unstable vital signs. medical/trauma patient with minor illness or injury and stable vital signs After the receiving facility acknowledges the initial information, the EMT-P / EMT will give the appropriate patient information below: Age of patient Sex of patient Major problem / Complaint / Mechanism of Injury / Nature of Illness Mental status or Glasgow Coma Score (GCS) Pulse rate and rhythm Respiratory rate /oxygen saturation Blood pressure Treatment initiated Any delay in transport (extrication) Estimated Time of arrival. Winter Park Fire Department Updated 04/20/2020 1.02 RADIO REPORT FORMAT In the event that medical direction is required, personnel should contact the on-line physician at the receiving facility. If further medical direction is needed, contact the on-call Medical Director by contacting the Communication Center or directly. The medical director’s direct line is available on every Engine and Rescue vehicle assigned phone. For the purpose of these parameters, “Online Medical Control” is the physician at the receiving facility. If that physician is unavailable or the on-scene EMT-P or EMT requires additional guidance, the on-call medical director may be contacted. Winter Park Fire Department Updated 04/20/2020 1.03 REFUSAL OF SERVICE INTRODUCTION It is the intent of Winter Park Fire Department to provide expert pre-hospital medical evaluation, management and transport to a receiving hospital for all patients in need of such care. It is paramount to be certain that when a patient refuses medical care or transport, that they possess the capacity to make those decisions. They must not be impaired by their illness, injury, substance intoxication or psychological impairment. They must have the baseline mental capacity prior to their injury to understand their current circumstances. They must be at least 18 years of age or be an emancipated minor. PATIENT EVALUATION Obtain history from the patient and / or others in the area Obtain and record at least one (1) set of vital signs. If unobtainable, justify on report. If more than 10 minutes have passed, obtain a second set of vital signs Perform a brief physical examination, paying particular attention to alterations in mental status and to any traumatic injury or medical illness that may represent a threat to the well-being of the patient. DETERMINE IF THE PATIENT HAS AN “EMERGENCY MEDICAL CONDITION” If the patient is in immediate jeopardy to their health and well-being, as defined by Florida Statue 395.002, they are considered to have an emergency medical condition. Florida Statute 395.002 (8) “Emergency medical condition” means: (a) A medical condition manifesting itself by acute symptoms of sufficient severity which may include severe pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following: 1. Serious jeopardy to patient health, including a pregnant woman or fetus. 2. Serious impairment to bodily functions. 3. Serious dysfunction of any bodily organ or part. (b) With respect to a pregnant woman: 1. That there is inadequate time to effect safe transfer to another hospital prior to delivery; 2. That a transfer may pose a threat to the health and safety of the patient or fetus; or Winter Park Fire Department Updated 04/20/2020 1.03 REFUSAL OF SERVICE 3. That there is evidence of the onset and persistence of uterine contractions or rupture of the membranes. ASSESS THE CAPACITY OF THE PATIENT For EMS purposes, a competent patient shall be defined as one who: 1) Is over 18 years of age or is an emancipated minor 2) Is Awake, Alert and Oriented to Person, Place, Time and Event (AAOX4) 3) Has no sign of injury or illness which may impair the ability to make an informed decision 4) Is not apparently intoxicated by drugs or alcohol and has no evidence of mental incapacitation INCAPACITATED PATIENT If the patient has an “Emergency Medical Condition” and the patient (or parent or guardian) is unreasonable or “incapacitated”, and refusing transport: Explain to patient, (or parent or guardian), the need for transport, reassure the patient that no harm will result from the transport but that complications, up to and including death, may result from a delay in treatment. If the patient, (or parent or guardian), continues to refuse care enlist the aid of law enforcement personnel to secure the patient for transport. EMERGENCY EXAMINATION AND TREATMENT OF INCAPACITATED PERSONS FS 401.445 Indicates an EMT, Paramedic or Physician may, using reasonable force, restrain, examine, treat and transport patients to the appropriate facility if they meet the following criteria: The patient has an emergency medical condition which a reasonable person would seek medical attention and they are refusing, and The patient has a condition whether from a substance, medical, traumatic or psychological, which renders the patient unreasonable and/or incapable of providing appropriate informed consent. If the patient, (or parent or guardian), appears to have the capacity to refuse transport: Winter Park Fire Department Updated 04/20/2020 1.03 REFUSAL OF SERVICE Emphasize the need for care, the risks of refusal of care (if applicable), and the willingness of EMS to transport the patient. Emphasize that EMS stands ready to respond should the patient, parent or guardian change his or her mind. It is worthwhile to ask the patient and document their rationale for refusal, as well as their alternative plan for evaluation, management and transport regarding their medical concern. All episodes which involve refusal of care or assessment of competency must be documented completely on a patient care report. SELECT MEDICAL CONDITIONS Transport is not required, but should be offered, for select medical conditions (listed below), with stipulations: Hypoglycemia The patient has a competent adult that will remain with the patient. The patient is not taking a sulfonylurea medication1 Has the ability to recheck blood glucose Has adequate nutrition Seizures The patient must have an established history of seizures, and cannot have: fever repetitive seizures apparent head injury An unusual seizure for the patient New onset of seizures Asthma The patient has a history of asthma The patient has a competent adult that will remain with the patient. Has attained normal oxygen status and vital signs The patient has no signs of respiratory compromise REFUSAL DOCUMENTATION When documenting a refusal on a person deemed to be competent to make an informed refusal decision, the following statement needs to be documented as part of the narrative: Winter Park Fire Department Updated 04/20/2020 1.03 REFUSAL OF SERVICE “The patient (or parent, guardian or legal health care surrogate of the patient) may currently have an emergency medical condition and has been offered evaluation, management and transport to a health care facility. The patient (or parent, guardian or legal health care surrogate of the patient) is making an informed refusal of medical service and transportation and does not appear to be impaired or incapacitated by any substance or medical/trauma condition which makes their medical decision making unreasonable.” PEDIATRIC REFUSALS Minors can neither give informed consent nor refuse treatment. If a parent or gaurdian is not present for the acutely sick or injured child, always provide the appropriate medical care and transport to reduce injury and preserve life. If a parent or gaurdian refuses acutely needed care, first explain the rational and need for urgent or emergent management and transport. Make sure the parent’s opposition is not due to misunderstanding or language challenges. Enlist the help of other family members if available. If the parent declines transport for their child, and they have a reasonable care plan, (such as transportation by private vehicle) they may refuse the transport. This would be acceptable for a stable child not in immediate danger. Provide all appropriate treatment, on scene. This would include such things as a simple nebulizer treatment for a stable asthma exacerbation or splinting for minor orthopedic injuries. Document the interventions performed and the parent’s alternative care plan for their child. A parent can make healthcare decisions for their child unless their decision places the child’s health, well-being or life in jeopardy. Failure of a parent or gaurdian to provide necessary medical care is neglect. Observe for any signs of abuse or neglect and document. Do this without assigning blame or making accusations. If all else fails, enlist the help of law enforcement and transport as needed to preserve the well-being of the child. Winter Park Fire Department Updated 04/20/2020 1.03 REFUSAL OF SERVICE REFERENCE 1 Sulfonurea 395.002 anti-diabetic medications widely used in the treatment of type II diabetes. These medications have a long half-life and may result in prolonged hypoglycemic episodes. Examples include glyburide, glipizide, glimepiride, chlorpropamide) Definitions.—As used in this chapter: (8) “Emergency medical condition” means: (a) A medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following: 1. Serious jeopardy to patient health, including a pregnant woman or fetus. 2. Serious impairment to bodily functions. 3. Serious dysfunction of any bodily organ or part. (b) With respect to a pregnant woman: 1. That there is inadequate time to effect safe transfer to another hospital prior to delivery; 2. That a transfer may pose a threat to the health and safety of the patient or fetus; or 3. That there is evidence of the onset and persistence of uterine contractions or rupture of the membranes. 401.445 Emergency examination and treatment of incapacitated persons. (1) No recovery shall be allowed in any court in this state against any emergency medical technician, paramedic, or physician as defined in this chapter, any advanced practice registered nurse licensed under s. 464.012, or any physician assistant licensed under s. 458.347 or s. 459.022, or any person acting under the direct medical supervision of a physician, in an action brought for examining or treating a patient without his or her informed consent if: (a) The patient at the time of examination or treatment is intoxicated, under the influence of drugs, or otherwise incapable of providing informed consent as provided in s. 766.103; (b) The patient at the time of examination or treatment is experiencing an emergency medical condition; and Winter Park Fire Department Updated 04/20/2020 1.03 REFUSAL OF SERVICE (c) The patient would reasonably, under all the surrounding circumstances, undergo such examination, treatment, or procedure if he or she were advised by the emergency medical technician, paramedic, physician, advanced practice registered nurse, or physician assistant in accordance with s. 766.103(3). Examination and treatment provided under this subsection shall be limited to reasonable examination of the patient to determine the medical condition of the patient and treatment reasonably necessary to alleviate the emergency medical condition or to stabilize the patient. (2) In examining and treating a person who is apparently intoxicated, under the influence of drugs, or otherwise incapable of providing informed consent, the emergency medical technician, paramedic, physician, advanced practice registered nurse, or physician assistant, or any person acting under the direct medical supervision of a physician, shall proceed wherever possible with the consent of the person. If the person reasonably appears to be incapacitated and refuses his or her consent, the person may be examined, treated, or taken to a hospital or other appropriate treatment resource if he or she is in need of emergency attention, without his or her consent, but unreasonable force shall not be used. (3) This section does not limit medical treatment provided pursuant to court order or treatment provided in accordance with chapter 394 or chapter 397. History.—s. 17, ch. 89-275; s. 15, ch. 89-283; s. 3, ch. 89-336; s. 1, ch. 90-192; s. 25, ch. 92-78; s. 3, ch. 93-12; s. 25, ch. 93-39; s. 802, ch. 95-148; s. 1, ch. 2007-176; s. 10, ch. 2016-145; s. 37, ch. 2018-106. Winter Park Fire Department Updated 04/20/2020 1.04 PHYSICIAN OR NURSE ON SCENE INTRODUCTION The care of the patient at the scene of an emergency should be the responsibility of the individual in attendance who is the most appropriately trained in providing pre-hospital stabilization and transport. As an agent of the medical director of an EMS system, the EMT-P / EMT represents that individual. Occasions will arise when a physician on the scene will desire to direct pre-hospital care. A standardized method for dealing with these contingencies will optimize the care given to the patient. CRITERA FOR ON SCENE PHYSICIAN ASSUMING CARE OF A PATIENT The physician desiring to assume care of the patient must provide documentation of his status as a physician (M.D. or D.O.). Be licensed to practice medicine in the State of Florida. Allow documentation of his or her assumption of care in the patient care report. Contact with medical control at the receiving facility must be established as soon as possible. The physician assuming responsibility at the scene should be placed in contact with the medical control physician and acknowledgment of his or her acceptance of responsibility confirmed. Orders provided by the physician assuming responsibility for the patient, should be followed, if in the judgment of the EMT-P they do not endanger patient well-being. The EMT-P may request the physician to attend to the patient during transport if the suggested treatment varies significantly from standing protocol orders. If the physician's care is judged by the EMT-P to be potentially harmful to the patient, the EMT-P should: Politely voice his or her objections. IMMEDIATELY place the physician on the scene in contact with medical control for resolution of the problem. When conflicts arise between the physician on the scene and medical control, EMS personnel should follow the directives of the medical control physician. Offer no assistance in carrying out the order in question and provide no resistance to the physician performing this care. If the physician on scene continues to carry out the order in question, offer no assistance and enlist aid from law enforcement. Winter Park Fire Department Updated 04/20/2020 1.04 PHYSICIAN OR NURSE ON SCENE All interactions with physicians on the scene must be completely documented in the Patient Care Report. Should a Registered Nurse present at an emergency scene and wish to participate in administering care for the patient, he / she must function within the realm of Florida’s Nurse Practice Act.1 REFERENCES 1 2019 Florida Statutes, Nurse Practice Act 464.001-464.027 Winter Park Fire Department Updated 04/20/2020 1.05 TERMINATION OF RESUSITATION (TOR) INTRODUCTION This protocol was prepared in accordance with national standard recommendations, as a guideline when to terminate an active yet futile resuscitation effort. If the benefit of survival due to an intervention is under 1%, it is considered medically futile. Emergency transport has inherent risks to EMS personnel as well as the community. (traffic collisions, prolonged periods out of service, personal injury) Consideration to potential benefits versus risk were evaluated in composing this protocol. THE FOLLOWING ARE REASONS TO DISCONTINUE RESUCITATIVE EFFORTS, ONCE INITIATED MEDICAL PATIENTS The scene becomes unsafe A valid DNR is produced Rescuers are physically unable to continue resuscitation efforts Consultation with medical direction advises termination of efforts The National Association of Emergency Medical Service Physicians (NAEMSP) endorses the following criteria as having a greater than 99% positive predictive value for accurately predicting no chance of survival: When emergency medical services personnel did not witness the event When there is no shockable rhythm identified by an automated external defibrillator (AED) or other electronic monitors When spontaneous circulation does not return in the out-of-hospital setting Additionally, ALS personnel may terminate resuscitative efforts for cardiac arrest if ALL of the following criteria exist: The patient is 18 years or older EMS has provided over 20 minutes of CPR Initial rhythm is asystole or PEA, confirmed in two leads on a printed rhythm strip Rhythm remains in asystole or PEA throughout resuscitative efforts (nonshockable, (not V-Fib or V-Tach) No return of spontaneous circulation (ROSC) No defibrillation is performed EMS did not witness an arrest A secure airway is confirmed by digital waveform capnography Quantitative end-tidal CO2 (ETCO2) value is less than 10 mmHg despite effective CPR Winter Park Fire Department Updated 04/20/2020 1.05 TERMINATION OF RESUSITATION (TOR) Essentially, If there are no encouraging signs (pulse or cardiac rhythm) of a potential return of circulation in 20 minutes or greater, resuscitative efforts may be discontinued at the EMT-P’s discretion TRAUMA PATIENTS 20 minutes of asystole in the presence of obvious significant trauma The scene becomes unsafe Death is a predictable outcome Consultation with Medical direction advises termination of efforts PEDIATRICS Currently, there are no accepted guidelines for termination of resuscitative efforts of the pediatric patient. (11/2019) REFERENCES Libby C, Rawal AR. EMS, Termination Of Resuscitation And Pronouncement of Death. [Updated 2019 Apr 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541113/ Winter Park Fire Department Updated 04/20/2020 1.06 DETERMINATION OF DEATH INTRODUCTION (MEDICAL OR TRAUMA) For all emergency scenes where patient needs exceed available EMS resources, such as mass casualty incidents (MCI), initial assessment and treatment shall be in accordance with an approved triage methodology. Patients who appear to have expired will not be resuscitated or transported by Seminole County EMS personnel if any of the following obvious signs of death are present: Body decomposition Decapitation Transection of thorax Incineration Patients may also be considered deceased if all four presumptive signs and at least one conclusive signs of death are identified. All four of the following presumptive signs 1) Unresponsiveness 2) Apnea 3) Pulselessness (palpate for one minute) 4) Fixed dilated pupils -and- One conclusive sign 1) Dependent lividity 2) Rigor mortis 3) Massive trauma to the head, neck or chest with visible organ destruction. If there is any question regarding patient viability, including potential hypothermia, resuscitation will be initiated. DETERMINED DECEASED ON SCENE Immediately notify the appropriate authority Do Not leave the body unattended (Medical Examiner, law enforcement) Do Not remove any property from the body or scene for any purpose Do Not cover or manipulate the body If the body is in the public view and cannot be isolated, screened or blocked from view and is creating an unsafe situation, the body may be covered with a clean sterile burn sheet. The decision to not initiate resuscitative efforts in the above scenarios may be made without medical control interaction. Winter Park Fire Department Updated 04/20/2020 1.06 DETERMINATION OF DEATH (MEDICAL OR TRAUMA) PEDIATRICS All the above is appropriate care for the pediatric patient. A paramedic may decide to continue resuscitation efforts at their discretion in accordance with standard protocols. Reasons to continue may include scene safety, location, patient age and input from present family members. Winter Park Fire Department Updated 04/20/2020 1.07 CRIME OR UNATTENDED DEATH SCENE INTRODUCTION Law Enforcement agencies are charged with the responsibility of establishing the manner and cause of death for every unattended death that occurs within its jurisdictional boundaries. It is additionally responsible to charge persons who have committed criminal wrongdoing in connection with those deaths. An unattended death is one which does not occur under the direct supervision or treatment by a properly licensed medical doctor authorized to practice medicine within the State of Florida. Criminal wrongdoing includes all direct forms of physical assault resulting in death and the various stages of homicide. It also includes deaths that involve the delivery of certain controlled substances to a victim, gross negligence, and those that arise from criminal conspiracies. As a result, the need to examine every unattended death and eliminate criminal wrongdoing is the first step in any investigation. Situations that require investigation include but are not limited to: Homicide or Suicide Accidental or Industrial Drowning Sudden Infant Death Syndrome (SIDS) Drug Abuse Physical Abuse or Neglect Negligent Acts that produce Death Unattended Deaths for which a cause of death is unknown The age or lack of known medical history for the victim makes the death suspicious Examination of the deceased body and the location in which it was discovered will provide vital evidence used to establish what occurred and who may have committed any criminal offense. With the advance of forensic evidence testing at a genetic and atomic level, contamination of the death scene by first responders becomes critical. A balance must be struck between rendering aide likely to preserve the life of the victim and preservation of the potential crime scene needed to convict persons responsible for the wrongful death of the victim. The first and most critical step in this process is establishing if the victim has already died prior to the arrival of first responders. If there is any doubt as to the possibility of life, every effort should be made to preserve life with the secondary consideration being the preservation of evidence. Experienced first responders may be able to determine the death of a victim using visual observation only, in certain circumstances. Whenever these conditions are present, first responders should intrude no further into the scene than necessary to identify them. Visually Identifiable as Deceased Massive Trauma (Un-survivable) Decapitation Crushing Incineration Sectioning of the Torso Winter Park Fire Department Updated 04/20/2020 1.07 CRIME OR UNATTENDED DEATH SCENE Decomposition Pronounced and marked lividity Advanced decomposition producing: Skin discoloration/slippage Abdominal swelling and discoloration Gas expansion and odor Bodily fluid seepage/pooling Known to be deceased as a result of prior examination by: Physician Nurse Law Enforcement Officer EMT, EMT-P Any person authorized by Florida statutes to pronounce death Upon confirmation of the above factors first responders should employ the following guidelines: Limit entry to the immediate location of the deceased by no more than one (1) Rescue/EMT/Firefighter and or one (1) Law Enforcement Officer. No Physical Contact with the body unless needed to confirm death. No removal or cutting of restraints / ligature / nooses / knots. All Other Deaths Refer to Section 1.06 DETERMINATION OF DEATH Should be assessed according to probability of preserving life. Victims with signs of life should be treated with the primary and overwhelming objective of preservation of life. When conducting initial assessment for the presence of life the following should apply: Minimize changes to the immediate area where the victim is found Do not introduce any items not directly related to medical treatment Blankets/Coverings Food/Beverages/Personal/Tobacco/Personal items Do not cut through bullet holes or other defects in the victim’s clothing Do not remove clothing items from the scene Victims Pronounced Dead at the Scene Disengage any further contact with the body. Do not reposition, remove, or relocate body from its original location. Do not transport to a medical facility. Do not reposition, remove, or relocate items associated with the body such as weapons, personal property, notes, or any other items comprising elements of the scene. Do not attempt to conceal the victim from view by placing blankets or other items on the body. Document your actions and interactions with the body and scene in your notes. Winter Park Fire Department Updated 04/20/2020 1.07 CRIME OR UNATTENDED DEATH SCENE If you may have left any body fluid (including sweat, saliva and blood) on or near the victim, record this information in your notes and inform the criminal investigator. Winter Park Fire Department Updated 04/20/2020 1.08a MEDICAL EVALUATION OF PERSONS IN POLICE CUSTODY INTRODUCTION When called to a scene to assess a person in police custody perform all assessments and treatment consistent with the standards set for the typical, non-detained patient. EMS personnel do not perform formal medical clearance for patients in police custody prior to jail transport. Avoid stating “You can either go with law enforcement to jail or go with me to the hospital”. The danger of this phrase is it can give the perception of “custody”. to the person being transported and to bystanders as well. Patients in law enforcement custody may be under the influence of alcohol, and/or drugs. They may have attempted to flee or resist arrest. The patient may have a new or existing medical condition or injury. The patient may complain of chest pain, difficulty breathing, or injuries associated with the arrest. The patient’s mental status may be altered and demonstrate hostile or violent behavior. Approach the individual in a nonthreatening manner. Use extreme caution. Evaluate all patients as you would any other with a potential medical problem or traumatic injury. Do not let their legal status influence your clinical evaluation. 2.01 INITIAL MEDICAL ASESSMENT and CARE 2.02 INITIAL TRAUMA ASSESSMENT and CARE After assessing the patient, and treating any obvious conditions, transport to the emergency department should be offered If the detained patient refuses transport, execute a standard refusal process as detailed 1.03 REFUSAL TASER PROBE EVALUATION 1.08b TASER PROBE EVALUATION PEPPER SPRAY/MACE RELATED INJURIES 6.09 OPTHALMIC INJURIES PARAMETER ALTERED MENTAL STATUS 5.03 ALTERED MENTAL STATUS 5.11 PSYCHOLOGICAL/BEHAVIORAL EMERGENCIES PARAMETER 5.20 EXCITED DELERIUM or DRUG INDUCED AGITATION Winter Park Fire Department Updated 04/20/2020 1.08a MEDICAL EVALUATION OF PERSONS IN POLICE CUSTODY VIOLENT PATIENTS If the patient is uncooperative or violent, physically restrain as necessary with the assistance of law enforcement. Do not restrain the patient in a prone position. Document use, type, time applied, and reasons for the restraint application. Document vital signs, distal circulation, sensory, and motor assessments every 5 minutes. If patient requires transport, Law Enforcement must accompany patient to hospital. REFERENCES http://dt4ems.com/you-can-either-go-with-them-to-the-hospital-or-go-with-me-to-jail/ Winter Park Fire Department Updated 04/20/2020 1.08b TASER PROBE EVALUATION INTRODUCTION EMS personnel may be requested to assess patients after Taser deployment, and/or to remove Taser probes lodged in a subject’s skin. Be aware that secondary injuries may result from falls sustained after the device has been deployed. Subject may be dazed/ confused for several minutes post device deployment. The patient may require additional restraint. typical taser probe 2.01 INITIAL MEDICAL ASSESSMENT and CARE Perform a 12-Lead evaluation if the patient is greater than 35 years of age. STABLE (PROBE REMOVAL ONLY) Do not remove the barb if it is in the face, eye, neck, genitals, breasts or spinal column. Transport to a hospital for removal. 1) Utilize Personal Protective Equipment (PPE) 2) Place hand in the form of a “V” around the Taser dart in order to stabilize the surrounding skin and to keep loose skin from coming up with the dart. Firmly grasp the probe and with one smooth hard jerk, remove probe from subject’s skin 3) Prior to probe removal inform all caregivers that you are about to remove the contaminated sharp 4) Examine the probe and the patient closely in an effort to make sure the probe tip did not break off during removal. Accordingly, it is important that the person removing the barb visually inspect it to make sure that the tip is fully intact. If the barb remains in the subject, the patient will be transported to a medical facility for removal 5) Be careful to avoid accidental needle sticks when removing probes 6) Promptly dispose of the probe after removal and examination to ensure that it is intact. Place in an appropriate sharps disposal container. If the dart falls into the Winter Park Fire Department Updated 04/20/2020 1.08b TASER PROBE EVALUATION law enforcement chain of custody, ensure it is placed in an appropriate container that contains no other sharps 7) Provide wound care by cleansing the affected area with saline, and apply an adhesive cover 8) Inform patient of basic wound care and the need to seek additional care in event that signs of infection occur (redness- fever-drainage-swelling-etc.) 9) Clear and thorough documentation is required in the body of the report narrative whether or not EMS transports the patient 10) If transport is necessary, transport to the closest appropriate hospital If the patient is uncooperative, probes may be left on the patient during transport. UNSTABLE Treat following the appropriate medical or trauma protocol REFERENCES https://taserguide.com/how-to-remove-taser-barbs/ Winter Park Fire Department Updated 04/20/2020 1.09a TRAUMA TRANSPORT PROTOCOLS OVERVIEW INTRODUCTION Winter Park Fire Department will always strive for the following principles in caring for the citizens they serve. These include: 1. Timely response and minimal scene time 2. Excellent clinical assessment 3. Appropriate destination 4. Stewardship of resources There are many real-world situations which protocols may not address. Therefore, based on patient presentation, if a paramedic judges that a patient requires evaluation at Trauma Center, they are empowered to make that decision to transport accordingly. These trauma protocol documents are organized into four sections: 109a OVERVIEW 109b ADULT TRAUMA PATIENT 109c PEDIATRIC TRAUMA PATIENT 109d TRANSPORT DESTINATIONS DISPATCH Communications Center Winter Park Public Safety E-911 Communications Center is located at 550 N. Virginia Ave. Winter Park, Florida 32789. All Emergency Medical Service (EMS) calls for The City of Winter Park are received by and dispatched by this center. The entire county has an enhanced 911 system and a Computer Aided Dispatch (CAD) system. List of information to be obtained from caller: Location of patient(s) Type of trauma (Circumstances) Number of trauma victims Extent and severity of trauma injury Scene security / safety Name of caller Callback number All Winter Park Fire Department units and EMS Command personnel will be dispatched on recorded channels. All other requests for an emergency response agency will be made on recorded phone lines. Winter Park Fire Department Updated 04/20/2020 1.09a TRAUMA TRANSPORT PROTOCOLS OVERVIEW Method used to identify and dispatch the most readily available unit The Winter Park EMS System operates under a sophisticated “First Response” agreement between 8 cities and two counties. In this agreement the parties agree to provide reciprocal assistance on a joint response/automatic aid based on geographical location. Agencies participating in the First Response Agreement are: Seminole County Lake Mary Fire Department Longwood Fire Department Oviedo Fire Department Sanford Fire Department Seminole County Fire Department Orange County Maitland Fire Department Orange County Fire Rescue Winter Park Fire Department The closest available unit(s) will be dispatched by the Emergency Medical Services dispatcher based on CAD recommendations and/or Automatic Vehicle Locator (AVL) data. Prior to the first unit’s arrival, multiple response units may be dispatched by request of the Communications Supervisor or EMS Commander based on information received from caller(s). Paramedics upon arrival can request multiple response units. Process used to request assistance from emergency response agencies The Fire Department is requested to respond to all vehicle accidents, trauma alerts and unconfirmed trauma alerts. Law Enforcement is requested to respond to all vehicle accidents, violent or potentially patients or scenes deemed unsafe. Public Utility Agencies are requested when the need is identified Aero-Medical support may be requested by an on-scene Paramedic. In addition, the Communications Supervisor or EMS Commander can request air support prior to a unit’s arrival on scene based on information received from caller(s). Aero-medical resources are requested through the communications center. The following air resources are assigned by region based on availability and weather conditions: AIR CARE 3 (primary- Orlando Health South Seminole) AIR CARE 1 (secondary) AIR CARE 2 (tertiary) Winter Park Fire Department Updated 04/20/2020 1.09a TRAUMA TRANSPORT PROTOCOLS OVERVIEW ISSUING A TRAUMA ALERT A “Trauma Alert” is to be called by the first arriving unit, if in the judgment of the EMT / EMT-P incident commander that the adult or pediatric trauma patient meets the criteria to initiate a “Trauma Alert” Establish direct communication with the Trauma Center, Pediatric Trauma Center or other receiving facility on the appropriate facility’s radio talk group utilizing either an 800 MHz or VHF radio frequency. Give agency name, unit number and state “Trauma Alert”. Give brief description of the situation, location, criteria for calling a “Trauma Alert” and approximate transport time. Once transporting unit is in route to the trauma center or receiving facility, a complete radio report will be given as outlined in Administrative Policy 1.02 RADIO REPORT FORMAT. The transporting agency will provide documentation as prescribed in 64J-2.004 FAC for each adult or 64J-2.005 FAC for each pediatric patient or provide documentation on the Seminole County Abbreviated Report to the hospital staff upon delivery of the patient to the Trauma Center or receiving facility. REFERENCES 64J1.014(5) 64J-1.022, 64J-2.001 64J-2.002 64J-2.004 Adult Trauma Scorecard Methodology 64J-2 005 Pediatric Trauma Scorecard Methodology 252.34, FS 499, 893, 64F-12 (submitted and approved 03/03/2020 Florida Dept of health, letter on file) Winter Park Fire Department Updated 04/20/2020 1.09b TRAUMA TRANSPORT PROTOCOLS ADULT ADULT TRAUMA TRIAGE CRITERIA & METHODOLOGY Adult trauma criteria apply to those injured persons with anatomical and physiological characteristics of a person sixteen (16) years of age or older. Presence of at least one of the following four criteria to determine whether to transport as a trauma alert. These four criteria are to be applied in the order listed, and once any one criterion is met that identifies the patient as trauma alert, no further assessment is required to determine the transport destination in accordance to the Adult Trauma Scorecard methodology as set forth in 64J-2.004 FAC. 1) Meets color-coded triage system (see below) 2) Glasgow Coma Scale (GCS) ≤ 12 3) Meets local criteria (specify): Likely to require surgery within one to four (1-4) hours. 4) Paramedic Judgment: Patient does not meet any of the trauma criteria listed above however, in the judgment of the EMT / EMT-P should be transported as a trauma alert (document as required per 64J-1.014, FAC) Winter Park Fire Department Updated 04/20/2020 1.09b TRAUMA TRANSPORT PROTOCOLS ADULT ADULT COMPONENT BLUE RED AIRWAY1 RR ≥ 30 REQUIRES ACTIVE AIRWAY ASSISTANCE2 CIRCULATION SUSTAINED HR ≥ 120 BPM LACK OF RADIAL PULSE WITH SUSTAINED RAPID HEART RATE > 120 BPM OR BP < 90 mm hg BEST MOTOR RESPONSE BMR = 5 BMR OF ≤ 4 PRESENCE OF PARALYSIS OR SUSPECTED SPINAL INJURY LOSS OF SENSATION CUTANEOUS TISSUE LOSS3 OR GSW TO EXTREMITIES AMPUTATION4 OR 2°/3° BURNS TO ≥ 15% TBSA OR ANY PENETRATING INJURY TO HEAD, NECK OR TORSO5 LONGBONE FRACTURE SINGLE LONGBONE FX DUE TO MVA OR FALL > 10’ SIGNS OR SYMPTOMS OF MULTIPLE LONGBONE FX SITES6 AGE ≥ 55 MECHANISM OF INJURY EJECTION FROM VEHICLE7 OR DEFORMED STEERING WHEEL8 RED = any one (1) transport as a trauma alert BLUE= any two (2) transport as a trauma alert Airway evaluation is designed to reflect the intervention required for effective care Not just Oxygen 3 Degloving injuries, major flap avulsions (> 5 in.) 4 Amputations proximal to the wrist or ankle 5 Excluding superficial wounds in which the depth of the wound can be easily determined 6 Humerus, (radius,ulna), femur, (tibia or fibula) 7 Excluding any motorcycle, moped, all-terrain vehicle, bicycle, or open body of a pickup truck 8 Only applies to driver of the vehicle 1 2 Winter Park Fire Department Updated 04/20/2020 1.09b TRAUMA TRANSPORT PROTOCOLS ADULT REFERENCES 64J-2.004 FAC 64J-1.014 FAC Winter Park Fire Department Updated 04/20/2020 1.09c TRAUMA TRANSPORT PROTOCOLS PEDIATRIC PEDIATRIC TRAUMA TRIAGE CRITERIA & METHODOLOGY The EMT or paramedic shall assess the condition of those injured persons with anatomical and physiological characteristics of a person (15) years or younger using the scorecard methodology outlined in 64J2.005 FAC. Winter Park Fire Department recognizes that a child is not simply a small adult and that the adult trauma scores cannot be used as a reliable indicator of the degree of injury in the pediatric patient. Therefore, all pediatric patients will be scored using the pediatric trauma score outlined below. The presence of at least one of the following two criteria to determine whether to transport as a trauma alert. These two criteria are to be applied in the order listed, and once any one criterion is met that identifies the patient as trauma alert, no further assessment is required to determine the transport destination. 1) Meets color-coded triage system (see below) 2) Patient does not meet any of the trauma criteria listed above but, in the judgment of the EMT / EMT-P should be transported as a trauma alert (document a required per 64J-1.014, FAC) Winter Park Fire Department Updated 04/20/2020 1.09c TRAUMA TRANSPORT PROTOCOLS PEDIATRIC COMPONENT BLUE RED AIRWAY1 REQUIRES ACTIVE AIRWAY ASSISTANCE2 ALTERED MENTAL STATUS3 PRESENCE OF PARALYSIS OR LOSS OF SENSATION SUSPECTED SPINAL INJURY CONSCIOUSNESS SYMPTOMS OF AMNESIA LOSS OF CONSCIOUSNESS CIRCULATION LOSS OF RADIAL OR PEDAL PULSES OR SYSTOLIC B/P < 90 mm hg FAINT / NONPALPABLE CAROTID PULSE OR FAINT / NONPALPABLE FEMORAL PULSE OR BP < 50 mm hg FRACTURE SIGNS OR SYMPTOMS OF A CLOSED LONG BONE FRACTURE (DOES NOT INCLUDE ISOLATED WRIST OR ANKLE FXs) OPEN LONG BONE FX.5 OR MULTIPLE FX SITES OR MULTIPLE DISLOCATIONS (EXCEPT FOR ISOLATED WRIST OR ANKLE FX OR DISLOCATIONS) 4 MAJOR SOFT TISSUE DISRUPTION6 OR 2°/3° BURNS TO ≥ 10% TBSA OR AMPUTATION7, OR PENETRATING INJURIES TO HEAD, NECK OR TORSO8 CUTANEOUS SIZE ≤ 11 KILOGRAMS9 (Kg) RED = any one (1) transport as a trauma alert BLUE = any two (2) transport as a trauma alert 1 Airway evaluation is designed to reflect the intervention required for effective care Patient requiring intubation, manual jaw thrust, continuous suctioning or use of airway adjuncts to assist ventilatory efforts 2 Including drowsiness, lethargy, inability to follow commands, unresponsive to voice, totally unresponsive or coma 3 4 Carotid and femoral pulses are palpable but, radial or pedal pulses are not palpable 5 Humerus, (radius,ulna), femur, (tibia or fibula) 6 Major degloving injuries or major flap avulsions 7 Amputations proximal to the wrist or ankle Winter Park Fire Department Updated 04/20/2020 1.09c TRAUMA TRANSPORT PROTOCOLS PEDIATRIC 8 Excluding superficial wounds in which the depth of the wound can be easily determined 9 Or body length is equivalent to this weight on the Handtevy System REFERENCE 64J-2 005 Pediatric Trauma Scorecard Methodology 64J-1.014, FAC Winter Park Fire Department Updated 04/20/2020 1.09d TRAUMA TRANSPORT PROTCOLS DESTINATIONS INTRODUCTION This section discusses trauma transport decisions and provides a listing of regional hospitals and their capabilities. DESTINATION DECISIONS Transport or arrange transport for every trauma alert patient to a trauma center nearest to the location of the incident. Exceptions If the distance is not relevant to the length of time for transport due to the use of an air ambulance. Pediatric trauma alert patients shall be transported to the nearest trauma center with pediatric services even if a trauma center without pediatric services is nearer to the location of the incident. If a trauma center further from the location of the incident has a special resource(s) that the nearest trauma center does not have, such as burn center or hyperbaric chamber, which is needed for the immediate condition of the trauma alert patient, the EMS provider may transport to the trauma center having that special resource(s) even if the trauma center is not nearest to the incident. A trauma alert patient may be transported to a closer hospital other than a trauma center only if the hospital is closer to the scene of the incident, and the patient’s immediate condition is such that the patient’s life will be endangered if care is delayed by proceeding directly to the trauma center. Examples include, but are not limited to: Cardiac arrest secondary to trauma Lack of patent airway. Mass Casualty Situation (MCI) * For situations with multiple trauma patients, not meeting trauma alert criteria, the critical patients should be transported to the initial receiving hospital nearest the scene of incident. The non-critical patients should be transported to a different initial receiving hospital, if possible. There may be instances in mass casualty situations when the ground units will be overburdened and may need air transport to facilitate movement of multiple patients to initial receiving hospitals. This decision will be made by the Field Supervisor on the scene. Winter Park Fire Department Updated 04/20/2020 1.09d TRAUMA TRANSPORT PROTCOLS DESTINATIONS TRAUMA CENTERS The following is a list of trauma centers to where Winter Park Fire Department will routinely transport trauma alert patients. It is preferable that pediatric patients (15 years old and younger) and burn patients be transported to a Level I trauma center. Orlando Health Regional Medical Center (Trauma Level I, Burn Center) 1414 South Kuhl Avenue Orlando, Florida 32806 (321) 841-5111 Orlando Health Arnold Palmer Hospital for Children (Trauma Level I) 92 West Miller Street Orlando, FL 32806 (407) 649-9111 Central Florida Regional Hospital (Trauma Level II) 1403 Medical Plaza Drive Sanford, FL 32771 (407) 321-4500 Halifax Health Medical Center (Trauma Level II) 303 North Clyde Morris Boulevard Daytona Beach, Florida 32015 INITIAL RECEIVING HOSPITALS The following is a list of initial receiving hospitals to which Winter Park Fire Department will routinely transport trauma patients that are do not meet trauma alerts criteria. Initial receiving hospitals are indicated by written documentation. Seminole County AdventHealth Altamonte Springs 601 E. Altamonte Drive Altamonte Springs, Florida 32701 (407) 303-2200 Oviedo Medical Center 8300 Red Bug Lake Road Oviedo, FL 32765 (407) 890-2273 Winter Park Fire Department Updated 04/20/2020 1.09d TRAUMA TRANSPORT PROTCOLS DESTINATIONS South Seminole Hospital 555 West State Road 434 Longwood, Florida 32750 (407) 767-1200 Orange County AdventHealth Apopka 2100 Ocoee Apopka Road Apopka, FL 32703 (407) 609-7000 AdventHealth East Orlando 7727 Lake Underhill Road Orlando, Florida 32822 (407) 303-8110 AdventHealth Orlando 601 East Rollins Street Orlando, Florida 32803 (407) 303-5600 AdventHealth Winter Park Memorial Hospital 200 Lakemont Avenue Winter Park, Florida 32792 (407 646-7000 Nemours Children Hospital 13535 Nemours Parkway Orlando, FL 32827 (407) 567-400 Volusia County AdventHealth Fish Memorial 1055 Saxon Boulevard Orange City, Florida 32763 (386) 917-5000 FREE STANDING EMERGENCY DEPARTMENTS The following is a list of Free Standing Emergency Departments to where Winter Park Fire Department will elect to transport when the injured patient appears to have a minor injury and is unlikely to require hospital admission or emergent or urgent surgical intervention beyond the capabilities of a free standing emergency department. Winter Park Fire Department Updated 04/20/2020 1.09d TRAUMA TRANSPORT PROTCOLS DESTINATIONS AdventHealth Lake Mary FSED 950 Rinehart Road Lake Mary, FL 32746 (321) 363-0400 AdventHealth Oviedo FSED 8100 Red Bug Lake Road Oviedo, FL 32765 (407) 977- 2320 AdventHealth Waterford Lakes FSED 12691 East Colonial Drive Orlando, FL 32826 (407) 281-3600 Baldwin Park ER FSED 2361 N Semoran Boulevard Orlando, FL 32807 (407) 677-2400 Heathrow ER FSED 4525 International Parkway Sanford, FL 32771 (407) 328-0201 (Operations suspended 04/10/20) Orlando Health ER Lake Mary FSED 380 Rinehart Road Lake Mary, FL 32746 (321) 842-0560 REFERENCES 64J-2.002 Prehospital Requirements for Trauma Care. Winter Park Fire Department Updated 04/20/2020 1.10 EMERGENCY TRANSPORT INTRODUCTION “Lights & Siren” If circumstances demand emergency hospital care for patient stability, rapid transport is indicated. Each case will be unique and compelling reasons MUST be documented. If the situation warrants, DO NOT delay at the scene. EXAMPLES OF EMERGENCY TRANSPORT SITUATIONS INCLUDE BUT ARE NOT LIMITED TO: Inability to establish or maintain a patent airway or effective ventilations Complicated obstetrical patient Respiratory arrest, cardiac arrest STEMI or Cardiac Alert Stroke Alerts Penetrating wounds to chest or abdomen Massive internal hemorrhage Head injury with rapidly deteriorating condition Trauma Alert Criteria The few minutes that this type of transport may gain must be of significant benefit to justify the risk of emergency transport The use of emergency transport must be weighed against the potential injury to the patient, EMS personnel and the community at large versus the possible benefit to the patients' by transporting emergently. Winter Park Fire Department Updated 04/20/2020 1.11 CRITERIA FOR HELICOPTER TRANSPORT INTRODUCTION Determine potential need for aero-medical transport of the patient. A critical illness or injury at the time of request thought to need life or limb saving intervention HELICOPTER TRANSPORT INCLUSION CRITERIA Patient need for advanced trauma or medical services where none are available or will be significantly delayed (greater than 30 minutes) Traffic conditions or geographic terrain which prohibits adequate ground transport of the patient Meaningfully shortening the time to delivery of definitive care to patients with time-sensitive medical conditions (distance, traffic conditions) Providing necessary specialized medical expertise or equipment to patients before and/or during transport Providing transport to patients inaccessible by other means of transport HELICOPTER TRANSPORT EXCLUSION CRITERIA Bariatric patient known or estimated to be three-hundred fifty (350) lbs (159kg) or greater. Patient who is combative and cannot be physically and/or chemically restrained. Hazmat contaminated patient. There must be a significant benefit to transporting a patient by aircraft Situations in which the time differential between air and ground transport may substantially impact the outcome of the patient Patients who meet the "Trauma Alert" criteria as specified by 1.09a TRAUMA TRANSPORT PROTOCOL-ADULT, 1.09b TRAUMA TRANSPORT-PEDIATRIC and in whom the time difference between air and ground transport may substantially impact the outcome of the patient. The paramedic in charge of the patient is responsible for determining if aero-medical transport is warranted. The paramedic should notify the Incident Commander of the Winter Park Fire Department Updated 04/20/2020 1.11 CRITERIA FOR HELICOPTER TRANSPORT need for aero-medical transport as soon as possible in order to minimize response and transport times. The decision to use aeromedical transport should be made through a collaborative effort based on the information provided by the paramedic caring for the patient along with other important scene factors such as: time of day location, access to the patient The incident commander has the final authority whether aeromedical transport would be utilized based on an assessment of all the compelling factors of the incident. When aeromedical transport is used, the incident commander should also request for assistance from other agencies as needed to help secure the incident site and landing zone. The Communications Center will advise the priority channel on which ground to air communications will occur. If initial indications indicate that air transport may be required, the air transport should be allowed to progress towards the scene in order to decrease response times. LANDING ZONE (LZ) PREPERATION Area should be at least 100 ft. X 100 ft. (day or night) solid level, ground free of overhead obstructions, ground obstructions, people and any material which might fly loose. If there are obstructions, inform helicopter crew via radio. THE HELICOPTER PILOT MAKES THE FINAL DETERMINATION FOR A SAFE LANDING ZONE (LZ). Mark the four corners of the LZ with lights, flares or high visibility material. The best way to mark the landing position in the LZ at night is to use two vehicles with headlights on low beam shining across the LZ with the intersection of the beams at the landing point. Turn headlights OFF after landing. Do not shine headlights or any lights directly at the aircraft. Keep spectators at least 200 feet from the touchdown area and emergency personnel at least 100 feet away. DO NOT ALLOW ANYONE TO APPROACH THE HELICOPTER AFTER LANDING Winter Park Fire Department Updated 04/20/2020 1.11 CRITERIA FOR HELICOPTER TRANSPORT The individual in charge of the LZ should be clearly identified day or night with either an orange vest or traffic control flashlight and must be wearing eye protection. He/she should have radio contact with the helicopter and is responsible for directional information. When the helicopter is making the final approach to the LZ or lifting off appropriate LZ Radio traffic procedures shall be in effect. Once the patient is packaged and ready to load, the helicopter crew may select 2 or 3 personnel to assist loading. When approaching or departing the helicopter, be aware of the tail rotor. Remain low at all times and follow the crew's directions for safety. REFERENCES State of Florida DOH EMS regulation 64J-2 FAC Douglas J. Floccare, David F. E. Stuhlmiller, Sabina A. Braithwaite, Stephen H. Thomas, John F. Madden, Daniel G. Hankins, Harinder Dhindsa & Michael G. Millin (2013) Appropriate and Safe Utilization of Helicopter Emergency Medical Services: A Joint Position Statement with Resource Document, Prehospital Emergency Care, 17:4, 521-525, DOI: 10.3109/10903127.2013.804139 https://www.nj.gov/health/ems/special-services/fly-or-drive-criteria/ Winter Park Fire Department Updated 04/20/2020 1.12 MEDICAL PATIENT TRANSPORT DECISION INTRODUCTION Protocols are guidelines that cannot always dictate what to do in all circumstances. Specific condition clinical entities have their own listed protocol guideline, below. The principles in making transport decisions include: Excellent clinical assessment Paramedics should consider all options and choose what is the best option for the patient based on the clinical scenario and the continuity of medical care for the patient. Appropriate destination There are several local hospital destinations with a variety of avalable service lines. The paramedic should maintain a knowledge base of local hospital resources. Patient preference We strive to honor patient destination requests with consideration for the continuity of care and taking into account the impact on the patient’s family. Stewardship of resources Availability of EMS resources may make certain elective transports untenable. Paramedics should be compassionate when patient wishes are not feasible. STABLE PATIENT When feasible, all patients will be transported to the hospital of their choice. For the benefit of the community and depending on the request, this may not always be an option. UNSTABLE PATIENT All patients whose condition meets the definition of UNSTABLE (with the exception of surgical trauma patients) will be transported to the closest appropriate receiving facility. If several hospitals are within the same approximate distance from the scene, allow the patient and / or patient’s family to select the closest appropriate receiving facility of their choice. If the patient and family refuse transport to the closest hospital(s), use paramedic judgment. SPECIFIC CONDITON PROTOCOLS 1.09a, 1.09b, 1.09c, 1.09d TRAUMA TRANSPORT PROTOCOLS 1.13 OBSTETRICAL PATIENT TRANSPORT DECISION 5.04 STROKE PARAMETER 4.01 CHEST PAIN ACUTE CORONARY SYNDROME 4.14 LVAD PARAMETER Winter Park Fire Department Updated 04/20/2020 1.13 OBSTETRIC PATIENT TRANSPORT DECISION INTRODUCTION An approximate clinical guideline of determining gestational age is fundal height. The uterus can be palpated at the umbilicus at about 20 weeks. PATIENT KNOWN TO BE < 20 WEEKS GESTATION Last menstrual period, < 20 weeks or verifiable ultrasound proven dates or other proof of < 20 weeks gestation. Transport to the closest emergency department (not closest obstetric facility). PATIENT KNOWN (OR POSSIBLE) ≥ 20 WEEKS GESTATION If imminent delivery or medically unstable mother, transport to the closest ED, (not closest obstetric facility). If patient with non-traumatic abdominal, pelvic or back complaints, (including bleeding or vaginal fluid leak). Transport to the closest appropriate obstetric facility. Contact appropriate obstetric facility ED for radio report and any additional direction/assistance. May transport to the patient’s requested obstetric receiving facility if patient is not having imminent delivery. Non-trauma Alert patients are to be transported to the ED of the closest obstetric receiving facility. PREGNANCY AND A TRAUMA ALERT Transport to Orlando Regional Medical Center If clinical condition makes transport to ORMC untenable, Central Florida Regional is an alternate destination APPROPRIATE OBSTETRIC RECEIVING FACILITIES Central Florida Regional Hospital (Seminole) Advent Health Altamonte (Seminole) Winnie Palmer Hospital (Orange) Call ORMC and transport at their directive. Advent Health Orlando (Orange) Advent Health Winter Park Memorial (Orange) Winter Park Fire Department Updated 04/20/2020 1.14 EMERGENCY INTER-FACILTY TRANSPORT INTRODUCTION The Winter Park Emergency Fire Department (WPFD) does not routinely provide interfacility transports. However, during times of system disaster or unusual circumstances, requests for Emergency Interfacility Transports will be considered on a case-by-case basis. When a request is approved, the WPFD will provide Advanced Life Support (ALS) and Basic Life Support (BLS) transport for interfacility transfers in accordance with the following guidelines: CRITERIA FOR TRANSPORT A paramedic must attend the patient during the transport. The responsible physician at the transferring facility must order the patient transfer certifying that the transfer is medically appropriate, and that acceptance of the patient has been obtained from the receiving physician and facility. The determination of appropriateness and all actions required under federal and state law are the exclusive responsibility of the transferring physician and facility. The transferring physician and/or his or her designee must request the designated agency to provide ground / air transport for the patient in either an emergency or nonemergency mode. Transport for inter-facility patient transfers will be provided in a timely manner to the extent resources permit without seriously hampering the availability of emergency personnel to respond to their primary responsibilities. Requests may be triaged on a medical priority basis by the designated agency supervisory / administrative personnel. HAND OFF COMMUNICATION The attending paramedic must obtain a verbal patient report from the transferring nurse. In addition, it is the responsibility of the paramedic to confirm the physician’s orders for patient management during transport by reviewing the patient’s hospital orders with nurse and / or physician prior to transporting patient. The patient’s chart copies, x-rays, belongings, etc. must be transported to the receiving facility with the patient and documented on the patient care report. MANAGEMENT DURING TRANSPORT Treatment is to be continued in route as ordered. General care measures will follow normal established agency protocols Winter Park Fire Department Updated 04/20/2020 1.14 EMERGENCY INTER-FACILTY TRANSPORT If the patient requires medications or interventions that are beyond the scope of normal EMT-P practice parameters, the transferring facility must provide the appropriate personnel. This may include clinical situations such as high-risk obstetrical patients, or those patients requiring special equipment or monitoring. The specially trained personnel serve as the priority caregiver during the transfer unless it directly conflicts with WPFD guidelines. All efforts should be made by the EMT-P or EMT to assist in patient care during the transfer, however, these efforts must not conflict with the physician’s orders or WPFD guidelines If the patient is determined to be unstable or it is anticipated that the patient’s condition may likely deteriorate in route to the receiving facility, the paramedic should voice his / her concerns to the physician and / or nurse and notify the field supervisor. If the physician believes that the benefits of the transfer outweigh the risks; the facility must send a registered nurse or respiratory therapist to accompany the patient.. Medical equipment and supplies which may be needed during transfer that are not routinely carried on WPFD units must be provided by the transferring medical facility. A patient care report shall be generated for all inter-facility patient transfers. Winter Park Fire Department Updated 04/20/2020 1.15 EMS SATURATION DISASTER RESPONSE LEVELS INTRODUCTION There will be times when the demand for Emergency Medical Services (EMS) taxes or exceeds the capacity of the EMS system thereby, creating a disaster. The Winter Park Fire Department (WPFD) is determined to have reserves available to handle the next emergency and has developed this plan and its concepts to define different levels of disaster status. The following is a simplified view of EMS disaster status and also some specific concepts and actions to take when certain levels of disaster are reached within the WPFD system. LEVELS OF EMS SATURATION GREEN The system is in condition green when all transport units, personnel, and equipment are available for the next emergency call. Green could also be defined loosely as being within a standard response time in any given area in the system. Standard response time is a statistical and historical average. YELLOW Condition yellow occurs when the availability of transport units drops due to an increase in call volume and/or hospital delays. This does not including units temporarily out-ofservice for training. It is when the medical need begins to tax the system, yet things are not at a critical level. Response times have increased to 1½ to 2 times normal response time. Dependency on mutual aid is implemented as needed. RED Condition red is reached when there are no available transport units in the county for an extended period of time and the ability to provide any reasonable response in a timely manner is severely compromised. Red is a condition that would be considered a severe disaster in the WPFD system. Dependency on mutual aid is implemented as needed. EMS SATURATION DISASTER RESPONSE PLAN WPFD units should notify the communications center of “DELAYED OFFLOAD” whenever they have been delayed 15 minutes or greater. Crews are required to notify the communication center immediately after patient care is transferred to hospital personnel and again when they are back in-service. This plan is intended to be an outline of conditions that define EMS disaster response levels and help provide a template for actions to be taken by WPFD to expedite units back into service. These are subject to change at any given time. The overall most important concept is that this is not a license to "drop off" a patient at a hospital. With each patient we must identify when the patient requires active monitoring by a medical professional. Winter Park Fire Department Updated 04/20/2020 1.15 EMS SATURATION DISASTER RESPONSE LEVELS NON-TRANSPORT CRITERIA Minor Wounds Minor extremity injuries with no deformities or loss of neurological/vascular function. Educate patient that “delayed treatment” is an acceptable practice, even if a fracture exists. Minor lacerations or abrasions with hemostasis and normal distal function – educate patient on follow up for “delayed closure” (an accepted medical practice). Initiate wound management including cleaning with soap and water, bandaging and splinting as appropriate. NOTE: If the patient has a deep wound, inquire when they had their last tetanus shot and advise them to follow-up with a physician once adverse conditions have ended. Minor Medical Conditions (examples) Earache Typical headache for patient not in severe pain Back pain – typical patient not in severe pain Sore throat (that can swallow), have patient drink/swallow water Baker-acted patients without any injuries Minor Asthma Hypoglycemia Treat and Release In the event we have patients requiring a breathing treatment or treatment for hypoglycemia and the patient feels better and does not want to go to the hospital; it is appropriate to leave the patient with family or another caregiver. It is imperative that you perform a thorough evaluation and use good judgment before leaving any patient. In the event that you do transport a patient to the hospital and the ED is busy, please be patient and cordial with the ED staff. If we are in “Condition Yellow or Red”, notify the charge nurse, and follow our standing procedures. Remember, teamwork, common sense, and good judgment goes a long way. DETERMINATION TO IMPLEMENT THIS POLICY ESF 4-9-10 have the authority to activate the implementation of this policy when conditions are warranted. Winter Park Fire Department Updated 04/20/2020 1.16 EMS OFFLOAD POLICY INTRODUCTION It is Winter Park Fire Department’s intent to offload patients immediately upon arrival to the emergency department so that the rescue unit is available to return to serve their community in a timely manner. Upon arrival to the emergency department the care of the patient becomes the hospital’s responsibility. There are instances when offload delays may occur due to: Capacity issues in the department/hospital Number of EMS units arriving in the department in close time proximity Acuity of patients in the emergency department EMS TRANSFER TIME Actual time from EMS unit entering department to the offload of the patient from the EMS stretcher to a hospital location, including the waiting room. This coincides with the EMS unit’s arrival time to transfer time radio reports. Under normal conditions, the expectation is that this will take 15 minutes. NOTE: These time parameters apply when the patient is stable. In the event the patient is unstable, and the offload time exceeds fifteen (15) minutes, the crew will make immediate notification of this offload delay to their captain. CONDITION GREEN: (45 MINUTES MAXIMUM) Upon arrival to the department, The EMS crew member will meet with the EMS triage RN, so the nurse can provide a primary triage assessment of the patient. If patient care has not been turned over to the ED staff at 15 minutes from arrival, the crew will notify the Winter Park Communications Center of “DELAYED OFFLOAD” in accordance with 1.15 EMS SATURATION DISASTER RESPONSE LEVELS When 20 minutes have elapsed from time of arrival, the EMS crew will notify the charge RN that they have waited 20 minutes of the 45-minute maximum wait time and the EMS crew will be required to leave at or before 45 minutes. If the wait for offload continues to 30 minutes, the EMS crew will again notify the charge RN that they have now waited 30 minutes of the 45-minute maximum wait time and the EMS crew will be required to leave at or before 45 minutes. If the wait for offload continues to 45 minutes, the EMS unit may leave the patient in the department and return to service. The EMS crew member will notify the charge RN that they are leaving and returning to service. It is recommended that the ED charge RN should immediately provide staff and a stretcher prior to the EMS staff leaving the department. If a stretcher or location is not provided, the EMS crew will create an offload option which may include triage chair, triage stretcher, vacant stretcher, wheelchair or foldable cot. Winter Park Fire Department Updated 04/20/2020 1.16 EMS OFFLOAD POLICY CONDITION YELLOW: (30 MINUTES MAXIMUM) Upon arrival to the department, The EMS crew member will meet with the EMS triage RN, s so the nurse can provide a primary triage assessment of the patient. The crew will advise the that WPFD is in condition yellow which mandate a 30-minute maximum offload time. If patient care has not been turned over to the ED staff at 15 minutes from arrival, the crew will notify the Winter Park Communications Center of “DELAYED OFFLOAD” in accordance with 1.15 EMS SATURATION DISASTER RESPONSE LEVELS When 20 minutes have elapsed from time of arrival, the EMS crew will notify the charge RN that they have waited 20 minutes of the 30-minute maximum wait time and the EMS crew will be required to leave at or before 30 minutes. If the wait for offload continues to 30 minutes, the EMS unit may leave the patient in the department and return to service. The EMS crew member will notify the charge RN that they are leaving and returning to service. It is recommended that the ED charge RN should immediately make arrangements to provide staff and a stretcher prior to the EMS staff leaving the department. If a stretcher or location is not provided, the EMS crew will create an offload option which may include triage chair, triage stretcher, vacant stretcher, wheelchair or foldable cot. IN CONDITION RED ALL OFFLOADS WILL BE IMMEDIATE Winter Park Fire Department Updated 04/20/2020 1.17 EMT & EMT-P PARAMEDIC CERTIFICATION PROCEDURES LICENSING & CERTIFICATION It is within the responsibilities of the EMS captains to ensure that all licensing, certification, and recertification for personnel and vehicles is done per requirements and in the time required as outlined in F.A.C 64J. ALL REQUIRED LICENSES AND CERTIFICATIONS MUST BE CURRENT FOR PERSONNEL TO FUNCTION WITHIN THEIR POSITION. It is the responsibility of all personnel for keeping their individual licenses and certifications from expiring. If any required licenses or certifications are expired that individual does not meet the requirements outlined in F.A.C. 64J or 401.281, F.S., and as a result, is not legally able to function in their position. Therefore, it is imperative that each individual maintains awareness of the expiration date of each of their certifications and licenses. Examples, include, but are not limited to: Vehicle driver’s license Advanced Cardiac Life Support (ACLS) Basic Life Support (BLS) Emergency Medicine Technician-Paramedic (EMT, EMT-P) license & certifications The department will make training opportunities available. If training opportunities provided within the department were not utilized by the individual, they must acquire the required training independently from sources outside the department. This training must be completed prior to the expiration of their licenses or certifications. Personnel should make arrangements to complete any training that is required to renew licenses or certifications well in advance of their expiration. Expiration of any of their licenses or certifications prohibit personnel from legally working and they must be relieved of duty until proof of current licensure or certification has been provided. Prior to returning to duty, documentation must be turned in to the EMS captain and a copy of current licensure or certification shall be placed in the employee’s personnel folder as required by the state of Florida. Persons not maintaining current licenses or certifications shall be subject to disciplinary action. EMERGENCY MEDICAL TECHNICIAN (EMT) Maintain current Florida EMT certification Maintain current CPR healthcare provider certification (AHA or equivalent) as approved by the Winter Park medical director Successful completion of thirty (30) continuing education units (CEUs) as required in F.A.C. 64E-2.008 and approved through the Winter Park medical director. FAILURE TO COMPLY WITH THE RECERTIFICATION REQUIREMENTS SHALL RESULT IN IMMEDIATE SUSPENSION OF CERTIFICATION AND THE INABILITY TO FUNCTION AS AN EMT. Winter Park Fire Department Updated 04/20/2020 1.17 EMT & EMT-P PARAMEDIC CERTIFICATION PROCEDURES EMERGENCY MEDICAL TECHICIAN-PARAMEDIC (EMT-P) Maintain current Florida State EMT-Paramedic certification Maintain current CPR Healthcare Provider certification (AHA or equivalent) as approved by Winter Park medical director. Maintain current Advanced Cardiac Life Support (ACLS) certification (AHA or equivalent) as approved by Winter Park medical director Demonstrate proficiency and recurring education in Prehospital Trauma Life Support (PHTLS) or International Trauma Life Support (ITLS) provider or instructor certification Maintain current Pediatric Education for Pre-Hospital Provider (PEPP) or Pediatric Advanced Life Support (PALS) provider or instructor certification. Successful completion of thirty (30) continuing education units (CEUs) as required by F.A.C. 64J and approved through the Seminole County Medical Director / EMS Office. FAILURE TO COMPLY WITH THE RECERTIFICATION REQUIREMENTS SHALL RESULT IN IMMEDIATE SUSPENSION OF CERTIFICATION AND THE INABILITY TO FUNCTION AS A PARAMEDIC. During suspension, an EMT-P may function as an EMT, provided they maintain State EMT certification. To have their paramedic certification reinstated personnel must successfully complete an individualized remediation program as established by Winter Park EMS Office. PROVISIONAL PARAMEDIC To begin the Provisional Paramedic Program the new or newly hired paramedic must have a State of Florida certification number. Purpose To establish a uniformed program in which a newly hired EMT-P or an employee which has just obtained a Florida Paramedic License will meet the high expectations as set forth by the Winter Park Fire Department and current protocols set forth by the Medical Director in areas such as: critical thinking skills, decision-making skills, expertise in protocols, medical skills and assessments, competency in the operations of EMS equipment and the safety care of the patient. Scope This program will be utilized department wide and encompass all new EMT-P’s and newly hired EMT-P’s. It will be administered to the provisional EMT-P by a paramedic preceptor under the direction of the EMS supervisors. Any deviations from this program must be obtained in writing from the EMS supervisor prior to and kept with the records of the provisional EMT-P, preceptor, and EMS supervisor. General These procedures set forth will include but are not limited to: The provisional period shall be for 20 shifts. The provisional EMT-P shall ride along with a preceptor. The provisional EMT-P shall act under the direct supervision of the Winter Park Fire Department Updated 04/20/2020 1.17 EMT & EMT-P PARAMEDIC CERTIFICATION PROCEDURES preceptor and be the lead medic on all incidents. During this time the preceptor and provisional EMT-P shall complete all required documentation for all alarms/runs. By the end of the provisional period the provisional EMT-P must meet the minimum rating expectation of “COMPETENT” for the previous 10 alarms/runs in each area of ratings. Must have passed 4 out of 4 of all critical EKG strip rhythm quizzes and rated competent in EMS equipment by the preceptor as defined by the Practice Parameters, EMS Supervisor and Winter Park Fire Department. At the completion of the provisional period, if the preceptor feels that additional time is needed- in consultation with the EMS supervisor and shift captain, or the provisional EMT-P has not met any of the program’s criteria, or if the Provisional EMT-P feels that they are not ready, and these concerns have been documented appropriately, the EMS supervisor can extend the provisional period as needed up to an additional 20 shifts with a 2nd preceptor- focusing on the areas of concern. At the end of the 2nd provisional period, if all criteria is met and the provisional paramedic is successful, the Full Status Paramedic letter that is included shall be submitted to the EMS supervisor for final approval and testing. If the preceptor believes that more time is deemed necessary, he / she will consult with the EMS supervisor, and an additional provisional period of 20 shifts will be scheduled with a 3rd preceptor (for a total of 6 months provisional time). The 3rd preceptor will not be required to do any of the EKG strip quizzes, equipment checks or protocol quizzes. Only the daily performance record on calls shall be completed and submitted daily as required. If at the end of the 3rd provisional period the provisional EMT-P is not recommended for full paramedic status, the provisional EMT-P shall wait a period of not less than six months, and not more than one year, after the 3rd provisional period to apply for a 4th and FINAL provisional period. During that time, they may take whatever steps are necessary to correct any deficiencies noted during the first three Provisional periods. The provisional EMT-P may then apply, through the Chain of Command, to be precepted for a 4th and final period. If, after the 4th and final provisional period, the candidate is unsuccessful, they will have exhausted all attempts at achieving full status as a paramedic for Winter Park Fire Department. By applying for, and participating in, the 4th and final provisional period, the candidate agrees that they will accept the decision of the EMS Captains, in conjunction with the Medical Director, as the final and ultimate disposition of this matter. During the six-month period that precedes the formal request for a 4th provisional period, the before mentioned provisional EMT-P may perform ALS skills under the supervision of a Winter Park Fire Department preceptor. It is important to note that the Winter Park Fire Department preceptor is not formally evaluating the candidate. This process serves only to allow said candidate to continue to improve upon the deficient areas noted during his formal provisional periods. It shall also serve as an opportunity to Winter Park Fire Department Updated 04/20/2020 1.17 EMT & EMT-P PARAMEDIC CERTIFICATION PROCEDURES develop the essential decision making and leadership skills that are vital for a paramedic to function successfully within the department. Upon successful completion of the Provisional Paramedic Program, the preceptor shall submit the Full Status Paramedic Recommendation Letter to the EMS Supervisor. The EMS Supervisor will then schedule protocol testing as required by the Winter Park Fire Department. 1. Daily Provisional Performance Record Required to be filled out each duty day in its entirety. Including rating each alarm/run, mandatory comments and an appropriate action plan for the provisional EMT-P noted by the preceptor. The preceptor will notify the station captain of progress each duty day and include both positive comments and concerns at which time the captain will sign the daily record at the end of each shift. c) Signed copies of the daily record are to be kept by the preceptor, provisional EMT-P, and a copy forwarded to the EMS supervisor daily. 2. EKG Strip Quizzes EKG strip quizzes will be administered at a minimum of once a week by the preceptor. Include commonly seen rhythms found on the rhythm strip generator used for training. The quiz has rhythms considered critical and cannot be missed. Must be correct in all 4 quizzes. If a critical rhythm is missed, then a new sheet must be started and added to the current quizzes until the provisional receives a 4 out of 4 correct in a row. These include: V-Fib V-Tach SVT Asystole 2nd Degree Type 2 3rd Degree Idioventricular Agonal ST Elevation MI ST Depression 3. Operation of all current EMS equipment utilized by the Winter Park Fire Department. Includes items such as: CPAP machine Glucometers Interosseous drill Scoop Stretcher Power Stretcher Long Backboards Short Spine Board Kendrick Extraction Device Traction splint Cardboard splints Nitrous Oxide Pedi– immobilizer Lucas machine Lifepak 15 Radio procedures This must be checked off weekly on the daily report. These will need to be reviewed on a weekly basis to assure competency is achieved in all areas prior to the provisional period being completed. 4. Daily protocol quizzes Protocol quizzes will be administered by the preceptor daily (no exceptions), to the provisional EMT-P in an attempt to assist in assessing his/her weaknesses and or Winter Park Fire Department Updated 04/20/2020 1.17 EMT & EMT-P PARAMEDIC CERTIFICATION PROCEDURES strengths and to be used as a tool in studying the WPFD protocols. These are not meant to be graded but used as a tool in facilitating familiarity with the protocols. The quizzes can be done with the preceptor or alone. The quizzes are to be selfgraded by open book review after consulting with the preceptor after administration. Quizzes chosen are at the discretion of the preceptor and the time available. It is suggested that the quizzes be chosen in areas that are noted to be deficient. All quizzes must be completed by the end of the provisional time period. REFERENCES F.A.C 64J. 401.281, F.S Winter Park Fire Department Updated 04/20/2020 1.18 EMS QUALITY IMPROVEMENT PROGRAM INTRODUCTION In an effort to provide the highest quality prehospital care and develop a high reliability organization, the Winter Park Fire Department (WPFD) has outlined the following Quality Improvement (QI) program. The goal of such an organization is provide errorfree care, and continually improve patient outcomes over time. This process entails continual measurement, reassessment, education and the implementation of corrective actions. The overall culture of the WPFD QI program is to promote an encouraging, non-punitive reporting atmosphere, to facilitate early identification of risks to patient safety. PRINCIPLES OF A QUALITY IMPROVEMENT PROGRAM The following principles are adapted from recommendations from the EMS Agenda 20501 Inherently Safe & Effective The goal of the WPFD is to be inherently safe in its operations in order to minimize exposure of people injury, infections, illness or stress. Decisions are made with the safety of patients, their families, clinicians and the public as a priority. Clinical care and operations are based on the best available evidence, allowing systems to deliver effective service that focuses on outcomes determined by the entire community, including the individuals receiving care. Sustainable & Efficient WPFD will make every attempt to provide care in a fiscally responsible, sustainable framework that provides value to the community, minimizes waste and operates with transparency and accountability Adaptable & Innovative Technologies, system designs, educational programs and other aspects of EMS systems are continuously evaluated in order to meet the evolving needs of people and communities. Innovative individuals and organizations are encouraged to test ideas in a safe and systematic way and to implement effective new programs. Socially Equitable Access to care, quality of care and outcomes are not determined by age, socioeconomic status, gender, ethnicity, geography or other social determinants. Caregivers feel confident and prepared when caring for children, people who speak different languages, persons with disabilities or other populations that they may not interact with frequently. Winter Park Fire Department Updated 04/20/2020 1.18 EMS QUALITY IMPROVEMENT PROGRAM Reliable & Prepared The care WPFD strives to provides is consistent, compassionate and guided by evidence—no matter when or where it is needed or who is providing the care. EMS systems are prepared for anything by being scalable and able to respond to fluctuations in day-to-day demand, as well as major events, both planned and unplanned. Integrated & Seamless Healthcare systems are fully integrated. WPFD frequently collaborates with community partners, including hospitals, public safety agencies, public health, social services and public works. Communication and coordination across the care continuum are seamless, leaving people with a feeling that one system, comprising many integrated parts, is caring for them and their families Key Performance Indicators (KPIs) KPI’s measure ongoing clinical performance, identify areas for improvement, and assess the impact of process changes. These include factors of recognition of injury and illness, appropriate interventions and appropriate transport destinations. Queries Include: What is the aim? How and what should be measured? What changes should be made to improve the process/system/outcome? Examples EKG for chest pain age > 35 STEMI Recognition aspirin for suspected Acute Coronary Syndromes high quality CPR Airway management Scene time Trauma Transport DATA COLLECTION AND REVIEW Quality Improvement data may come from a variety of sources Patient Run Reports Patient Comments Emergency Department /Physician feedback Hospital Outcome Data Peer Review Committee Feedback Investigations may be made based on an individual event or encounter, as well as investigation of particular clinical situations. These may be based on diagnosis, intervention or key performance indicators, described above. Winter Park Fire Department Updated 04/20/2020 1.18 EMS QUALITY IMPROVEMENT PROGRAM STRUCTURE AND COMPONENTS Medical Director Responsible for implementation and audit of the QI Program. Provide medical guidance and leadership to ensure that the techniques and practice parameters meet or exceed local, state and national standards of pre-hospital care. The Medical Director shall perform his/her functions in accordance with the Medical Director Contract and Florida Administrative Code Chapter 64J 2. Administrator of Record Comprised of an EMS captain or administrative liaison, to review charts, collect data and maintain findings. EDUCATION- MEDICAL DIRECTOR MEETINGS The medical director will provide up to date, face to face meetings on current prehospital medical care on a regular basis. For 2020, this will comprise of meetings with each shift, six times per year, with six separate lecture topics. RIDE ALONGS Medical Director shall periodically ride with various units to evaluate crew performance in the pre-hospital setting and interactions with hospital personnel. CHART REVIEW The Medical Director, Administrator of Record and the paramedic author shall review charts on a regular basis. The purpose of these reviews is to give feedback to the author and assure compliance with WPFD protocols. as well as Florida Statures. Review may include cardiac arrest, trauma alerts, deviation from protocol and other reports that are chosen. Deviations from protocols shall be forwarded to the Winter Park Medical Director immediately after such a report is completed or upon its discovery during the Q.I. review process. EMS QUALITY COUNCIL Composed of the WPFD leadership and local hospital leadership, The Quality Council is chaired by the medical director and works closely together with partners of the WPFD to identify problems and facilitate solutions. The quality council will meet on a regular basis PROTOCOL DEVELOPMENT The WPFD practice protocols will be revised on an annual basis, to ensure current clinical practice. Each protocol has a date with its last review. Medical Director Meetings will correlate with current protocols. Winter Park Fire Department Updated 04/20/2020 1.18 EMS QUALITY IMPROVEMENT PROGRAM PEER REVIEW COMMITTEE Once a month, each shift will review 3-5 blinded charts, from another shift and determine if the following aspects of the patient encounter were appropriate. 1) DOCUMENTATION POOR /ACCEPTABLE/ GOOD/ EXCELLENT COMMENTS: 2) PATIENT MANAGEMENT POOR/ ACCEPTABLE/ GOOD/ EXCELLENT COMMENTS: 3) TRANSPORT DESTINATION POOR/ACCEPTABLE/ GOOD/ EXCELLENT COMMENTS: The chart, once reviewed, will be returned to the author with the peer review comments. No punitive action will be based on the findings of the committee. This will be for education only. ANNUAL REVIEW OF THE QI PROGRAM The QI Program will be evaluated annually by the Winter Park Medical Director and Administrator of Record. The measurable objectives of the program will be compared to the performance in order to determine the effectiveness of the program. The QI will be enhanced as appropriate. REFERENCE 1 https://www.ems.gov/pdf/EMS_Agenda_2050_Summary.pdf Lincoln EW, Reed-Schrader E, Jarvis JL. EMS, Quality Improvement Programs. [Updated 2019 Jul 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536982/ Winter Park Fire Department Updated 04/20/2020 1.19 BLOOD EXPOSURE (HIV PROPHYLAXIS) INTRODUCTION In the event of significant exposure to a potentially HIV infected patient, the EMS Captain or their designee will provide immediate time sensitive care. Antiretroviral HIV medications are most effective if given as soon as possible, within the first two hours following an exposure and may significantly decrease the possibility of an emergency responder becoming infected. A significant exposure is defined as a percutaneous injury (e.g., a needle stick or cut with a sharp object) or contact of mucous membrane or non-intact skin (e.g., exposed skin that is chapped, abraded, or interrupted by dermatitis) with blood, tissue, or other body fluids that are potentially infectious. Blood, visibly bloody body fluids, semen and vaginal secretions are considered potentially infectious. The following fluids also are considered potentially infectious if they are visibly bloody: cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid, feces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomit. PROCEDURE: Upon the realization that a significant exposure has occurred as a result of patient contact while on-duty, the exposed responder should: □ Take immediate steps to flush or cleanse the exposed area with soap and water or an approved bactericidal / viricidal product (first-aid treatment). □ The supervisor or the affected personnel shall immediately notify Winter Park Communications that a “significant exposure” has occurred. Have Winter Park Communications contact the on-duty EMS Captain (EMS61) and the Battalion Chief. □ Gather as much information about the “Source individual” as possible. Include this important information on the bottom of form 318-A (Post Exposure Testing Form) All information gathered is considered to be protected by HIPPA laws and shall only be given to those who have the “need to know”. □ The exposed individual shall be taken off duty for the remainder of the shift. □ The EMS Captain will contact the contracted infectious disease physician, and the medical director. and have the physician directly call the exposed responder. Winter Park Fire Department Updated 04/20/2020 1.19 BLOOD EXPOSURE (HIV PROPHYLAXIS) EMS Captain □ Respond to the scene or station with the Post Exposure Prophylaxis (PEP) kit and exposure forms, meet with exposed employee and facilitate the consultation with the infectious disease physician. □ Once the employee is interviewed by the physician, the EMS Captain and the employee will reconfirm the medications prescribed to the employee. Including initial dosages, frequency and time. □ Administer the prescribed medication(s) to the employee. □ The medication dispensing form 318A must be completed with the required information about the patient (employee) and the prescription information. It must include the dosage of the medication, the frequency and time. □ Complete the enclosed “Post Exposure Testing Form” form that is in the PEP manual. Mark the specific labs ordered by the ID physician. Have the employee proceed directly to Advent Health Winter Park Hospital laboratory to get baseline labs drawn. The testing form must be taken by the exposed to the lab and given to the lab personnel. The lab reports must note which ID physician was contacted and the labs must be routed back to the Infectious Disease Physician’s office. The ID Physician shall schedule a follow up with the exposed personnel. Risk Management □ The supervisor