Clinical Standards PDF

Patient Assessment Adult Primary Assessment Patient Assessment Clinical Indications: Begin an ABC approach to the patient from a general impression and establish the presence of a life threatening injury or illness. Initial Assessment 1. Quickly assess level of consciousness using the AVPU Metho...

Patient Assessment Adult Primary Assessment Patient Assessment Clinical Indications: Begin an ABC approach to the patient from a general impression and establish the presence of a life threatening injury or illness. Initial Assessment 1. Quickly assess level of consciousness using the AVPU Method. A Alert: Eyes Open V Verbal: Responds to vocal stimuli P Pain: Responds only to pain U Unresponsive: No response to verbal or Painful stimuli 2. Assess the airway (protect c-spine if uncertain) a. Responsive - no intervention needed, proceed to step 3. b. If unresponsive - use the appropriate medical or trauma maneuver to open the airway c. If airway remains partially or totally obstructed, continue attempts to clear the airway (refer to airway emergencies). 3. Assess adequacy of breathing a. Observe chest rise and fall, auscultate breath sounds anteriorly, posteriorly and peripherally. b. Observe for signs of distress - use of secondary muscles, cyanosis c. Count the respiratory rate and obtain pulse oximeter reading (SpO2) if available d. If breathing adequate - go to step 4. e. If breathing is inadequate and patient is unresponsive - assist breathing with appropriate device f. If breathing is inadequate and patient is responsive - administer OXYGEN as needed, as necessary to maintain SaO2 > 94% 4. Assess the circulation / perfusion a. Assess rate and quality of pulses - peripheral and central pulses b. Stop any active bleeding, assess skin color, temperature, and obtain blood pressure. c. If there is no palpable pulse or rate is too slow to maintain cerebral blood flow, begin CPR d. If bleeding is present - manage bleeding 5. Provide care for any compromise in airway, breathing, circulation, or neurological status per protocol and perform basic life support as per current American Heart Association Guidelines. 6. Identify priority patients and make a transport decision. a. Priority patients include those with compromises in airway, level of consciousness, breathing, and circulation, which are not easily remedied with basic intervention. b. If identified as a non-priority medical patient, go to Patient Assessment Medical. c. If identified as a non priority trauma patent, go to Patient Assessment-Trauma. 7. Further Assessments, Go to: Patient Assessment-Medical or Patient Assessment-Trauma Responsoft EMS Protocols Page 149 10/13/2020 Patient Assessment Patient Assessment-Medical Patient Assessment Clinical Indications: If patient unresponsive, go to Rapid Assessment. History of Present illness including but not limited to below: Focused History and Physical Exam Non-Priority Medical Patients 1. History of Present illness including but not limited to: O-Onset of the problem P- Provocation Q- Quality – “Crushing, Pressure, Stabbing" R- Radiating S- Severity "1 - 10 Scale" and Duration T- Time since this onset of this episode 2. Provide appropriate interventions as per protocols. Splint injured, painful or swollen extremities. Apply dressings and bandage all wounds. Consult MCP with any questions, further treatments or omission of interventions as written. Priority Medical Patients Rapid Assessment 1. Rapidly assess the patient “head to toe". (1 - 1 1/2 minutes total) Head, Ears, Eyes, Nose, Throat The head should be examined for signs of abnormality. The ears should be examined for presence of fluid and foreign bodies. The pupils should be checked for symmetry and response to light. The nose should be examined for presence of fluid and patency. Examine the throat for signs of obstruction, redness and patency. The neck should be examined for pain, stiffness or injury. The neck veins should be assessed for signs of extreme distention. If there is any evidence of neck injury, employ cervical spine precautions. Assess for any signs of trauma. 2. Chest, and Abdomen The chest should be examined for signs of visible injury. Assess for breath sounds as well as chest movement, symmetry, and effort. The chest should be palpated for pain. The abdomen should be assessed for signs of injury, pain, tenderness, rigidity, and guarding. The pelvis should be palpated for stability if any history of trauma. 3. Extremities and Back The lower as well as the upper extremities should be examined -and assessed for presence of pulses, sensation, and motor function. Note if edematous or signs of poor perfusion exist. The back should be examined for signs of pain. For patients with possible spinal injury, assess the back during the log roll procedure. 4. A SAMPLE history should also be obtained if possible. This should include: S - Signs and Symptoms A - Allergies M - Medications P - Past illnesses L - Last meal E - Events of the injury or illness A. Obtain baseline vital signs and prepare the patient for transport. Responsoft EMS Protocols Page 150 10/13/2020 Patient Assessment Patient Assessment-Trauma Patient Assessment Clinical Indications: Rapid Assessment should be performed on all priority transport patients after the Initial Assessment. Patient with a mechanism or nature of illness consistent with the possibility of spinal trauma should first have manual spinal control and after the rapid assessment be fully spinal immobilized. Non-Priority Trauma Patients 1. Assess injuries based on chief complaint. a. Obtain Vital Signs b. Provide care based on signs and symptoms. c. Continue with Detailed Assessment as appropriate Priority Trauma Patients Rapid Trauma Assessment 1. Rapidly assess the patient “head to toe". (1 - 1 1/2 minutes total) Head, Ears, Eyes, Nose, Throat The head should be examined for signs of abnormality. The ears should be examined for presence of fluid and foreign bodies. The pupils should be checked for symmetry and response to light. The nose should be examined for presence of fluid and patency. Examine the throat for signs of obstruction, redness and patency. The neck should be examined for pain, stiffness or injury. The neck veins should be assessed for signs of extreme distention. If there is any evidence of neck injury, employ cervical spine precautions. Assess for any signs of trauma. 2. Chest, and Abdomen The chest should be examined for signs of visible injury. Assess for breath sounds as well as chest movement, symmetry, and effort. The chest should be palpated for pain. The abdomen should be assessed for signs of injury, pain, tenderness, rigidity, and guarding. The pelvis should be palpated for stability if any history of trauma. 3. Extremities and Back The lower as well as the upper extremities should be examined -and assessed for presence of pulses, sensation, and motor function. Note if edematous or signs of poor perfusion exist. The back should be examined for signs of pain. For patients with possible spinal injury, assess the back during the log roll procedure. 4. Neurological Survey If not already done, a neurological evaluation as well as a history should be obtained. The pupils should be assessed for equality and reaction to light. The level of consciousness should be assessed using the AVPU method: A – Alert V – Verbal P – Pain U - Unresponsive 5. A SAMPLE history should also be obtained if possible. This should include: S - Signs and Symptoms A - Allergies M - Medications P - Past illnesses L - Last meal E - Events of the injury or illness 6. Exposure A thorough exam cannot be accomplished without properly exposing a patient. Passive warming Responsoft EMS Protocols Page 151 10/13/2020 Patient Assessment Pediatric Primary Assessment Patient Assessment Clinical Indications: All Levels Any child that can be measured with the Broselow-Luten Resuscitation Tape. 1. Scene size-up, including universal precautions, scene safety, environmental hazards assessment, need for additional resources, by-stander safety, and patient/caregiver interaction. Consider the number of patients, mechanism of injury or nature of the illness. Request additional help if necessary. 2. Priorities of management are established on a life-threatening basis. Begin an A.B.C. approach to the patient to form a general impression and establish the presence of a life threatening injury or illness. Obtain and record the chief complaint of the patient. Quickly assess level of consciousness using the A.V.P.U. method: A - Alert - eyes open V - Verbal - responds to vocal stimuli P - Pain - responds only to pain U - Unresponsive - no response to Verbal or Pain. 3. Evaluate for the presence of increased intracranial pressure (ICP). In the infant, increased ICP may be manifested by a full or bulging anterior fontanel, a weak, shrill or irritable cry, and poor muscle tone. Pupillary responses, level of consciousness, recognition of parents, and Glasgow Coma Score (GCS) should also be documented. 4. Assess the airway (protect c-spine if uncertain) When establishing an airway, remember the differences between the adult and pediatric airway. The young child has a disproportionately large tongue, which can easily occlude the airway. A small amount of blood or vomitus can also obstruct the airway. Deciduous, or “baby teeth”, are poorly anchored and easily dislodged. a. Responsive - no intervention needed, proceed to step 3. b. If unresponsive - use the appropriate medical or trauma maneuver to open the airway if airway remains partially or totally obstructed, continue attempts to clear the airway (refer to airway emergencies). 5. Assess adequacy of breathing a. If patient is not breathing, ventilate patient via bag valve mask (BVM). b. Observe chest rise and fall; auscultate breath sounds anteriorly, posteriorly and peripherally. (see Respiratory Distress Protocol) observe for signs of distress - use of secondary muscles, nasal flaring, and tripod position. If oxygen is indicated and the child has a patent airway and good respiratory effort, administer Oxygen to maintain SpO2 >94%. Do not hesitate to administer oxygen to the pediatric patient. Oxygen, c. If the child requires ventilatory assistance, administer 100% Oxygen via BVM. The neonatal size ventilation bag is not recommended equipment for field use. d. When possible, monitor oxygen saturation with continuous pulse oximetry and document findings every 5-10 minutes. 6. Assess the circulation / perfusion a. Assess rate and quality of pulses - peripheral and central pulses. Early signs and symptoms of shock in children include a rapid heart and respiratory rate (again, remember age-dependent vital signs), agitation, and poor peripheral perfusion (capillary refill > 2 seconds). Hypotension is a LATE and ominous finding. Document vital signs (including temperature and blood pressure if appropriate) and peripheral perfusion. b. Stop any active bleeding, assess skin color, temperature, and obtain blood pressure. c. If there is no palpable pulse or rate is too slow to maintain cerebral blood flow, begin CPR. Further Assessments, Go to: Pediatric Patient Assessment-Medical or Patient Assessment-Trauma Pediatric Assessment-Trauma Responsoft EMS Protocols Page 152 10/13/2020 Patient Assessment Pediatric Assessment-Medical Patient Assessment Clinical Indications: If patient unresponsive, go to Rapid Assessment. History of Present illness including but not limited to below: Focused History and Physical Exam Non-Priority Medical Patients 1. History of Present illness including but not limited to: O-Onset of the problem P- Provocation Q- Quality – “Crushing, Pressure, Stabbing" R- Radiating S- Severity "1 - 10 Scale" and Duration T- Time since this onset of this episode 2. Provide appropriate interventions as per protocols. Splint injured, painful or swollen extremities. Apply dressings and bandage all wounds. Consult MCP with any questions, further treatments or omission of interventions as written. Priority Medical Patients Rapid Assessment 1. Rapidly assess the patient “head to toe". (1 - 1 1/2 minutes total) Head, Ears, Eyes, Nose, Throat The head should be examined for signs of abnormality. The ears should be examined for presence of fluid and foreign bodies. The pupils should be checked for symmetry and response to light. The nose should be examined for presence of fluid and patency. Examine the throat for signs of obstruction, redness and patency. The neck should be examined for pain, stiffness or injury. The neck veins should be assessed for signs of extreme distention. If there is any evidence of neck injury, employ cervical spine precautions. Assess for any signs of trauma. 2. Chest, and Abdomen The chest should be examined for signs of visible injury. Assess for breath sounds as well as chest movement, symmetry, and effort. The chest should be palpated for pain. The abdomen should be assessed for signs of injury, pain, tenderness, rigidity, and guarding. The pelvis should be palpated for stability if any history of trauma. 3. Extremities and Back The lower as well as the upper extremities should be examined -and assessed for presence of pulses, sensation, and motor function. Note if edematous or signs of poor perfusion exist. The back should be examined for signs of pain. For patients with possible spinal injury, assess the back during the log roll procedure. 4. A SAMPLE history should also be obtained if possible. This should include: S - Signs and Symptoms A - Allergies M - Medications P - Past illnesses L - Last meal E - Events of the injury or illness A. Obtain baseline vital signs and prepare the patient for transport. Responsoft EMS Protocols Page 153 10/13/2020 Patient Assessment Pediatric Assessment-Trauma Patient Assessment Clinical Indications: Rapid Assessment should be performed on all priority transport patients after the Initial Assessment. Patient with a mechanism or nature of illness consistent with the possibility of spinal trauma should first have manual spinal control and after the rapid assessment be fully spinal immobilized. Non-Priority Trauma Patients 1. Assess injuries based on chief complaint. a. Obtain Vital Signs b. Provide care based on signs and symptoms. c. Continue with Detailed Assessment as appropriate Priority Trauma Patients Rapid Trauma Assessment 1. Rapidly assess the patient “head to toe". (1 - 1 1/2 minutes total) Head, Ears, Eyes, Nose, Throat The head should be examined for signs of abnormality. The ears should be examined for presence of fluid and foreign bodies. The pupils should be checked for symmetry and response to light. The nose should be examined for presence of fluid and patency. Examine the throat for signs of obstruction, redness and patency. The neck should be examined for pain, stiffness or injury. The neck veins should be assessed for signs of extreme distention. If there is any evidence of neck injury, employ cervical spine precautions. Assess for any signs of trauma. 2. Chest, and Abdomen The chest should be examined for signs of visible injury. Assess for breath sounds as well as chest movement, symmetry, and effort. The chest should be palpated for pain. The abdomen should be assessed for signs of injury, pain, tenderness, rigidity, and guarding. The pelvis should be palpated for stability if any history of trauma. 3. Extremities and Back The lower as well as the upper extremities should be examined -and assessed for presence of pulses, sensation, and motor function. Note if edematous or signs of poor perfusion exist. The back should be examined for signs of pain. For patients with possible spinal injury, assess the back during the log roll procedure. 4. Neurological Survey If not already done, a neurological evaluation including GCS as well as a history should be obtained. The pupils should be assessed for equality and reaction to light. The level of consciousness should be assessed using the AVPU method: A – Alert V – Verbal P – Pain U - Unresponsive 5. A SAMPLE history should also be obtained if possible. This should include: S - Signs and Symptoms A - Allergies M - Medications P - Past illnesses L - Last meal E - Events of the injury or illness 6. Exposure A thorough exam cannot be accomplished without properly exposing a patient. Passive warming Responsoft EMS Protocols Page 154 10/13/2020 Clinical Standards Consent, Refusal or Treatment/Transport Part A Clinical Standards STANDARD: An adult of minor with the capacity to make an informed decision has the right to refuse treatment and/or transport PURPOSE: To create a policy that establishes a patient’s right to the refusal of treatment and/or transport APPLICATION: Right of Consent or Refusal: All patients who have capacity as defined later in this protocol have the right to give informed consent for treatment and transport or to refuse treatment and/or transportation. Patient’s should be advised by the EMS personnel of his/her diagnostic impression and the course of treatment prescribed by Whitehall EMS protocols. This should be explained in terminology understood by the patient. Implied Consent In potentially life or limb threatening emergency situations where a patient is unable to give informed consent the law presumes consent for emergency care would be given if they were able. Consent for emergency care is implied if the patient is 1. Unable to communicate because of illness, injury, unconsciousness and is suffering from what appears to be a life- threatening emergency OR 2. Suffering from impaired mental capacity (eg lacks capacity to make an informed decision) OR 3. Is a minor who is suffering from what reasonably appears to be a life-threatening injury whose parents or guardian is not present Limitations to the Right of Refusal: All patients who are unconscious or mentally impaired such that they can not make a rational decision regarding their immediate situation will be transported to the closest appropriate facility Patients are considered to lack the capacity to make an informed decision and are unable to refuse care and/or transportation when they are impaired. Patients who are impaired include but are not limited to the following: 1. Patient’s exhibiting suicidal behavior or ideation 2. Patient who are intoxicated with drugs or alcohol or who are altered due to other toxic exposures (eg CO) Patients with medical conditions that may cause impairment (eg uncorrected hypoglycemia, hypoxia) See: Consent, Refusal Refusal of of Treatment/Transport-Part Treatment/Transport PartBB Responsoft EMS Protocols Page 155 10/13/2020 Clinical Standards Consent, Refusal of Treatment/Transport Part B Clinical Standards Withdrawal of Consent A patient with the capacity to make an informed decision may withdraw consent for treatment at any time The medic in charge shall consider the following when making a judgement regarding the patient’s capacity to withdraw consent: A patient (or legal guardian of a minor patient) may be considered to have the ability to make an informed decision when (all must be met) 1. Able to demonstrate capacity to make decisions a. Capacity is defined as: i. Ability to “Evidence a Choice”: 1. Make a consistent decision 2. Re-ask the question with different phrasing later in the process ii. Ability to understand relevant information: 1. Have the patient paraphrase the information provided iii. Ability to appreciate the situation and its consequences: 1. Can they explain specifics of the potential consequences? iv. Ability to manipulate information rationally: 1. Can they explain to you why they’ve made their decision If a patient or a legal guardian of a minor patient with the capacity to make an informed decision refuses consent or withdraws consent for treatment the EMS personnel shall document 1. Patient’s Assessment, including vital signs a. If patient/legal guardian refuses any exam please document portions of exam available by sight only (for example: alertness, orientation, respiratory effort, gross motor exam, skin exam (eg. sweaty, pink, blue)). 2. All care provided 3. Assessment of the patient’s capacity to refuse transport and treatment. 4. Discussion of the conversation proving informed consent a. This should include evidence that the patient meets the definition of capacity as define in this protocol b. Documentation that patient is AOx4 is not sufficient to show capacity. 5. Patient acknowledges understanding the diagnostic impression provided by the EMS personnel on scene, the course of treatment prescribed by Whitehall EMS protocols, and the risks of non-treatment and transport. 6. Advice to the patient to call 911 again at any time if they wish to be transported ot the hospital if their condition changes A patient or legal guardian of a patient who refuses to consent to or withdraws consent for treatment should acknowledge and sign the refusal statement on the electronic patient care report of paper equivalent. This signature is not a substitute for thorough documentation in the chart of the refusal. If the patient refuses to sign, their refusal should be witnessed by at least two people, preferably one being a non ems provider. Minors, developmentally disabled patients and patients deemed to lack capacity to make an informed decision should be treated after consult with the patient’s guardian, parent, spouse, or other responsible caregiver. If the guardian, parent, spouse or other responsible caregiver is not immediately available, the patient should be treated as per protocol and transported to the most appropriate hospital. Responsoft EMS Protocols Page 156 10/13/2020 Clinical Standards Controlling Protocol and In-Charge Paramedic Clinical Standards STANDARD: Whitehall EMS providers are responsible for providing patient care in accordance with the prescribed Whitehall EMS protocols, standards and procedures. In cases of multiple agencies providing care to the same patient, the EMS protocol for the EMS provider in charge of that patient is in effect. PURPOSE: Establish a clinical hierarchy of authority for on-scene patient care. APPLICATION: 1. Medical care by all Whitehall EMS care providers is governed by the Whitehall EMS medical protocol. This medical protocol is in effect whenever a Whitehall EMS provider provides medical care regardless of the jurisdiction of that EMS run. 2. The in-charge medic/provider is responsible for that patient’s care. A superior officer is permitted to override the in-charge paramedic when all of the following are in effect: a. The officer is on duty for Whitehall Division of Fire.. b. The officer has current certification by the Ohio EMS Board that is equal to or greater than that of the in-charge provider. c. The officer has attended all applicable Whitehall EMS protocol updates Responsoft EMS Protocols Page 157 10/13/2020 Clinical Standards COTS Exceptions to Trauma Transport and Caveats Clinical Standards Five Exceptions to Mandatory Transport to a Trauma Center 1. It is medically necessary to transport the victim to another hospital for initial assessment and stabilization before transfer to an adult or pediatric trauma center; 2. It is unsafe or medically inappropriate to transport the victim directly to an adult or pediatric trauma center due to adverse weather or ground conditions or excessive transport time; 3. Transporting the victim to an adult or pediatric trauma center would cause a shortage of local emergency medical service resources; 4. No appropriate adult or pediatric trauma center is able to receive and provide adult or pediatric trauma care to the trauma victim without undue delay; 5. Before transport of a patient begins, the patient requests to be taken to a particular hospital that is not a trauma center or, if the patient is less than eighteen years of age or is not able to communicate, such a request is made by an adult member of the patient's family or a legal representative of the patient.. Caveats for the Central Ohio Trauma System NOTE: Incidents resulting in multi/mass casualties are addressed by specific surge plans or regional guidelines. NOTE: Transport trauma adult burn patients to the Wexner Medical Center at The Ohio State University (adult); transport pediatric burn trauma patients to Nationwide Children’s Hospital. NOTE: Transport isolated globe injuries to Grant Medical Center, Mount Carmel West or the Wexner Medical Center at The Ohio State University. NOTE: Transport upper extremity amputations to designated hand/microvascular centers at Riverside Methodist Hospital, the Wexner Medical Center at The Ohio State University and Nationwide Children’s Hospital. NOTE: Trauma patient < 16 years who appear or provide history of pregnancy should be transported to an ADULT trauma center. Responsoft EMS Protocols Page 158 10/13/2020 Clinical Standards Criteria for Death or Withholding Resuscitation Clinical Standards STANDARD: To define set criteria that determines death in the field.Cardiopulmonary resuscitation is to be withheld only if the patient is obviously dead per the criteria below or has a valid DNR in effect. If EMS provider(s) are unsure whether the patient meets criteria, resuscitation is to be performed. PURPOSE: Establish clinical criteria that provide a process for determining death in the field. PROCEDURE: A patient is considered unsuitable for resuscitation DOA when one or more of the following criteria are met: 1. Patient is found unresponsive, has suffered an unwitnessed cardiac arrest with unknown downtime and cardiac monitor shows asystole. Asystole must be confirmed in two (2) leads. 2. Patient has injuries that are incompatible with life (e.g. decapitation) 3. Decomposition or rigor mortise has set in. Indications for determining death at the scene must be documented in the patient care report. The Termination of Resuscitation Clinical Standard takes precedence over this Clinical Standard. Responsoft EMS Protocols Page 159 10/13/2020 Clinical Standards DNR-Advanced Directive Part A Clinical Standards Policy: Any patient presenting to any component of the EMS system with the completed State Of Ohio Do Not Resuscitate Form (DNR) shall have the form honored. Purpose:  To honor the terminal wishes of the patient.  To prevent the initiation of unwanted resuscitation.  To be compliant with Ohio Standards. Definitions: Cardiac Arrest – Absence of palpable pulse. Respiratory Arrest – Absence of spontaneous respirations or presence of agonal breathing. DNR – Do not resuscitate. If patient is in cardiac or respiratory arrest do not provide CPR, insert endotracheal tube/supraglottic airway, defibrillate or give ACLS drugs. DNR Comfort Care (DNRCC) – A patient receives any care that eases pain and suffering, but no resuscitative measures to save or sustain life. This protocol is activated immediately when a valid DNR order is issued or when a living will requesting no CPR becomes effective. DNR Comfort Care – Arrest (DNRCC-Arrest) – A patient receives standard medical care until the time he or she experiences a cardiac or respiratory arrest. Standard medical care may include cardiac monitoring or intubation prior to the occurrence of cardiac or respiratory arrest. This protocol is activated when the patient has a cardiac or respiratory arrest. Procedure: 1. When confronted with a cardiac arrest patient or an unstable patient, one of the following conditions must be met in order to honor a DNR request and withhold CPR and ACLS therapy: a. A State of Ohio DNR form with either the DNRCC or DNRCC- Arrest box checked. The form must be signed by the patient or their representative and countersigned by a physician, physician assistant or nurse practitioner. OR; b. The patient has a DNR armband or wallet card. EMS providers are not required to search a patient for DNR identification. However, if DNR identification is discovered, EMS personnel must make a reasonable attempt to verify the patient’s identity. Once the patient’s identity is verified, EMS providers must honor the DNR directive. Responsoft EMS Protocols Page 160 10/13/2020 Clinical Standards 2. DNR-Advanced Directive Part B Clinical Standards A DNR request may be overridden by the request of: a. The patient b. The guardian of the patient c. An on-scene Physician NOTE: If the DNR form is signed by the patient – only the patient may revoke/override the DNR request. 3. If family members or other persons are present and ask that resuscitative efforts be withheld in the absence of an advanced directive, determine their relationship to the patient and the patient’s history. If the patient has an obvious life-limiting illness (terminal cancer, advanced neurological disease, etc.), resuscitative efforts may be withheld. If there is no obvious life-limiting illness, begin resuscitation based on appropriate protocol(s) and contact medical control for further guidance. 4. Living wills or other documents indicating the patients desire to withhold CPR or other medical care may be honored only in consultation with the patient’s family. Responsoft EMS Protocols Page 161 10/13/2020 Clinical Standards DNR-Advanced Directive Part C Responsoft EMS Protocols Page 162 Clinical Standards 10/13/2020 Clinical Standards DNR-Advanced Directive Part D Responsoft EMS Protocols Page 163 Clinical Standards 10/13/2020 Clinical Standards EMS Blood Collection of Blood Sample Clinical Standards STANDARD: Whitehall EMS providers will not obtain a blood sample for toxicology testing if requested by a law enforcement officer. Responsoft EMS Protocols Page 164 10/13/2020 Clinical Standards High Performance/Priority Based CPR Part A Clinical Standards Our Key Principles: 1. High quality CPR is key to resuscitation effectiveness and our primary task. It is the first patient care priority once on-scene. 2. 3. 4. 5. 6. 7. o CPR is continuous and not stopped for ventilation, airway insertion or other interventions. o 4 minutes (2 cycles) of manual CPR should be administered before a mechanical CPR device applied. o Crews should practice applying mechanical CPR device so application during cardiac arrest results in minimal interruption of CPR. o Pauses should be 10 seconds or less. Mechanical CPR device should be applied in 20 seconds or less. Unless safety or physical space issues exist, resuscitations are most effectively performed at the location the patient is initially found. The quality of compressions is the responsibility of every member of the team. Rhythm assessment is made every two minutes with defibrillation as indicated with a maximum pause in compressions of 10 seconds. The ALS component builds upon a strong BLS component maintaining an emphasis on minimum interruptions of compression. The use of a resuscitation checklist is highly desirable as a means to ensure completeness and repeatability of resuscitation tasks. Please see sample checklist on the following page. This model is meant to be flexible and each agency should tailor the roles to the resources that they have available. Teamwork requires practice. Agencies must commit to realistic practice involving first responders, transport resources and ALS providers. Practice should include feedback to the participants on the rate and depth of compressions, duration of pauses and include a calculation of compression fraction. Responsoft EMS Protocols Page 165 10/13/2020 Clinical Standards High Performance/Priority Based CPR Part B Clinical Standards Priority 6 Team Leader Battalion 1. Scene Safety 2. Interface with family a. Medication & health Hx. b. Advise family 3. Logistical support Priority 2 Ventilate Head 1. Open & clear Airway 2. Ventilate without interrupting CPR a. BVM b. SGA or ET after 4 minutes of CPR 3. Apply EtCO2 6 Priority 1 CPR & Defibrillate Right Arm 1. Assess responsiveness and check for pulse 2. Initiates continuous compressions 3. Alternates CPR with right arm every 2 minutes 4. Assists with mechanical CPR set up-after 4 minutes (400 manual compressions) 5. Peripheral IV if directed by In-Charge 2 1 1 3 4 Priority 4 Vascular Access Right Leg 1. IO access 2. Draws up medications, performs medication cross-check & administers Medication as directed by Code Commander 3. Communicates needs to Battalion Priority 1 CPR & Defibrillate Left Arm 1. Assess responsiveness and check for pulse 2. Initiates continuous compressions 3. Alternates CPR with right arm every 2 minutes 4. Assists with mechanical CPR set up-after 4 minutes (400 manual compressions) 5. Peripheral IV if directed by In-Charge Priority 3 In-charge (Code Commander) Left Leg 1. Monitor operation & rhythm interpretation 2. Directs resuscitation 3. Orders medications & performs medication cross-check 4. Communicates needs to Battalion 5 Priority 5 Runner (Identified by code commander as resuscitation progresses & circumstances allow) Wherever Needed 1. Assists with airway & setup of mechanical CPR 2. Equipment retrieval 3. Other duties as assigned Responsoft EMS Protocols Page 166 10/13/2020 Clinical Standards Interfacility Transfers Clinical Standards STANDARD: In general, Whitehall EMS providers should only provide interfacility transfers for time-critical conditions, including those who meet specialty designation center criteria who are not already at an appropriate specialty receiving center; e.g. trauma, stroke, STEMI, post-cardiac arrest and pediatrics. For this standard an “interfacility transfer” is defined as transfer from a hospital based emergency department, free standing emergency department or specialty in-patient hospital to another in-patient hospital. Whitehall EMS providers shall not transport patients in cardiopulmonary arrest who are actively being resuscitated (CPR in progress). Whitehall EMS providers shall transport patients to the closest appropriate facility as defined by the clinical standard on Patient Transport. Whitehall EMS agencies that anticipate providing interfacility transfers are expected to comply with the Ohio Board of Emergency, Medical, Fire and Transportation Services (EMFTS) position statements regarding: 1. Interfacility Transport of Patients by EMS providers and the Scope of Practice, June 2018 2. EMS Provider Transport of Patients with Pre-Existing Medical Devices or Drug Administrations, February 2018 PURPOSE: To provide guidance regarding transporting a patient from a medical facility to another facility when that patient requires Advanced Life Support during transport. APPLICATION: 1. The transporting paramedic should ensure that all appropriate documentation accompanies the patient. 2. The transporting paramedic should verify the receiving hospital and that the hospital has accepted the patient in transfer. 3. The patient will be transported to the closest appropriate facility as defined by the clinical standard on Patient Transport. 4. All EMS rendered treatments must comply with the Whitehall EMS protocol in effect at the time of transfer. 5. The transporting paramedic(s) may maintain any infusion or treatment in compliance with the two Ohio EMFTS Board position papers cited above. 6. If the transporting paramedic(s) are not comfortable maintaining medication infusions or treatment provided by the sending facility, then the paramedic(s) may request a registered nurse accompany the patient. 7. When transporting a registered nurse and a patient, both the transport crew and accompanying staff are responsible for patient care. 8. Should a Whitehall EMS crew be requested to provide interfacility transfer of a non-time-critical patient, the crew should contact their shift officer (e.g. battalion chief) for guidance. 9. Should a patient substantially deteriorate while in route to the receiving facility, the crew may divert to the closest appropriate hospital based emergency department for patient stabilization. The transferring facility should be notified via radio or cellular phone. Responsoft EMS Protocols Page 167 10/13/2020 Clinical Standards Responsoft EMS Protocols Interfacility Transport Part A Page 168 Clinical Standards 10/13/2020 Clinical Standards Responsoft EMS Protocols Interfacility Transport Part B Page 169 Clinical Standards 10/13/2020 IV/IO Clinical Standards IV Therapy •administer fluids •administer medications To minimize the risk of complications use: •Proper choice of equipment •careful choice of IV site •good insertion technique •aseptic preparation of infusions Pediatric Always be honest. Tell the child that the IV stick will hurt, but only for a short time. Do not promise there will only be 1 stick, or say that it won't hurt. Clinical Standards Patient Assessment Assess need for IV Emergent or potentially emergent medical or trauma condition IV Therapy Trauma Care & Burn ADULT: Large bore IV(s) Maintenance rate ADULT: No more than four (4) attempts unless patient is critical. External Jugular IV (>12 yo) may also be attempted during 4 attempts for life-threatening event (one attempt only) 150 ml/hr For Burns: > 20% BSA or Trauma If systolic BP < 90 mmHg, Absence of radial pulse, or decreased mental status secondary to hypoperfusion (not head trauma). 20ml/kg ml/kg NS Fluid Bolus 20 PEDIATRIC: Assess need for IV Emergent or potentially emergent medical or trauma condition 0.9% NS for all infusions Venipuncture Technique Inform patient of IV insertion. Use aseptic technique Assessment of patient and equipment Venipuncture technique Dressings and maintenance of safety Instructions to patient Documentation Pediatric Common IV sites are: Hand, foot, scalp, forearm & antecubital sites. Hand: try not to use child’s dominant hand or hand child uses for sucking thumb. Consider immobilizing arm prior to initiating IV. Consider Saline Lock when IV access but fluids or medication not indicated NEVER use D5W. Two (2) IV attempts in 90 seconds then IO If unstable, go directly to IO Infuse fluid until return of radial pulse or maximum of 2 liters. 20 20 ml/kg ml/kg as a bolus – may repeat twice. Consider administer via stopcock or IVP. Unsuccessful or Critical Intraosseous Intraosseous Infusion EZ-IO (Proximal Tibia) Intraosseous Infusion EZ-IO (Humerus) Intraosseous Infusion EZ-IO (Distal Tibia) for life-threatening event Monitor infusion Responsoft EMS Protocols Page 170 10/13/2020 Clinical Standards Responsoft EMS Protocols Ohio Prehospital Trauma Triage Decision Tree - 2019 Update Page 171 Clinical Standards 10/13/2020 Clinical Standards Pain Control Standard Clinical Standards STANDARD: Patients with acute pain will be provided appropriate interventions to assist in controlling their pain. PURPOSE: To make our patients as comfortable as possible during transport to an appropriate facility. PROCEDURE: 1. Injuries/Illnesses sustained by patients or procedures performed by personnel may produce acute pain. 2. It is the desire of Whitehall EMS that all transports are as comfortable as possible for the patient. 3. Interventions for pain control include extremity immobilization, application of ice packs and administration of medications as identified elsewhere in the Whitehall EMS protocol. 4. Pre-hospital narcotics are not indicated for all EMS patients with the complaint of pain. Pain control by EMS providers is limited to severe acute pain (not stable chronic pain) that is of readily identifiable source (e.g. multiple trauma, severe burns, extremity fracture with deformity) or of acute onset with readily apparent patient discomfort (e.g. kidney stones, myocardial infarction). 5. Sedation and pain control medications may interfere with the physician’s ability to properly assess the patient on arrival to the Emergency Department. There is a balance between decreasing pain and anxiety and interfering with the physician’s assessment of the patient. 6. Patients that have sedatives or narcotics administered must be transported. They are unable to decline transport. 7. The Medication Administration Cross-Check standard must be followed. Responsoft EMS Protocols Page 172 10/13/2020 Clinical Standards Patient Restraint Clinical Standards STANDARD: Use of restraints is permitted when necessary to:  Control a patient that is exhibiting violent behavior due to acute medical condition and restraints are necessary to protect patient or EMS crew.  Prevent a patient from interfering with medical care such as pulling out an endotracheal tube or IV. PURPOSE: To identify appropriate means to effectively restrain a violent patient while assuring patient and crew safety. APPLICATION: Patient restraint may be necessary for the safety of the patient or EMS crew. Restraint can be chemical (IV or IM midazolam, ketamine) or physical (wrist/ankle straps or Posey vest). Restraint use by EMS is not permitted if restraint use is solely part of a law enforcement action. This restriction does not apply if the medic is part of tactical EMS crew acting in the “Hot Zone”. Chemical restraint is preferred over physical. Please refer to the chemical restraint protocol for further details When restraint is used, the patient must be supine with head elevated 30 degrees or on left side in recovery position. Restraining patient face down, with hands behind back or hands and legs behind back (hog-tied) is prohibited. If the patient is in police custody and in handcuffs then a police officer must ride in the back of the medic vehicle with the patient. The use of physical or chemical restraint must be documented in the run report. Documentation should include reason for restraint (violent behavior or interruption of medical care) and the position of the patient while in restraints. If restraint is used then a patient must be transported to an emergency department. When giving the radio report to the ED, the EMS provider should advise the call taker of the use of chemical or physical restraint and request for security to be present upon their arrival. Responsoft EMS Protocols Page 173 10/13/2020 Clinical Standards Patient Transport Part A Clinical Standards STANDARD: Patients will be offered transportation an appropriate local hospital. Patients will be appropriately restrained during transport to assure their safety. Patient monitoring will be provided as indicated by the patient’s clinical condition. Such monitoring will continue until patient handoff at the receiving hospital is completed. This includes maintaining monitoring while off-loading patient at receiving hospital. Certain clinical conditions dictate specific transport decisions as directed in this standard. PURPOSE: This standard establishes a uniform protocol for the transportation of the sick and injured. APPLICATION: All sick and injured persons requesting transport shall be transported without delay to an appropriate local hospital of the patient’s preference. If the patient has no preference, the patient will be taken to the closest appropriate hospital based upon the patient’s medical history and clinical condition. Unstable patients will be taken to the closest appropriate hospital. Conditions requiring transportation to hospitals with specialty services are outlined as part of this standard. Safe Patient Transport Patients are at risk of injury when transported by EMS. EMS must provide appropriate stabilization and protection to all patients during transport. 1. All patients shall receive a minimum assessment as outlined in the Adult and Pediatric Universal Patient Assessment protocols. 2. Patients with any of the following will be moved to the transporting vehicle via cot or wheelchair (not self ambulated): a. Chest pain b. Dyspnea c. Altered level of consciousness d. Unstable vital signs i. Systolic BP < 90 ii. Heart rate < 50 or >120 BPM iii. SaO2 < 94% iv. Respiratory rate >30 respirations per minute e. Clinical condition requiring treatment with bronchodilators or IV fluid bolus f. Severe pain g. Any other illness or injury that prevents the patient from ambulating without assistance. 3. 4. 5. 6. 7. 8. 9. Patients will be secured to the vehicle’s transport cot with seatbelts. Drive cautiously at safe speeds observing traffic laws. Tightly secure all monitoring devices and other equipment. Insure that all pediatric patients less than 40 lbs. are restrained with an approved child restraint device and secured as per the manufacturer’s instructions. Insure that all EMS personnel use the available restraint systems during the transport. Do not allow the parents, caregivers or other passengers to be unrestrained during transport. Do not allow the parent or caregiver to hold a pediatric patient during transport. Responsoft EMS Protocols Page 174 10/13/2020 Clinical Standards Patient Transport Part B Clinical Standards Load & Go Situations Any of the following patient conditions will be considered a “load & go”. There is an expected scene time of 15 minutes or less. 1. Airway obstruction that does not respond to standard maneuvers (can’t intubate, can’t ventilate). 2. Traumatic cardio-respiratory arrest. (Unless termination required by Termination of Resuscitation Protocol.) 3. Pericardial tamponade. 4. Major chest injury (i.e. tension pneumothorax, massive hemothorax, sucking chest wound, penetrating wounds with shock, flail chest). 5. Head injury with decreasing level of consciousness and/or unilateral dilated pupil. 6. Any other patient with unstable vital signs 7. STEMI patients. 8. CVA patients with 911 call of < 5 hours since symptom onset. The only field treatment to be instituted prior to or during transport (and only if specifically needed) are as follows: 1. Airway management with C-spine control, including adequate positive pressure ventilation in head injured patients. 2. Chest wound management (i.e. tension pneumothorax, sucking chest wound, flail chest stabilization). See specific protocol. 3. IV or IO vascular access if placed during extrication or during transport. 4. C-collar and backboard when appropriate. 5. Cardiac monitor. 6. Hemorrhage management. Transport to Hospital of Record Patients who have been treated and released from a local hospital within the previous 30 days and are suffering from a recurrence, exacerbation or complication of the condition resulting in that admission will be transported to that hospital. Patients with chronic medical conditions who consistently receive treatment for a condition by a hospital will be transported to that hospital, even if the hospital is on DIVERT status. Such patients include but are not limited to those requiring care related to transplant or dialysis services. The requirements of this section do not apply if the patient is unstable. An unstable patient will be transported to the closest appropriate hospital. Responsoft EMS Protocols Page 175 10/13/2020 Clinical Standards Patient Transport Part C Clinical Standards Specialty Transport Destinations Trauma Trauma patients shall be transported in accordance with Ohio’s Trauma Triage Protocol ( Adult and Pediatric Trauma Triage) to a Level I & Level II Trauma Centers. Pregnant trauma patients should not be taken to Nationwide Children’s Hospital, regardless of age.  Grant Medical Center – Level I  Riverside Methodist Hospital - Level II  OSU Wexner Medical Center – Level I  Mt Carmel East - Level II  Nationwide Children’s Hospital – Level I Acute ST Elevation Myocardial Infarction Patients with an acute ST Elevation MI will be transported to the closest hospital with ability to provide emergent cardiac catheterization. These hospitals are:  Mount Carmel East Hospital  Riverside Methodist Hospital  Mount Carmel St. Ann’s Hospital  Doctors West Hospital  Grant Medical Center  OSU Wexner Medical Center Acute Stroke Patients with symptom duration of <5 hours (based upon when “last normal”) should be taken to the closest of the following facilities based upon their Los Angeles Motor Score (LAMS)     Mount Carmel East Hospital Mount Carmel St. Ann’s Hospital Grant Medical Center OSU East Hospital LAMS 1-3   Riverside Methodist Hospital OSU Wexner Medical Center LAMS 4-5 These patients are more likely to have large vessel occlusion and should go to a comprehensive Stroke Center. Patients with LAMS of 4 or 5 should be taken to a Comprehensive stroke facility unless bypassing a primary stroke center results in an incremental increase in transportation time greater than 15 minutes.   Mount Carmel East Hospital Riverside Medical Center  OSU Wexner Medical Center Amputations  Riverside Methodist Hospital  The Ohio State University Wexner Medical Center  Nationwide Children’s Hospital Responsoft EMS Protocols Page 176 10/13/2020 Clinical Standards Patient Transport Part D Clinical Standards Specialty Transport Destinations-continued Environmental Emergencies Burns  The Ohio State University Wexner Medical Center  Nationwide Children’s Hospital Carbon monoxide Exposure  The Ohio State University Wexner Medical Center Psychiatric Patients  Adult Patients - transport to closest facility  Pediatric Patients o ALL pediatric (<18 yo) patients must be transported to Nationwide Children's Behavioral Health Pavilion. Pregnancy Related Complications: Ohio State University Hospital East DOES NOT have Obstetrics services. Patients with pregnancy related complications should be transported to another facility Left Ventricular Assist Devices Any patient with a left ventricular assist device (LVAD) will be transported to OSU Wexner Medical Center, or Riverside Methodist Hospital, regardless of the nature of their complaint. Inter-Facility Transfers (Hospital-to-Hospital) Inter-facility transfers are those where EMS is called by one medical facility for the purpose of emergently transporting a patient to an emergency department of a hospital more fitting to the patient’s specific needs. Whitehall EMS providers only transport patients to another emergency department or labor & delivery. See Interfacility Transfers clinical standard. In situations where a patient calls 911 from a hospital emergency department lobby and who has already been triaged, the EMS crew shall notify the EMS Supervisor or Battalion Chief on duty and the triage nurse prior to making any patient disposition decisions. Whitehall EMS does not provide routine inter-facility transfers in situations where no emergent medical condition exists, i.e.: inpatient hospital transfers or transporting patients from a nursing home to scheduled appointments. Responsoft EMS Protocols Page 177 10/13/2020 Clinical Standards Patient Transport Part E Clinical Standards Patient Handoff in Triage Emergency depart volume may dictate that some EMS patients be taken to triage rather than an open bed. Patients that can be safely evaluated in triage are those who present with and maintain stable vital signs in the pre-hospital setting, and whose chief medical complaint is one that may not represent an immediate life threat. The decision regarding a triage handoff of care rests with the receiving facility. EMS providers should not determine whether a patient is suitable for triage. The following patients are not candidates for transport to triage: 1. Patients transported to Nationwide Children’s Hospital 2. Adults over age 70 3. Residents of nursing homes or extended care facilities 4. Patients who are intoxicated 5. Patients with acute psychiatric disorders 6. Patients who have had a recent seizure 7. Patients in police custody 8. Patients who are unstable, non-ambulatory or who have IV/IM/intranasal or aerosolized medications administered prior to arrival at the ED. Transport to Free Standing Emergency Department: Patients may be transported to freestanding emergency departments. Transportation to a freestanding emergency department (FSED) should only occur after: 1. The paramedic has done a complete an thorough assessment to ensure the patient is appropriate for transport to a FSED 2. The patient must consent to the transport to a FSED 3. The reporting paramedic must contact the FSED to verify the facility is capable of managing the patient's condition 4. If you arrive at a FSED and they determine they do not have the resources to care for the patient, you may honor the request. As the patient as presented to the FSED the facility MUST complete a medical screening exam per EMTALA prior to transfer occurring NOTE: Specialty Patients require transport destinations as defined by the clinical standards patient transport section of the protocol Responsoft EMS Protocols Page 178 10/13/2020 Clinical Standards Physician on Scene Clinical Standards STANDARD: The medical direction of pre-hospital care at the scene of an emergency is the responsibility of those most appropriately trained in providing such care. All care should be provided within the rules and regulations of the state of Ohio. PURPOSE: With the exception that a physician, from time to time, may accompany Whitehall EMS providers as they perform their duties in the field, or otherwise be involved as a Good Samaritan, the following statement of policy is provided in order to clarify the role of the physician to the scene of an emergency. Obviously, a physician may be present at the scene under a variety of circumstances. For example, he/she may be: 1. 2. 3. A physician of undetermined training and background who happens upon the scene and then acts in the capacity of a Good Samaritan. An industrial physician who is present on an industrial site injury/illness. A physician who is present in his office and has requested emergency medical services (EMS). In case of the "Physician as the Good Samaritan", the medic/squad shall perform its duties in the usual manner under the direction of accepted protocols. Any participation by the Good Samaritan physician shall be courteously declined, unless first approved by the ranking officer. In the event the Good Samaritan assumes responsibility, it must continue at the scene, in transit, and until relieved by another physician in the emergency department to which the patient is delivered. In the case of the "industrial physician,” if the medic/squad is called in a life or limb threatening illness/ injury where an industrial physician is in attendance, the physician will assume full responsibility for the management of the patient and will supervise the EMS providers. Ohio’s Scope of Practice including position statements from the Ohio Emergency Medical, Fire and Transportation Services Board permit EMS providers to continue medications or interventions initiated prior to EMS arrival. This includes blood products. EMS may not initiate additional blood products while in route to the hospital. EMS is not permitted to continue chemotherapeutic agents during transport. Hence the ordering physician does not need to accompany the patient during transport but should be identified in the patient care report as the ordering physician. APPLICATION: When called to the scene by a physician in his office, the medic/squad shall perform its duties in the usual manner under the direction of written protocol. The physician in his office may elect to take charge and supervise the management of the patient. An EMT-A, Advanced EMT-A, or EMT-P is protected by civil immunity when following the direction of a physician unless the actions of the EMT-A, Advanced EMT-A, or EMT-P can be characterized as willful and wanton misconduct. A fully licensed physician who wishes to assume control of the emergency medical care of the patient must agree to the following: Responsoft EMS Protocols Page 179 10/13/2020 Clinical Standards 1. 2. Physician on Scene-continued Clinical Standards Provide the EMT-A. Advanced EMT-A, EMT-P with satisfactory proof that he/she is a physician. The State Medical Board License card is preferred Recognize the following: a. EMT-A, EMT-A Advanced, or EMT-P can function only within the scope of his/her training and statutory authority. b. Any orders given beyond the training and/or authority of the EMT-A, EMT-A Advanced, or EMT-P, or conflicting with his/her training or authority requires the physician responsible for assuring adequate supervision and transport. This means the physician will accompany the patient to the hospital unless it is a multiple-casualty incident or disaster situation and he/ she deems it necessary to stay at the scene. A "Cooperating Physician" may be a physician at the scene of a medical emergency who can control/ supervise the activities of the EMT-P within the scope of the EMT-P training and authority. The physician who has assumed control at the scene is responsible for assuring adequate supervision over the activities of the EMT-P until supervision/control is transferred to the receiving hospital personnel. If a level of care beyond the training and/or authority of the EMT-P has been established, the physician assumes responsibility for medical care during transport. When an EMT-P is operating by written standing orders prepared by a medical advisor or advisory board, a physician at the scene can assume control of the EMT-P and may supersede the written orders and require the cooperation and assistance of the EMT-P. After assuming control, the physician can transfer care of the patient back to the EMT-P, if the care has not gone beyond the EMT-P level of training and/or authority. If the level of care goes beyond the EMTP's scope of training and/or authority, the physician who assumes control is responsible for assuring the adequate supervision of the medical care during transport until supervision/control is transferred to the receiving hospital personnel. Responsoft EMS Protocols Page 180 10/13/2020 Clinical Standards Pre-Existing Medical Devices/Drug Administrations Part A Clinical Standards Responsoft EMS Protocols Page 181 10/13/2020 Clinical Standards Pre-Existing Medical Devices/Drug Administrations Part B Clinical Standards Responsoft EMS Protocols Page 182 10/13/2020 Clinical Standards Safe Discharge of Diabetic Patients Clinical Standards STANDARD: All diabetic patients who suffer an episode of hypoglycemia should be offered transportation to an emergency department. Patients who have the capacity to refuse transport (see Refusal of Treatment and/or Transport standard) may refuse transportation to an emergency department if they meet the additional parameters identified below. Patients who suffer a second episode of hypoglycemia within 24 hours will be transported to an emergency department. PURPOSE: This standard outlines a process for a diabetic patient to safely decline transportation to an emergency department after suffering an episode of hypoglycemia. APPLICATION: In order for a diabetic patient with suffering from a hypoglycemic episode to decline transportation to an emergency department he/she must: 1. Have a history of insulin dependent diabetes 2. Return to normal mental state within a. 10 minutes of IV Dextrose administration, or b. 15 minutes of IV/IM Glucagon or oral glucose administration 3. Have pretreatment glucose < 60 mg/dl 4. Have post treatment glucose > 80 mg/dl 5. Tolerate food by mouth 6. Have no other complicating factors or comorbid conditions such as fever, symptoms of stroke 7. Agree to follow up with primary care physician 8. Not currently use sulfonylureas. Examples include: 9. Generic Name chlorpropamide glimepiride glipizide glyburide tolazamide tolbutamide Have normal vital signs Responsoft EMS Protocols Brand Name Diabinase Amaryl Glucotrol, Glucotrol, XL DiaBeta, Glynase, PresTab, Mictonase Page 183 10/13/2020 Clinical Standards Special Needs Patients Clinical Standards Patients with Special Circumstances/Special Health Care Needs STANDARD: This standard is established to p