Hanover Fire EMS Procedures-Guidelines Manual PDF

Hanover Fire EMS Procedures-Guidelines Manual Chapter 5 - Emergency Medical Services Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Eme...

Hanover Fire EMS Procedures-Guidelines Manual Chapter 5 - Emergency Medical Services Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Emergency Medical Services - 235 Published with permission by Hanover Fire EMS  Procedure Hanover Fire EMS 500 Procedures-Guidelines Manual Patient Care Documentation (SOG) 500.1 PURPOSE This SOP defines the expectations, scope, and processes department personnel shall follow in order to document patient encounters, clinical events, and delivery of emergency medical care. 500.2 SCOPE This document applies to all department personnel responding to emergency incidents. Code of Virginia 32.1 – 116.1 requires each Emergency Medical Services Agency to participate in the Emergency Medical Services Patient Care Information System. Documentation of emergency response includes submission of “The minimum data set shall include, but not be limited to, the type of medical emergency or nature of the call, the response time, the treatment provided and other items as prescribed by the Board” (of Health). The Old Dominion EMS Alliance (ODEMSA) outlines specific regional requirements under the current patient care protocols. ODEMSA 2018 Patient Care Protocols: Section 12 Administration This policy reinforces these specific ODEMSA Patient Care Protocols; Protocol 12.2 Documentation. 500.3 PREREQUISITES Department personnel will completely and properly document all patient encounters in accordance with Virginia Office of EMS regulations, Old Dominion EMS Alliance (ODEMSA) Patient Care Protocols, and Hanover Fire-EMS policy and patient care guidelines. Patient Care Reports shall provide a clear clinical outline of the situation, assessment, care delivered and appropriate transfer of care. Thorough documentation protects the patient, the department personnel, department Operational Medical Director, and Hanover County. A patient is defined as any individual that requests evaluation by EMS. If an individual is not legally competent due to age, injury, chronic illness, intoxication, minor status, etc… always err on the side of patient safety and assume and document an implied request for evaluation. 500.4 RESPONSIBILITIES All patient encounters, which result in some component of an evaluation, must have an electronic Patient Care Report (ePCR) completed. This is documented through the department’s current ePCR system. The senior certified EMS provider, in cooperation with the responding ambulance officer in charge, is responsible for documentation of patient care. The ranked apparatus officer or acting officer is responsible for assuring all responses for the shift are completely documented by the end of the shift. Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Patient Care Documentation (SOG) - 236 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Patient Care Documentation (SOG) Code of Virginia requires patient transport reports must be printed and submitted to the receiving facility within 12 hours of the transport. It is expected that the report is completed and printed at the time of transport unless circumstances dictate otherwise, such as equipment failure or call volume. 12VAC5-31-1140. Provision of Patient Care Documentation 500.5 PROCEDURE (a) Patient Care Documentation 1. Each unit responding to the incident is expected to complete an ePCR with the information available to the provider in charge. 2. Quick Response Vehicle (QRV), Fire Apparatus, and administrative personnel providing Advanced Life Support should add themselves to the crew of the transporting unit. 3. A copy of the ePCR must be provided to the appropriate, receiving medical facility within 12 hours of transport. 4. All Patient Care Reports require a narrative component that “paints” an accurate picture of the scene, patient presentation, and all occurrences during the interactions with that patient. This is expected no matter the disposition of the call. 5. The narrative is considered an essential component of the patient and should include, at minimum: (a) Reason for request/dispatch (b) Presenting complaint on arrival (c) How the patient was found and transferred (d) Detailed history of present illness: (e) Signs and Symptoms, Allergies, Medications, Prior medical history, Last oral intake, and Events leading up to incident. (f) Descriptions of complaint: Onset, Provocation/palliation, Quality, Radiation, Severity, Time. Specific location and laterality. (g) A pain scale should be obtained. (h) Interventions and response to interventions (i) Condition on arrival and any changes enroute (j) Specify facility, room, and report provided to level of care. 6. All personnel providing care during transport should be added to the crew, to include students and observers. Station daily logs should reflect the name and nature of any non-departmental personnel, along with any affiliated programs (name of educational program). 7. All interventions performed should be credited to the individual performing it through the “drop down” personnel list in the PCR. Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Patient Care Documentation (SOG) - 237 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Patient Care Documentation (SOG) 8. All administrative personnel, not assigned to a specific EMS vehicle, need to be documented on the call. 9. If part of the first response, rendering and transferring care, then the administrative personnel shall complete an independent ePCR from the transport vehicle, assigned to the generic vehicle “EMS405” for ALS personnel. 10. If assisting in clinical care, interventions performed must be documented and accredited to the personnel performing. 11. Supervisory personnel responding for incident command and control are not routinely added unless directly involved in clinical care. 12. Critical and high risk interventions shall be documented by the provider performing with additional narrative added as needed. These procedures include, but are not limited to: (a) Endotracheal Intubation: narrative by intubating medic describing landmarks visualized, use of bougie introducer, and verification (b) Rapid Sequence Intubation: narrative by RSI medic outlining clinical course, procedure, and report to receiving physician (c) Intraosseous vascular access: comment verifying placement and patency (d) Cricothyroidotomy: surgical and percutaneous: narrative provider outlining clinical course, landmark identification, verification and report to physician at hospital. 13. Interventions and vital signs shall be transferred from the cardiac monitor/ defibrillator and imported into the patient care report prior to providing the report to the receiving facility. Essential benchmark interventions include: (a) 12 Lead ECG (b) Waveform capnography (c) RSI medications (d) Cardiac medications (e) Cardiac electrical therapies. 14. The PCR shall reflect transfer of patient care to receiving personnel with a patient status. This includes transfer of care from first response units to transport units, as well as from transport units to hospital staff. 15. Personnel shall obtain receiving physician signature for the following specific medications and procedures: (a) Field Cease Resuscitation (when medications are used) (b) Rapid-Sequence Intubation (c) Administration of controlled substances (d) On-line medical control for specific medications or procedures. Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Patient Care Documentation (SOG) - 238 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Patient Care Documentation (SOG) (e) Deviation from ODEMSA or Department Patient Care Guidelines. 16. Personnel shall obtain the patient authorization signatures for billing and HIPPA purposes for all patient’s transported. 17. If the patient is documented as awake, alert, and oriented, then obtain the patient’s original signature, and it is the only signature required. 18. If the patient is unable to sign, or is a minor, then TWO signatures are required: (a) Minor patient: 1. Parent or legal guardian MUST sign; receiving hospital medical staff is preferred second signature, but EMS provider may sign. (b) Patient unable to sign due to incapacity or medical condition: 1. Patient family or legal power of attorney is preferred first choice. 2. Receiving hospital staff may sign if no family available. 3. EMS Personnel may sign a second signature. (b) Non-Patient Incidents/Canceled Incidents 1. EMS Units dispatched to Emergency Incidents FOR EMS PURPOSES are expected to initiate and complete an ePCR for all call types. 2. Non-patient incidents include Fire and Law Enforcement standbys, Fire Rapid Intervention Crew, and 3rd party incidents where no complainant is found 3. Documentation in the ePCR should include: (a) Call type and dispatch information (b) Incident times and CAD number (c) Disposition (d) Brief Narrative: What was found, what crew did or specific assignment. 4. Cancellations include incidents where a unit is dispatched and canceled by personnel on the scene of the reported emergency. 5. Situations not requiring ePCR completion: (a) Unit is dispatched and canceled by caller prior to marking enroute (b) Unit is dispatched and canceled by another department unit that is handling the incident; these represent CAD re-assignments for the same incident. 6. Fire apparatus and units responding to emergency incidents for the purpose of hazard mitigation are not required to complete an ePCR unless specifically tasked to perform patient care. 7. Fire Apparatus are EXPECTED to complete a fire report in the reporting software with a narrative detailing the response and actions taken. (c) Hanover County Quick Form Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Patient Care Documentation (SOG) - 239 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Patient Care Documentation (SOG) 1. The Department has developed a QuickForm for providers to us as an adjunct to the ePCR documentation. (See Appendix A for SAMPLE) 2. In certain circumstances a computer may not be available to the provider. It is acceptable for providers and first responders to utilize the Hanover QuickForm to gather pertinent information until they return to the station to fill out the ePCR. 3. The QuickForm may be used to obtain a patient refusal signature. In these situations, providers should follow the Paper Patient Care Report SOG 300.14 as required. 500.6 REFERENCES Old Dominion EMS Alliance Patient Care Protocols 2012 Code of Virginia EMS Regulations 12VAC5-31 Hanover Fire EMS Procedures-Guidelines Manual: 502.1 Purpose Board of Pharmacy Regulations 500.7 DEFINITIONS Patient: defined as any individual that requests evaluation by EMS. If an individual is not legally competent due to age, injury, chronic illness, intoxication, etc. always err on the side of patient safety and assume an implied consent request for an evaluation. Consent: A competent patient has the right to make decisions regarding care and must consent to emergency medical care. The acceptance of care is based on the information provided. 500.8 QUALITY AND ACCOUNTABILITY None Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Patient Care Documentation (SOG) - 240 Published with permission by Hanover Fire EMS  Procedure Hanover Fire EMS 501 Procedures-Guidelines Manual Patient Refusals (SOG) 501.1 PURPOSE The purpose of this SOG is to define the process and expectations to aide personnel in obtaining and documenting patient refusals for any and all incidents. As required by 12VAC5-31-1090. Refusal of care: a decision not to treat or transport a patient shall be fully documented on the pre- hospital patient care report. 501.2 SCOPE Events generally indicating refusal documentation: Anytime there is a medical call initiated by the patient or family member with the Patient. Anytime there is reason to believe that the person has a medical condition that requires further treatment or transportation to a medical facility. Anytime that the provider sees any obvious injury. Events that may not indicate refusal documentation: Stand-bys for fires, or hazardous materials incidents where no one is injured or exposed to hazardous material. Routine blood pressure checks at the request of the patient when the findings are within normal limits, and no other complaint is voiced. An ambulatory person that was an occupant of a minor crash or accident that does not wish to be evaluated. 501.3 PREREQUISITES Any competent adult has the right to refuse treatment and/or transportation offered by an EMS agency. The decision to refuse care must however be an informed one. The patient must understand the consequences of the refusal. In order for a decision to be informed, it is the responsibility of the EMS provider to properly assess the patient for any possible illness or injuries and to inform the patient of the findings. 501.4 RESPONSIBILITIES It is the responsibility of every individual EMS provider to accurately assess their patients and gather enough adequate information to make a sound decision. The following patients may refuse treatment and transport after appropriate assessment, treatment, and informed consent. Adults Emancipated Minor or minors between the ages of 14 to 18 as appropriate to ODEMSA Protocol 12-3: Minors Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Patient Refusals (SOG) - 241 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Patient Refusals (SOG) Patients with demonstrated “mental capacity:” Alert, oriented, with capacity to understand the circumstances surrounding their illness or impairment, and understanding of the risks associated with refusal. Patients under the age of 14 may not refuse without direct consent from the parent or legal guardian. Patients with impaired mental capacity, in general, may not refuse, without appropriate medical power of attorney. Patients under the influence of mental illness, drugs, alcohol intoxication, or physical/mental impairment may have impaired “mental capacity” and have limited ability to refuse treatment and transport. “At no time, should EMS personnel put themselves in danger by attempting to treat and/or transport a patient who refuses care.” All patient refusals must be documented in accordance with ODEMSA Patient Care Protocol 12.6* 501.5 PROCEDURES (a) Patient Information 1. When it is determined that the patient’s mental status is such that an informed decision can be made, the patient will be provided the following information: 2. That the crew is unable to perform as complete an assessment as hospital personnel and physicians. (a) That there may be an injury or condition that the provider cannot determine, or that the possibility exists that the patient’s condition is worse than it appears. (b) That the providers on scene, or another EMS unit will transport the patient to the most appropriate medical facility. (c) That if the patient later decides that they need medical care, they should contact their physician, go to an appropriate medical facility or call 911. (d) After informing the patient of the above information, the provider will ask if the patient and/or family if they have any questions. 3. After answering any questions that the patient or family may have, the Provider will ask if the patient and family understand all of the information that has been presented. 4. The information that was presented will be documented on the PPCR as to what the patient was told, and an overview of any questions, comments or opinions that the patient or responsible party may verbalize. 5. This is done in an effort to document that the patient/responsible party understands the 6. information that has been presented to them. (b) Refusal Documentation Requirements Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Patient Refusals (SOG) - 242 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Patient Refusals (SOG) 1. Initial patient assessment with full set of vital signs and mental status. 2. Medical care provided with consent of patient. 3. Reasons for treatment and transport, recommended evaluation, potential consequences of refusal of treatment and transport, and reason for refusal if applicable. 4. Patient refusal signature and third party witness to refusal if available (see below.) (c) Special Considerations 1. Effective July 1, 2000, the code of Virginia, Section 54.1-2969, was amended to allow a minor fourteen (14) years of age or older who is physically capable of giving consent, the right to give consent or to refuse EMS services. This may be done only after an attempt has been made to obtain consent from the minor’s parent or guardian, and within a reasonable length of time under the circumstances of the incident. 2. A pregnant minor shall be deemed an adult for the sole purpose of giving consent for herself and her child to medical treatment relating to the delivery of her child. Thereafter, the minor mother shall also be deemed an adult for the purpose of giving consent to medical treatment of her child. However, the minor mother still is a minor, and an attempt must be made to obtain consent from her parent or guardian for any medical treatment to the minor mother not related to the delivery of her child. 501.6 REFERENCES ODEMSA Protocols Expectations of Operational Medical Director Guidance of on-line medical control during emergency custodial orders (ECOs) Amended § 63.2-100 of the Code of Virginia Virginia vs. Cherixx 501.7 DEFINITIONS Consent: A competent patient has the right to make decisions regarding care and must consent to emergency medical care. The acceptance of care is based on the information provided. 501.8 QUALITY AND ACCOUNTABILITY Witness Signatures When possible, at least one witness should be at the patient’s side during the providers review of the required information. After the patient has voiced their understanding of the information, if at all possible at least one witness should sign in the appropriate location on the ePCR. The individuals used as witnesses should be one or more of the following: a family member, a bystander, or a second Fire-EMS provider. Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Patient Refusals (SOG) - 243 Published with permission by Hanover Fire EMS  Procedure Hanover Fire EMS 502 Procedures-Guidelines Manual Paper Patient Care Report (SOG) 502.1 PURPOSE The purpose this SOG is to establish the procedure for proper documentation and handling of patient care reports created using a paper form. 502.2 SCOPE This SOG will address the procedure to be followed by all department personnel when using a paper patient care report. 502.3 PREREQUISITES Hanover Fire-EMS personnel who are licensed by the Virginia Office of EMS as emergency medical care providers are required to render proper emergency medical care and document such care appropriately. All Hanover Fire-EMS personnel are required to protect the patient confidentiality for all patients or potential patients encountered. Proper handling of documentation by all personnel is critical. 502.4 RESPONSIBILITIES None 502.5 PROCEDURE (a) All patient contacts should be properly documented. The primary method for documenting patient contacts is direct entry into the electronic reporting platform. In situations where a patient contact is recorded on a paper patient care report, the following procedure should be used: 1. Properly document the patient contact using a current approved paper patient care report. 2. Restrict access to the paper document throughout its existence to insure patient confidentiality. 3. When you have access to the the electronic application, transfer all data from the paper report into the electronic report and any other information required to complete the electronic report. 4. Scan the paper patient care report and attach it to the electronic report. Insure all parts of the paper report are scanned including the back if information such as patient refusal signatures exists there. 5. Destroy the paper patient care report so that data cannot be recovered from it. (b) All stations have desktop computers with a scanner. Do not forward paper patient care reports to other department members or locations. 502.6 REFERENCES None Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Paper Patient Care Report (SOG) - 244 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Paper Patient Care Report (SOG) 502.7 DEFINITIONS None 502.8 QUALITY AND ACCOUNTABILITY None Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Paper Patient Care Report (SOG) - 245 Published with permission by Hanover Fire EMS  Procedure Hanover Fire EMS 503 Procedures-Guidelines Manual Patient Destination (SOG) 503.1 PURPOSE Provide department specific guidelines for EMS patient transport in Hanover County.This policy acts as a supplement to the Old Dominion EMS Alliance regional protocols. 503.2 SCOPE EMS transport agencies within Hanover Fire-EMS. 503.3 PREREQUISITES The patient's clinical condition and stability is the primary determinant in hospital destination, reflecting state and regional Trauma Triage guidelines, STEMI, and Stroke specialty services. Unstable patients should be transported to the closest, most appropriate facility.Consider the closest hospital MAY NOT be the most appropriate based on situation. Patient destination for ambulance transports follows the regional ODEMSA Patient Destination protocol as the principle source. This operational guideline clarifies the individual agency and locality considerations. Stable patients should be transported to their hospital of choice whenever possible. This provides improved patient satisfaction as well as continuity of care. Non-clinical considerations for hospital destination include distance, traffic conditions, weather, diversion, and operational tempo. Consult the on-duty Battalion Chief when non-clinical considerations create conflict with patient choices. Specialty service patients should be transported to the hospital managing their condition whenever possible. Specialty services include cardiac surgical devices, neurosurgical services, pediatrics, oncology, and hospice. Patients enrolled in hospice care should be transported to their facility of choice, as admission to other facilities may void hospice care. Patients recently discharged from a hospital should be returned to the same facility whenever possible. Contact medical control for directions if conflicts develop. Quality service delivery and professionalism is expected at all times. 503.4 RESPONSIBILITIES EMS unit Attendant in Charge (AIC) and provider with the highest level of certification is responsible for clinical care and patient destination. Battalion Chief on duty provides direction, if needed, in non-clinical conditions such as weather and distance, as well as unusual patient transport requests. The EMS Supervisor may also provide assistance and direction while on-duty. Operational Medical Director provides resource and review of patient destination decisions and may provide on-line medical control if needed Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Patient Destination (SOG) - 246 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Patient Destination (SOG) Hospital attending emergency physicians at receiving facilities provides on-line medical control for specific situations. Department Quality Assurance personnel review hospital destination decisions and make recommendations. 503.5 PROCEDURE (a) Free-Standing Emergency Departments 1. Free-Standing Emergency Departments provide initial clinical evaluation and medical stabilization in accordance to Federal EMTALA guidelines; however do not provide admission on site. Patients requiring hospital admission will be transferred from the free standing emergency department to an appropriate full- service hospital, most often by an EMS unit. 2. The following patient clinical conditions, in general, SHOULD NOT be transported to a free standing emergency department: (a) Acute MI/STEMI suspected or identified by 12 lead ECG (b) Patients in Cardiac Arrest (c) Multiple System Trauma patients or patients who meet Trauma Triage criteria (d) Open fractures/surgical orthopedic patients, long bone fractures (e) Acute or suspected stroke patients/neurological deficits (f) Intubated patients (g) Pediatric patients with complicated medical conditions. (h) Patients transported from a medical facility or nursing home UNLESS transported for a specific service available at the free standing ED (Radiology, PEG tube replacement) (i) Voluntary psychiatric patients seeking inpatient care 3. The following patient clinical conditions MAY BE appropriate for transport to a free standing emergency department: (a) General illness/complaint without comorbid or complicating factors (b) Musculoskeletal pain (c) Eyes, ears, nose, throat complaints without airway involvement (d) Minor trauma 1. MVC with minor or minimal complaints 2. Laceration repair 3. Closed, non-angulated orthopedic injury (e) Patient with resolved chief complaint requiring observation Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Patient Destination (SOG) - 247 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Patient Destination (SOG) 1. Resolved hypoglycemia 2. Improving, uncomplicated allergic reaction (f) Stable psychiatric patients in need of medical clearance AND local magistrate jurisdiction as determined by Hanover County Mental Health Services 1. ECO or TDO pending available psychiatric services 2. Hanover County Sheriff’s Office needs to retain physical jurisdiction pending transfer to facility 4. Patients with an uncontrolled airway or unstable vital signs should be transported to a full service hospital unless extenuating circumstances exist. (a) The location of the free standing Hanover Emergency Center is in close proximity to the full service Memorial Regional Medical Center. Based on this close proximity, the transport difference to the full ED nullifies transport of an unstable patient to the free-standing ED. 5. Contact the facility and speak to the ED Attending Physician as Medical Control, if there is a question about the capabilities of the facility. 503.6 REFERENCES Old Dominion EMS Alliance 2018 Regional Pre-hospital Patient Care Protocols Section 12 Administration, Protocol 12.4 Hospital Destination Policy ODEMSA Trauma Triage Plan, Stroke Triage Plan, STEMI Guidelines and Regional EMS Plan 503.7 DEFINITIONS None 503.8 QUALITY AND ACCOUNTABILITY None Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Patient Destination (SOG) - 248 Published with permission by Hanover Fire EMS  Procedure Hanover Fire EMS 504 Procedures-Guidelines Manual EMS Report Quality Review and Quality Improvement (SOP) 504.1 PUPROSE This document provides procedures for conducting Incident Quality Review and Quality Improvement. The primary function is providing quality improvement through continuous assessment and constructive feedback. The goal in Incident Review and Quality Improvement is understanding how the department performs and what opportunities exist for improved processes. 504.2 SCOPE General Incident Review Criteria: Provider request for review Officer request for review High Risk/Significant Incident Deviation from protocol during patient care Delayed report completion Bi-annual provider review External or Internal complaint concerning patient care Department personnel may request incident review or post-incident analysis through supervising officer or by making the appropriate selection within the EMS report. 504.3 RESPONSIBILITIES Quality Improvement Officer: The EMS supervisor will be tasked with overseeing the departments EMS quality review and improvement. The EMS supervisor will be involved with all complaints associated with patient care. This position will also oversee and designate quality reviewers. Designated Quality Reviewers: Individuals selected and vetted by the Quality Improvement Officer for the purpose of assisting with review and improvement of EMS reporting and care. All identified operational concerns associated with the quality improvement program shall be forwarded to the appropriate officer within the Operations Division. All identified training concerns associated with the quality improvement program shall be forwarded to the appropriate officer within the Training Division. Assistant Chief of Operations: Manages operations battalions and department response; directs quality assurance review to appropriate resources. Operational Medical Director: Provides clinical oversight and medical direction. Reviews incidents and provides recommendations for improvement. Outlines expected clinical performance. Serves as highest level reviewer of clinical incidents. Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. EMS Report Quality Review and Quality Published with permission by Hanover Fire EMS Improvement (SOP) - 249  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual EMS Report Quality Review and Quality Improvement (SOP) 504.4 PROCEDURE (a) An incident review may be initiated through any of the criteria listed above. 1. EMS Quality Reviews are based off of specific criteria, including incident type: (a) High risk incidents include: 1. Cardiac Arrest 2. Advanced Airway Management 3. Pediatric High Risk Interventions 4. Rapid Sequence Intubation 5. Situations or procedures as designated by the Operational Medical Director (b) Exceptional incidents outside existing standards or requiring specific medical control orders. (c) Routine review of incidents for compliance with existing patient care guidelines. May be either complaint or location specific; for example review of all “chest pain” complaints or all “medical facility” transports. (d) Other incidents or criteria at the discretion of the EMS Quality Improvement Officer. 2. Incident reviews should be tasked to the most appropriate and qualified personnel for the situation. Formal reviews should involve personnel not directly involved in the situation. 3. If a formal review is initiated, it will be through an email alert from Imagetrend, generated by the Quality Improvement Officer. 4. The reviewer assigned may: (a) Review Patient Care Report as well as any and all documentation pertinent to the incident. (b) Interview appropriate personnel involved and request written statements. (c) Contact complainant for statements as needed. (d) Obtain disposition of incident or patient (e) Reference applicable standards, procedures, and guidelines, including but not limited to: (examples provided) 1. Department Guides: (a) Hanover Specific Patient Care Guidelines 2. Regional and State Documents 3. Old Dominion EMS Alliance Patient Care Protocols (latest edition) 4. Virginia EMS Regulations 5. Submit summary report to incident providers including following areas: Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. EMS Report Quality Review and Quality Published with permission by Hanover Fire EMS Improvement (SOP) - 250  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual EMS Report Quality Review and Quality Improvement (SOP) (a) Statement of Facts and collected data (b) Incident as applied to referenced standards (c) Identify variance from standards (d) Recommendations for process improvement and training (e) Requests for improvement/completion of incident documentation 6. Submit patient care and medical case reviews to the Operational Medical Director for review (b) The reviewer and all involved personnel must maintain the security of patient protected health information and confidentiality of any personnel involved. (c) Any identified potential disciplinary or human resources issues shall be managed in accordance with Hanover County Human Resources Policy and any appropriate department Standard Operating Procedure. (d) At the conclusion of each quality review, the designated reviewer should provide the involved personnel with a summary of findings. (e) Each quality review should be documented and data collected for periodic summary. 504.5 DEFINITIONS Quality Review: The process by which patient care and documentation are assessed for compliance within standards to identify areas of improvement and provide feedback to providers. Quality Improvement: Consists of systematic and continuous actions that lead to measurable improvement in documentation and patient care. High Risk/Significant Incident: Incidents where patient condition and/or associated interventions have the potential for serious harm to patients or department personnel. 504.6 QUALITY AND ACCOUNTABILTY Based on the recommendations of the Quality Improvement Officer the following implementations may occur: Remedial training Disciplinary action Revoked privileges Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. EMS Report Quality Review and Quality Published with permission by Hanover Fire EMS Improvement (SOP) - 251  Procedure Hanover Fire EMS 505 Procedures-Guidelines Manual Medication Storage and Recordkeeping (SOP) 505.1 PURPOSE All Personnel share the responsibility of maintaining security of narcotics. No rationale exists for breaching the legal and ethical accountabilities related to narcotic handling. Patient safety is imperative, and health promotion related to impairment is essential among healthcare providers employed by Hanover Fire-EMS. Hanover Fire-EMS will have a thorough controlled drug policy and procedure that meets all state and federal regulations and the minimum guidelines listed below. Furthermore, the purpose of this policy is to train members of the department on the procedure for accurate record keeping and accountability for narcotics stored by Hanover Fire- EMS. 505.2 SCOPE This procedure shall apply to all Hanover Fire-EMS Personnel. 505.3 PREREQUISITES There are no prerequisities for this procedure. 505.4 RESPONSIBILITIES The substance control manager shall be responsible for the department’s adherence to this policy and all state and federal regulations that govern the content and medications described in this SOP. 505.5 PROCEDURE (a) The Substance Control Manager will be able to accurately account for the location of all departmental RSI Boxes, and accurately account for all narcotics stored outside the ODEMSA Drug Boxes. A RSI Box Deployment Log will be maintained with the records. See Appendix A. (b) At the Beginning of each shift, crews will fill out the Department’s Drug/RSI Box Accountability Log. Daily logs shall be updated each time the box is exchanged or used. All files will be stored electronically and managed by the Substance Control Manager. (c) Each month, the Control Substance Manager will perform a monthly audit of all records, verifying the accurate account of all narcotics stored in the main storage area, and in each RSI Box. (Form) (d) When a provider administers RSI drugs, the RSI Medic should fill out the proper Rapid Sequence Intubation Incident Report and Checklist. This form and a copy of the patient care record should be forwarded to the Substance Control Manager. The manager creates a case number, and should log the narcotics used and/or wasted by incident number, date, time, and patient name, according to the Narcotics Accountability Form. The Narcotics Accountability Form should be attached to the proper narcotics invoice.. (e) When a medication expires or when RSI drugs are administered, crews should exchange the RSI Box with authorized departmental officials. Documentation inside Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Medication Storage and Recordkeeping (SOP) Published with permission by Hanover Fire EMS - 252  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Medication Storage and Recordkeeping (SOP) the box should be updated including, filled dated, initials of person filling the box, seal numbers, etc. See Appendix E All other records should be updated including the Deployment Log, accountability logs, and a narcotics count if applicable. 505.6 REFERENCES (a) Hanover County RSI Protocol and Program (b) Old Dominion EMS Alliance (ODEMSA) protocols (c) Commonwealth of Virginia Board of Pharmacy (d) United States Department of Justice, Drug Enforcement Administration 505.7 DEFINITIONS Controlled Substance: A drug or chemical substance whose possession and use are regulated under the Controlled Substances Act. 505.8 QUALITY AND ACCOUNTABILITY (a) All questions or concerns should be directed to the Controlled Substance Manager. (b) Medications stored in the storage area will be inventoried monthly, and all records pertaining to the delivery, dispensing, and administration will be accurately maintained in the storage area, or with the Control Substance Manager. (c) All staff members that have access to the storage area will be trained on proper record keeping, and up-to-date with departmental policies regarding the medication and its storage. Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Medication Storage and Recordkeeping (SOP) Published with permission by Hanover Fire EMS - 253  Procedure Hanover Fire EMS 506 Procedures-Guidelines Manual Gum Elastic Bougie as Endotracheal Tube Introducer (SOG) 506.1 THERAPEUTIC GOAL To provide aid in placing an oral endotracheal tube during difficult intubations. Use of a bougie should be considered for all endotracheal intubations as a resource/guide. 506.2 EQUIPMENT 1. Appropriate personal protective equipment. 2. Stethoscope and vital sign monitoring device (including ECG and SPO2). 3. ETCO2 detector 4. Gum Elastic Bougie. 5. Surgilube, or equivalent water-soluble lubricant. 6. Appropriate sized ETT. 7. 10 ml syringe. 8. Sedatives and/or paralytics as appropriate. 9. Equipment to perform endotracheal intubation. 10. Backup secondary airway device. 506.3 INDICATIONS 1. When orotracheal intubation is considered difficult due to: a. Unfavorable anatomy. b. Known or suspected neck trauma limiting neck mobility. 506.4 CONTRAINDICATIONS 1. ETT to be placed is less than 6.0 mm internal diameter (adults). 2. Should not be used for nasal intubations. 506.5 PROCEDURE 1. Apply appropriate PPE. 2. Assess airway and need for a Bougie. 3. Prepare equipment needed for endotracheal intubation as indicated. 4. Begin intubation procedure. 5. Lubricate a Bougie with water-soluble lubricant. 6. Perform laryngoscopy and when anatomy is identified, pass the Bougie into the trachea or anteriorly toward the presumed opening of the trachea. Tracheal placement of the Bougie is noted by a clicking feel/sound as the flexed tip of the Bougie passes over the tracheal rings. 7. Advance the Bougie until the thick black line on the Bougie is at the patient’s mouth or until the device is well inside the tracheal lumen (adults, 30cm). 8. Thread the proximal end of the Bougie through the distal end of a lubricated endotracheal tube. Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Gum Elastic Bougie as Endotracheal Tube Published with permission by Hanover Fire EMS Introducer (SOG) - 254  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Gum Elastic Bougie as Endotracheal Tube Introducer (SOG) 9. Advance the tracheal tube over the Bougie until the bougie exits the proximal opening in the tracheal tube. It may be helpful to continue laryngoscopy during this to assist ready passage of the endotracheal tube. 10. If resistance is encountered at the vocal cords, withdraw the tracheal tube 1-2 cm, rotate it 90 degrees counterclockwise and then readvance the tracheal tube. 11. When the tracheal tube is clearly in the trachea, remove the Bougie and inflate the cuff. 12. Confirm proper endotracheal tube placement with two verifications. 13. Ventilate the patient with 100% oxygen. 14. Secure the ETT. Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Gum Elastic Bougie as Endotracheal Tube Published with permission by Hanover Fire EMS Introducer (SOG) - 255  Procedure Hanover Fire EMS 507 Procedures-Guidelines Manual Cyanokit (SOG) 507.1 THERAPEUTIC GOAL Cyanide is an extremely toxic poison. In the absence of rapid and adequate treatment, exposure to a high dose of cyanide can result in death within minutes due to inhibition of cytochrome oxidase resulting in arrest of cellular respiration. Specifically, cyanide binds rapidly with cytochrome a3, a component of the cytochrome c oxidase complex in mitochondria. Inhibition of cytochrome a3 prevents the cell from using oxygen and forces anaerobic metabolism, resulting in lactate production, cellular hypoxia and metabolic acidosis. The action of Cyanokit® in the treatment of cyanide poisoning is based on its ability to bind cyanide ions to form cyanocobalamin, which is then secreted in the urine. Cyanide poisoning may result from inhalation, ingestion, or dermal exposure. The primary utilization for Cyanokit® with Hanover Fire EMS is for victims of an enclosed space fire with combustion of modern construction. Common building materials known to release high levels of cyanide during combustion include, but not limited to: glass fibers, melanine, nitrile rubber, particle board, laminate products, and building insulation foam. 507.2 EQUIPMENT 1. Cyanokit is in a single 5 g vial; powder form must be reconstituted with 0.9% sodium chloride. (May be packaged in 2-2.5g vials). 2. 250ml 0.9% sodium chloride (Normal Saline) (Discard 50ml) 3. Transfer spike 4. Vented IV tubing (Open side port) 507.3 INDICATIONS 1. Smoke Inhalation with known or suspected cyanide poisoning. 2. Suspected Carbon Monoxide (CO), Cyanide (CN), or Combined Exposure with clinical presentation of cyanide poisoning: a. Headache, dizziness, confusion, (Altered Mental Status) b. Anxiety, restlessness c. Chest pain, shortness of breath, nausea/vomiting 3. Victim of enclosed-space fire. 4. Suspected exposure to weaponized Cyanide variant. 507.4 CONTRAINDICATIONS 1. Hypersensitivity to hydroxocobalamin or cyanocobalamin. 2. Allergy to Vitamin B12 3. Cardiac arrest with burns greater than 50%. Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Cyanokit (SOG) - 256 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Cyanokit (SOG) 507.5 PROCEDURE Don the appropriate PPE and remove the patient from the source of the smoke/inhalation. Initiate appropriate resuscitative care for patient clinical presentation. Initiate cardiopulmonary resuscitation and place cardiac monitor/defibrillator as soon as feasible. 2. Assess the patient: (a) Exposure to fire or smoke in an enclosed space (b) Evidence of trauma and/or burns. (c) Evidence of soot in nose, mouth, or oral pharynx. (d) Altered Mental Status 3. Evaluate airway and breathing. Establish airway patency and support ventilations as needed. (a) Administer 100% O2 with Non-rebreather mask if conscious, BVM for ventilations, or intubate with PEEP, as indicated. 4. Place patient on cardiac monitor and obtain vital signs including heart rate and blood pressure. Initiate capnography monitoring if available. 5. Consider rapid decontamination by removal of victims soot impregnated clothing if possible. 6. Consider appropriate trauma protocol and spinal immobilization as indicated. 7. Initiate intravenous or interosseous access as needed; 2 access points preferred. 8. Administer Cyanokit® 5g IVPB and monitor for clinical response and evaluate need for second 5g dose. (Contact Medical Control as indicated) (a) Adult: Give 5 g IV infused over 15 minutes. If signs and symptoms persist, and dose is available, contact medical control to administer a second dose administered to maximum of 10 grams. The infusion rate for second dose is usually between 15 minutes and 2 hours. (b) Pediatric: Give 70 mg/kg, up to 5 g IV infused over 15 minutes. If signs and symptoms persist, a repeat dose can be administered. The infusion rate for second dose is usually between 15 minutes and 2 hours. 9. If hypotensive, consider fluid challenge. Titrate fluid resuscitation to American Burn Association recommendations and patient blood pressure. Do not administer the entire volume during initial resuscitation. 10. Monitor ECG, Pulse Oximetry, if available (Note: Pulse oximeters may give false readings in patients exposed to CN/methemoglobin or CO.) 11. Treat other presenting symptoms. (a) Consider CPAP if patient awake (b) Treat seizures per most current ODEMSA Patient Care Protocols (c) Consider pain management 12. Transport to appropriate facility. Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Cyanokit (SOG) - 257 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Cyanokit (SOG) (a) Patients with suspected inhalation injury or burns from structure fires should be transported to the regional burn resource at VCU Medical Center/Evan-Haynes Burn Center. 507.6 CAUTIONS 1. Observe for allergic reaction and treat as presenting: (a) Allergic reactions may include anaphylaxis, chest tightness, edema, urticarial, pruritus, dyspnea, rash, and angioneurotic edema. 2. Substantial increases in blood pressure following administration may occur. 3. Cyanokit is Pregnancy Category C and should be used only if potential benefit justifies the potential risk, 4. Safety and effectiveness has not been established in pediatric patients; contact Medical Control. 507.7 LOGISTICS AND QUALITY ASSURANCE 1. Document administration in EMS Reporting System or most current version of electronic Patient Care Report under “CYANOKIT” 2. Provide patient turnover report and obtain the following information for report (a) Receiving physician name and title (Attending, resident, emergency physician, or trauma/burn) (b) Trauma identifier number (Unique trauma naming format for VCUHS) (c) Any issues or variations from protocols or PCG (d) Disposition of patient at departure (Expired, transferred to OR/burn unit, or still in Emergency Department) 3. If available, exchange Cyanokit with VCUHS Communications Center. VCUHS will only exchange Cyanokits on a 1:1 basis for patients transported and kit administered by EMS. VCUHS will not exchange expired Cyanokits or ones transported to other facilities. At this time, the pharmacy at VCU does not exchange Cyanokits, only the communications room. 4. If unable to exchange and replace Cyanokit, notify Battalion Chief. Based on available resources, Operations Battalion Chiefs may redeploy remaining available Cyanokits to central units. 6. Notify Quality Assurance officer of incident: provide trauma identifier, physician name, date and time of incident, and disposition at ED. QA officer will contact receiving facility for patient follow up. 507.8 PREPARATION AND ADMINISTRATION 1. One 5 gram vial is a complete starting dose 2. Reconstitute: Place the vial in an upright position Add 200 mL of 0.9% Sodium Chloride injection* to the vial using the transfer spike. Fill to the line. Discard approximately 50ml of saline; try not to over pressurize glass vial. (Image 1) 3. Normal Saline (0.9% Sodium Chloride) injection is the recommended diluent (diluent not included in the kit). Lactated Ringers injection and 5% Dextrose injection have also been found Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Cyanokit (SOG) - 258 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Cyanokit (SOG) to be compatible with hydroxocobalamin and may be used if 0.9% Sodium Chloride is not readily available. 4. Mix: The vial should be repeatedly inverted or rocked, not shaken, for at least 60 seconds prior to infusion. (Image 2) (a) Inspect for particulate matter and color prior to administration (b) Discard if particulate matter is present or if the solution is NOT dark red. 5. Infuse Vial: Use vented intravenous tubing, hang and infuse over 15 minutes. OPEN VENT PORT ON SIDE OF DRIP CHAMBER IN ORDER TO START FLOW. (Image 3) 6. Dedicate one IV access to Cyanokit administration as it is physically incompatible with other meds frequently used with resuscitation. 7. Please count the 200ml of the Cyanokit infusion into the patient’s total resuscitation effort. Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Cyanokit (SOG) - 259 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Cyanokit (SOG) Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Cyanokit (SOG) - 260 Published with permission by Hanover Fire EMS  Procedure Hanover Fire EMS 508 Procedures-Guidelines Manual Continuous Positive Airway Pressure (CPAP) (SOG) 508.1 THERAPEUTIC GOAL Continuous Positive Airway Pressure has been shown to rapidly improve vital signs, gas exchange, reduce the work of breathing, decrease the sense of dyspnea, and decrease the need for endotracheal intubation in patients who suffer from shortness of breath from asthma, COPD, pulmonary edema, CHF, and pneumonia. In patients with CHF, CPAP improves hemodynamics by reducing left ventricular preload and afterload. 508.2 EQUIPMENT 1. Oxygen regulator with a 6-inch hose and quick connect (if necessary). 2. Face mask, corrugated tubing, and adjustable PEEP valve. (All parts are disposable). 3. Appropriate sized mask. Delivered in Medium and Large. 4. Oxygen tank with adequate amount of volume. 508.3 INDICATIONS 1. Any patient who is in respiratory distress with signs and symptoms consistent with asthma, COPD, pulmonary edema, CHF, or pneumonia who: (a) is awake and able to follow commands, (b) is over 12 of age and able to fit the CPAP mask, (c) has the ability to maintain an open airway, (d) AND exhibits two or more of the following; i. a respiratory rate greater than 25 breaths per minute, ii. SPO2 of less than 94% at any time, iii. use of accessory muscles during respirations. 508.4 CONTRAINDICATIONS 1. Respiratory arrest or patient with tracheotomy. 2. Excessive fluid retention. 3. Pneumothorax or chest trauma. 4. Decreased cardiac output and gastric distention. 5. Severe facial trauma. 6. Hypotension secondary to hypovolemia. 508.5 PROCEDURE 1. Explain the procedure to the patient. 2. Ensure adequate oxygen supply to ventilation device (15L/min). 3. Place the patient on continuous pulse oximetry. 4. Place the patient on cardiac monitor (if available) and record rhythm strips with vital signs. Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Continuous Positive Airway Pressure (CPAP) Published with permission by Hanover Fire EMS (SOG) - 261  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Continuous Positive Airway Pressure (CPAP) (SOG) 5. Place the delivery device over the mouth and nose. 6. Secure the mask with provided straps or other provided devices. 7. Use adjustable PEEP valve within scope of practice. 8. Check for air leaks. 9. Monitor and document the patient’s respiratory response to treatment. 10. Check and document vital signs every 5 minutes. 11. Administer appropriate medication as certified (continuous nebulized Albuterol for COPD/ Asthma and repeated administration of nitroglycerin tablets/paste for CHF per protocol) 12. Continue to coach patient to keep mask in place and readjust as needed. 13. Contact medical control to advise them of CPAP initiation. 14. If respiratory status deteriorates, remove device and consider intermittent positive pressure ventilation via BVM and/or placement of non-visualized airway or endotracheal intubation. 508.6 REMOVAL PROCEDURE 1. CPAP therapy needs to be continuous and should not be removed unless the patient can not tolerate the mask or experiences respiratory arrest or begins to vomit. 2. Intermittent positive pressure ventilation with a Bag-Valve-Mask, placement of a non- visualized airway and/or endotracheal intubation should be considered if the patient is removed from CPAP therapy. 3. Do not remove CPAP until hospital is able to provide airway therapy. Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Continuous Positive Airway Pressure (CPAP) Published with permission by Hanover Fire EMS (SOG) - 262  Procedure Hanover Fire EMS 509 Procedures-Guidelines Manual Tourniquet Therapy (SOG) 509.1 THERAPEUTIC GOAL To stop blood loss by applying pressure to an artery. 509.2 EQUIPMENT 1. Appropriate personal protective equipment. 2. Tourniquet. 509.3 INDICATIONS 1. A tourniquet should be used to control potentially fatal hemorrhagic wounds only after other means of stopping blood loss have failed and/ or in the presence of significant extremity hemorrhage and/or any of the following are present: (a) Need for airway management. (b) Need for breathing support. (c) Circulatory Shock. (d) Need for other emergent interventions or assessment. (e) Bleeding from multiple locations 509.4 CONTRAINDICATIONS 1. Do not place tourniquet over a joint or an impaled object. 509.5 PROCEDURE 1. Apply appropriate PPE. 2. Placement: (a) Expose the extremity by removing clothing in proximity to the injury. (b) Place directly over exposed skin at least 3- 5 cm proximal to the wound margins. (c) Route the self-adhering band around the extremity. (d) Pass the band through the outside slit of the buckle. (e) Pull the self-adhering band tight. (f) Twist the rod gradually until all hemorrhage stops. (g) Lock the rod in place with the clip. (h) Record the date/time of application on the tourniquet. 3. Evaluation: (a) The tourniquet is effectively applied when there is cessation of bleeding from the injured extremity, indicating total occlusion of arterial blood flow. (b) As resuscitation proceeds and perfusion improves, further tightening may be required. 4. Tourniquet time and removal: Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Tourniquet Therapy (SOG) - 263 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Tourniquet Therapy (SOG) (a) Tourniquets should be reassessed and removed as soon as possible under conditions where the hemorrhage can be directly controlled. See Tourniquet Reassessment and Tourniquet Removal Algorithms below. (b) Tourniquet placement must be communicated in patient reports for all pre-hospital to hospital and inter-hospital transfers. (c) Keep tourniquet on throughout the transport – a correctly applied tourniquet should only be removed by the receiving hospital. Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Tourniquet Therapy (SOG) - 264 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Tourniquet Therapy (SOG) Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Tourniquet Therapy (SOG) - 265 Published with permission by Hanover Fire EMS  Procedure Hanover Fire EMS 510 Procedures-Guidelines Manual Adults and Pediatrics EZ IO (SOG) 510.1 THERAPEUTIC GOAL To provide an alternative route for administration of intravenous fluids and medications in the adult patient when standard peripheral intravenous access has been unsuccessful, or is not appropriate. 510.2 EQUIPMENT 1. Personal Protective Devices 2. IV tubing and fluid 3. EZ IO 4. Intraosseous Infusion System 5. Betadine and Alcohol prep pads 6. 10cc Aspiration syringe with 5cc of NaCl 7. IV tubing and IV fluid 510.3 EZ-IO™ FROM VIDACARE The EZ-IO™ is approved for patients 3kg and above as follows: Proximal tibia: 40 kg and greater AND 3-39 kg (peds needle) Proximal humerus: 40 kg and greater 510.4 INDICATIONS 1. Unsuccessful establishment of peripheral intravenous access or inability to perform venous cannulation as a result of anatomical abnormalities or inadequate positioning. 510.5 CONTRAINDICATIONS Contraindications to the use of the EZ-IO include: 1. Ability to obtain IV access by another route (peripheral or external jugular). 2. Fracture or burns of the tibia or femur (tibial site), fracture of the humerus (humeral site). 3. Previous orthopedic procedures at or proximal to insertion site. 4. Infection at the insertion site. 5. Inability to locate landmarks. 6. Excessive tissue over the insertion site. 7. Known congenital defect of the involved bone. 8. Known bone pathology (cancer or osteoporosis). 9. Unstable thoracic injuries (sternal intraosseous only). 510.6 PROCEDURE 1. Always observe body substance isolation procedures and aseptic technique. 2. Assure that there are no contraindications present. 3. Locate the desired insertion site: (a) For the proximal tibia: Locate the patella and the tibial tuberosity. The needle will be inserted 1 cm width medial to the tibial tuberosity. (See Figure 1) Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Adults and Pediatrics EZ IO (SOG) - 266 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Adults and Pediatrics EZ IO (SOG) (b) For the proximal humerus: orient the arm at the patient’s side, firmly adducted, with the forearm flexed across the umbilicus. Locate the greater tubercle of the humerus. The needle will be inserted laterally, perpendicular to the bone at 90 degrees 4. Clean the insertion site with alcohol or betadine. (See Figure 2) 5. Prepare the EZ-IO Driver and Needle set. The needle is sterile and should remain so. The top of the needle is magnetized and will attach to the end of the driver. Once the needle is attached to the driver, remove the needle from its plastic container. 6. Twist the sterile needle cap (cover) and gently remove it from the end of the needle. Do not touch the end of the needle otherwise. 7. Place the driver in your dominant hand. Relocate your insertion site with the opposite hand. 8. Position the needle over the insertion site with the needle at a 90 degree angle to the surface of the bone. Power the needle with firm pressure thru the skin until it reaches the surface of the bone (See Figure 3). There is a 5 mm mark on the needle that should still be visible. If it is not, the procedure should be abandoned as the needle may not be long enough to penetrate the IO space. 9. If appropriate, continue the insertion, powering the needle with firm and steady pressure until the flange touches the skin or a sudden lack of resistance is felt (indicating entrance into the bone marrow cavity). 10. Remove the driver. 11. While grasping the hub with one hand, rotate the stylet counterclockwise (unscrew it) and remove it. (See Figure 4) 12. Confirm placement by aspirating 2 cc of blood. The needle should be well seated in the tibial/ humeral bone at 90 degrees. 13. Flush the needle with 10 cc of sterile saline. There should be a free flow of fluid with no leakage of fluid under the skin. Consider use of Lidocaine (40 mg adult or 0.5mg/kg for pediatric patients) prior to the flush for awake patients. 14. Attach I.V. tubing and cover with sterile dressing. (See Figure 5 and 6) 15. Apply yellow instructional wrist band to patient. 16. The EZ-IO should not be left in place for more than 24 hours. It can be removed by pulling the hub while rotating gently in a clockwise fashion. Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Adults and Pediatrics EZ IO (SOG) - 267 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Adults and Pediatrics EZ IO (SOG) Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Adults and Pediatrics EZ IO (SOG) - 268 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Adults and Pediatrics EZ IO (SOG) Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Adults and Pediatrics EZ IO (SOG) - 269 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Adults and Pediatrics EZ IO (SOG) Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Adults and Pediatrics EZ IO (SOG) - 270 Published with permission by Hanover Fire EMS  Procedure Hanover Fire EMS 511 Procedures-Guidelines Manual Rapid Sequence Intubation (RSI) (SOG) 511.1 THERAPEUTIC GOAL To establish, secure, and maintain a patent airway in a patient requiring endotracheal intubation facilitated through a rapid sequence of sedating and neuromuscular blockading medications. This Patient Care Guideline provides the procedure and medication sequence for pre-hospital Rapid Sequence Intubation.The medications described within are selected to optimize the RSI Program and provide options for maintaining the program operational status during variable situations. Department providers of RSI are selected through the recommendations of the Operations leadership and designation of the Chief of Fire EMS and the department Operational Medical Director. 511.2 EQUIPMENT 1. Basic and Advanced Airway Equipment (a) Bag-valve-mask device (b) Oxygen supply (c) Basic adjuncts (d) Suction hooked up and working correctly. 2. All equipment necessary for endotracheal intubation and confirmation of placement. (a) Video laryngoscope is preferred if available. (b) Bougie endotracheal introducer (c) Capnography 3. The medications for RSI include: (a) Sedating Medications: i. Ketamine ii. Etomidate iii. Midazolam b. Depolarizing neuromuscular blockers: succinylcholine. c. Nondepolarizing neuromuscular blockers: vecuronium and rocuronium. d. Analgesic medications: i. Fentanyl ii. Ketamine 4. Medication kits: Provider will decide best medication for patient presentation and anticipated clinical course. 1. Hanover Fire EMS RSI kit Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Rapid Sequence Intubation (RSI) (SOG) - 271 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Rapid Sequence Intubation (RSI) (SOG) i. Sedation agent: (a) Etomidate 40mg syringe (2mg/ml) x1 (b) Ketamine 200mg vial (20mg/ml)x1 ii. Initial Paralytic: (a) Succinylcholine 200mg vial x2 (b) Rocuronium 100mg vial x1 (if used, no longer term paralytic is used) iii. Long term paralytic: (a) Vecuronium 10mg x1 (needs 10ml sterile water to reconstitute) (b) Rocuronium 100mg x1 iv. Ancillary agents: (a) Atropine 1mg prefilled syringe x1 for rescue of vagal response (b) v. Syringes and needles: (a) 10ml x3 (b) 20cc x2 (c) 5cc x2 (d) 1cc x1 (e) 18 gauge fill needles 5. Rescue airway devices: (a) Supraglottic device (b) Surgical airway equipment 6. ECG monitor, pulse-oximeter and means to assess end tidal CO2. 511.3 INDICATIONS 1. Failure of airway maintenance or protection. 2. Failure of ventilation or oxygenation. 3. Anticipated clinical course (i.e. patients whose condition and airways are predicted to deteriorate, either because of dynamic and progressive changes related to the presenting condition or because of the work of breathing will become overwhelming in the face of catastrophic illness or injury). 4. Combativeness or agitation that threatens the airway and spinal cord stability. 5. Trismus. 6. Laryngospasm. 7. Prolonged seizure activity. 8. Impaired airway maintenance in combative patients secondary to illness or injury. Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Rapid Sequence Intubation (RSI) (SOG) - 272 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Rapid Sequence Intubation (RSI) (SOG) 511.4 CONTRAINDICATIONS 1. Individual medication contraindications. See medication reference for specific contraindications and reactions (a) Succinylcholine has significant side effects and contraindications to be considered 511.5 PROCEDURE 1. Perform a thorough and detailed patient assessment. Determine need for RSI based on clinical findings and anticipated clinical course. (a) Document assessment and impression (b) Detailed neurological exam is essential prior to administration of neuromuscular blockade. i. Glasgow Coma Scale ii. Stroke scale iii. Extremity pulse, movement, and sensation 2. Initiate Pre-Oxygenation: (a) Administer 100% oxygen by NRB mask at minimum, with goal to achieve nitrogen washout during procedure. (b) Apply high-flow oxygen via nasal cannula at 15lpm for oxygenation prior to and during procedure (c) If pre-oxygenation SpO2 is less than 95%, and patient’s respirations are inadequate, ventilate with BVM at 100% oxygen. 3. Monitor the patient’s heart rate, ECG, pulse oximetry, EtCO2, and blood pressure. (a) Utilize procedure benchmarks on the cardiac monitor and transfer to electronic Patient Care Report. (b) Record vital signs at least every five minutes for patients receiving RSI, more often if indicated. 4. If BVM ventilations are necessary, administer in synchrony with the patient’s natural respirations where possible and apply cricoid pressure continuously to prevent excessive gastric distention. If unable to ventilate patient and maintain oxygen saturations > 94%, place an oral adjunct and perform 2-person, 4-handed bagging technique. 5. Establish and maintain a patent, free flowing IV/IO (if this is not rapidly available, consideration for intramuscular use of medications is appropriate). (a) Optimize blood pressure prior to procedure 6. Assemble and check equipment. 7. Expect the DIFFICULT AIRWAY and evaluate patient for anticipated difficulty ventilating, performing laryngoscopy, placement of extraglottic device, and cricothyrotomy using the systematic approach mnemonics respectively: Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Rapid Sequence Intubation (RSI) (SOG) - 273 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Rapid Sequence Intubation (RSI) (SOG) (a) Look externally for obvious structural things that may make intubation difficult (i.e. - receding mandible, short, bull neck, poor dentition, facial trauma, abnormal facial anatomy, obesity, high arching palate, or large front teeth). (b) Consider obstructions and neck mobility as potential complications i. Airway destruction ii. Foreign body iii. Cervical spine stabilization (c) Maintain cervical spinal stabilization manually for trauma patients; replace cervical collar after completing intubation. 8. The RSI provider shall clearly designate the role of all personnel participating in the procedure. Teamwork is essential to the success of the procedure. Ideally, three personnel should be available, with a minimum of two cleared Advanced Life Support providers required.The RSI Paramedic is responsible for overall patient care and procedure. (a) Intubating medic: must be cleared to intubate in department and not in the field training program. (b) RSI Medic will administer medications (c) If patient is perceived to be a difficult airway, or if conditions dictate, the RSI provider may take the role of primary intubating medic and delegate medication administration to the second ALS provider. The RSI paramedic should calculate and prepare the medications prior to administration. 9. Prepare Medications (cross check all medications with your partner for correct drug and correct amount based on patient weight). Utilize quick reference sheet to calculate. All meds should be administered via the IV or IO route if available. The IM route is last option. (a) Consider pre-medication based on patient condition: 1. Fentanyl 1-3mcg/kg IV (a) Increased intracranial pressure (b) Cardiovascular disease and increased blood pressure (b) Atropine is retained for management of symptomatic bradycardia after the procedure i. 0.5 mg for bradycardia with hypotension 10. Select and Administer induction agent before paralysis. (a) Etomidate: 0.3mg/kg i. Onset: 15-45 sec; Duration: 3-12 min. ii. If septic or hypotensive (systolic BP 2days old. (c) Spinal cord injuries >2 days old. (d) Burn injuries >24hrs old. (e) Pseudocholinesterase deficiencies. (f) Known history of malignant hyperthermia. (g) Neuromuscular disorders (e.g., muscular dystrophy). (h) Penetrating eye injuries. (b) Rocuronium 1.0mg/kg (Tier 2 adults, Tier 1 pediatrics) i. Onset: 55-70 sec; Duration: 30-60 min (Rocuronium) ii. Thorough neuro exam essential prior to administration iii. Anticipate extended support of airway and ventilation and provide appropriate repeat dose of sedation and analgesia 12. Await flaccid paralysis or adequate relaxation. (a) Evaluate eyelash response and mandible tension 13. Intubate and place endotracheal tube per standard of practice. Confirm visually. Utilize the bougie introducer for all RSI procedures. The most experienced ALS provider on scene should perform the intubation if not the RSI paramedic. 14. Limit intubation attempts to avoid hypoxia. If oxygen saturation drops below 92% during procedure, stop procedure and provide support of oxygenation and ventilation. Maintain oxygen via nasal cannula at 15 lpm during attempt. 15. If FIRST attempt by the second ALS provider is not successful, the RSI paramedic shall perform all subsequent attempts. The RSI provider may perform TWO attempts and then a rescue airway device must be placed. (a) Ventilate the patient and prepare for another attempt (consider changing equipment or position or utilizing assistive devices such as the Bougie or maneuvers such as External Laryngeal Manipulation). Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Rapid Sequence Intubation (RSI) (SOG) - 275 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Rapid Sequence Intubation (RSI) (SOG) (b) Re-medicate the patient if required. 16. Confirm endotracheal placement of tube via waveform capnography (a) Optimize oxygenation and ventilation, titrating ventilation rate to maintain SaO2 of 96-98% and End-tidal CO2 of 35-45mmHg. (b) Document additional clinical confirmation findings per procedure standards (c) Document depth and landmark 17. Post-Intubation Management: (a) Secure endotracheal tube with commercial tube holder (b) Document depth and landmark (c) Place cervical collar to limit movement (d) Consider placement of gastric (OG/NG) tube to decompress stomach contents if available 18. Consider additional sedation and paralysis if indicated (avoid long-acting paralysis in patients who are at risk for seizures or whose neurologic exam may be changing if it is deemed safe to do so). (a) If Rocuronium is administered as the primary paralytic for RSI, then NO ADDITIONAL PARALYTIC MAY BE ADMINISTERED DURING TRANSPORT. (b) Medication considerations include: i. Duration of action of initial medications ii. Patient hemodynamics iii. Transport time (c) Signs of inadequate sedation and/or pain control include i. Tachycardia ii. Hypertension iii. Tearing at eyes 19. Sedation and Analgesia medications: Provider will determiine best medication for patient presentation and clinical course. (a) Midazolam 2-5mg IV i. Reduce dose or avoid if systolic BP is less than 100mmHg (b) Fentanyl 1-3mcg/kg i. From ODEMSA medication kit ii. Consider for extended transport or hypotensive patients (c) Etomidate 0.1mg/kg i. Dose to balance of available medication Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Rapid Sequence Intubation (RSI) (SOG) - 276 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Rapid Sequence Intubation (RSI) (SOG) ii. Consider for hypotensive patients, asthmatics, and trauma (d) Ketamine 1mg/kg i. Dose to balance of available medication ii. Used for rapid sedation if patient suddenly wakes and jeopardizes airway 20. Long term paralytics: Consider only if succinylcholine used as initial paralytic and patient is sedated. If transport times are short do not administer. Clearly communicate time of last paralytic to receiving facility. (a) Vecuronium 0.1mg/kg IV (b) Rocuronium 1.0mg/kg IV 21. Record vital signs every five minutes and re-verify endotracheal tube placement with each movement. 22. If intubation is unsuccessful after 2-3 attempts: (a) Consider placement of a rescue airway device (ex. I-Gel). (b) Consider maintaining a BLS airway for the duration of the transport. 23. If intubation attempts are unsuccessful and BVM ventilation is ineffective: (a) Consider surgical cricothyroidotomy (adults). (b) Consider needle cricothyroidotomy (pediatric). 24. Special Considerations: (a) Pediatrics i. Consider ONLY if skill set of RSI Paramedic and crew matches to the situation ii. The most experienced provider available should perform the intubation iii. Obtain on line medical control from appropriate facility. iv. Maintain standard dosage per kilogram. v. Vecuronium will metabolize much faster in pediatrics (b) Geriatrics i. Consider potential electrolyte imbalances that may contraindicate Succinylcholine. ii. Lower dosages of paralytics may be appropriate due to decreased renal or hepatic function. iii. Contact medical control (c) Tactical EMS Providers (approved by the Operational Medical Director) i. Consider sedation per protocol, if available. (a) Midazolam 0.05-0.1 mg/kg IV every 3-5 minutes. (Usual adult dosage is 2-4mg IV). Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Rapid Sequence Intubation (RSI) (SOG) - 277 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Rapid Sequence Intubation (RSI) (SOG) (b) Second tier as approved through ODEMSA regional medication list. ii. Consider pain management per protocol, if available. (a) Fentanyl 1-2 mcg/kg slow IVP (may repeat in 10 minutes, titrated to effect). (b) d. Consider Half dosing sedation/induction medications for patients that are hemodynamically unstable (i.e. Systolic BP < 90.) 25. Transport considerations: (a) Patients should be transported to the most appropriate facility for the clinical problem (b) Notify receiving facility of the need for ventilator and additional sedation (c) RSI patients should remain on the EMS cardiac monitor until physically transferred to the hospital stretcher (d) Verification of ET placement should occur before and after movement via waveform capnography (e) The Microstream EtCO2 adapter used by the department is compatible with most receiving hospital Capnography monitors and should be transferred to the hospital. (f) The RSI Paramedic should present the case and circumstance to the attending emergency physician (g) If any conflict or complications develop: failed intubation, esophageal intubation, death of patient; notify the RSI Coordinator and OMD immediately i. If receiving physician questions RSI care, please involve the OMD with any physician conflicts. 26. Notification and Documentation: (a) If an RSI is performed, the on-scene personnel should notify the Emergency Communications Center via radio in order to create a recorded benchmark and CAD note i. ECC benchmarks include “RSI complete” (b) Notification order. i. Battalion Chief, by radio or ECC if not on scene ii. Rideboard form completion iii. Operations Assistant Chief (same day by Battalion Chief). iv. County OMD (same day by pager, phone, or e-mail) v. RSI Coordinator for QA and follow up. (c) Documentation in electronic Patient Care Report i. Indication for procedure. ii. Vital signs (including pulse-oximetry) before, during and after procedure. Copyright Lexipol, LLC 2024/05/01, All Rights Reserved. Rapid Sequence Intubation (RSI) (SOG) - 278 Published with permission by Hanover Fire EMS  Hanover Fire EMS Procedures-Guidelines Manual Procedures-Guidelines Manual Rapid Sequence Intubation (RSI) (SOG) iii. Medications, routes and doses. iv. Verification of proper placement of ETT including size and depth. End tidal CO2 is absolutely mandatory. v. An attached printed EtCO2 waveform corresponding to the patient post- intubation. vi. Report by AIC: interventions must reflect RSI Paramedic’s participation. vii. RSI report form must be filled out by the RSI provider 1. RSI report form must be signed by receiving physician and returned to Logistics with used RSI kit 2. This is part of the department’s pharmacy record and retained as dictated by the Board of Pharmacy for accountability of all controlled substances. 3. A c