Transcript Westchester Regional EMS Program Medical Control Physician

Westchester Regional
Emergency Medical Services
On-line Medical Control
Physician Course
& Regional System Overview
Revised September 2006 in accordance with DOH and REMAC requirements for online medical control
Katherine O’Connor, BS, EMT-P, Regional Program Coordinator
Sep 2006 Version
1
Course Objectives
This program will be reviewing:
 the components of the Westchester Regional EMS
System.
 the role and structure of the Regional EMS Council,
Program Agency, and REMAC
 the Quality Improvement (QI) Process for EMS
 the role of Medical Control (on and off line)
 New York State and Westchester Regional EMS
protocols and policies
 the process to obtain and retain Online Medical
Control credentials in the Westchester Region
Sep 2006 Version
Westchester REMAC OLMC System Overview
2
Westchester Regional
Emergency Medical Services System
Sep 2006 Version
Westchester REMAC OLMC System Overview
3
The Regional EMS System
□ The Region is co-terminus with the
County of Westchester, covering an
area of 450 square miles and almost
one million residents
□ The Regional EMS System is an
amalgam of volunteer and career
providers, independent and fire service
based organizations
□ There are 11 Medical Control Hospitals
□ Combined EMS Call Volume in
Westchester is over 100,000 per year.
Sep 2006 Version
Westchester REMAC OLMC System Overview
4
The Regional EMS System
□ Levels of EMS Operations:
□ Basic Life Support First Response (BLSFR) – 33
□ Mostly fire and police based services
□ CPR, Certified First Responder (CFR) and EMT level trained
providers
□ Non-certified EMS, Non-transport
□ Advanced Life Support First Response (ALSFR) – 2
□ NYS Certified EMS service – non-transport
□ Paramedic Staffed
□ Ambulance (ALS and BLS) – 43
□ NYS Certified EMS service - transport
□ BLS Ambulance (EMT-B level of care)- 28
□ ALS Ambulance (EMT-I / EMT-P) - 15
Sep 2006 Version
Westchester REMAC OLMC System Overview
5
The Regional EMS System
□ Levels of Hospital Operations:
□ Medical Control Hospitals – (11)
□ Provide on-line medical control to all levels of EMS providers
□ Must meet requirements found in Medical Control Plan
□ Representatives are voting members of REMAC
□ 911 Receiving Hospitals – (None currently in region)
□ Accepts acute emergency patients via ambulance, but does not
provide on-line medical control
□ Does not meet criteria for Medical Control Hospital
□ Status automatically given to hospitals out-of-region
□ Cannot vote on REMAC
□ Special Resource Hospital – (One as of 8/1/2006)
□ Out-of-region hospital facility approved by the REMAC to give
OLMC to Westchester Regional EMS providers due to an identified
need for additional resources in a given response area
□ Must meet requirements found in Medical Control Plan
□ Does not vote on REMAC
Sep 2006 Version
Westchester REMAC OLMC System Overview
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Regional EMS Council
□ Created by law in 2000; Established by NYS
DOH Commissioner in June 2001
□ Developed in accordance with NYS Public
Health Law (Article 30) and NYS DOH
guidelines, in order to assist in the development
and maintenance of the EMS System, through
facilitation, coordination and provision of
technical assistance.
□ Made up of members of various EMS
stakeholders throughout the region.
□ The Program Agency and the Regional
Emergency Medical Advisory Committee
(REMAC) work in conjunction with the Regional
EMS council.
Sep 2006 Version
Westchester REMAC OLMC System Overview
7
Regional Program Agency
□ Westchester County Department of
Emergency Services, EMS Division
□ Identified by the Regional EMS Council to
the NYS DOH
□ Contractually responsible for supporting,
maintaining and improving emergency
medical care in the region.
□ Operates the Regional EMS Office
□ Provides staff for all Regional EMS Council
activities
□ Facilitates Quality Improvement with
REMAC
□ Provides educational programs for
providers and medical control physicians.
Sep 2006 Version
Westchester REMAC OLMC System Overview
8
Regional Emergency Medical
Advisory Committee
□ The Regional Emergency Medical Advisory Committee
(REMAC) is comprised of physician representatives
from each of the Medical Control facilities and nonvoting individuals representing the following;
•Medical specialties (3) •Fire service (2)
•Pediatrics
•Psychiatry
•Trauma
•Career
•Volunteer
•EMS organizations (3)
•Public Safety (1)
•Municipal
•Proprietary
•Volunteer
Sep 2006 Version
Westchester REMAC OLMC System Overview
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REMAC
REMAC OFFICERS
REMAC Chair
SEMAC Representative
SEMAC Alternate
NON-VOTING MEMBERS
Dr. Nicholas DeRobertis □ Medical Specialty (Trauma)
- VACANT
Dr. Timothy Haydock
□ Medical Specialty (Pediatrics)
Pending
- Dr. Joli Yuknek (WPHC)
□ Medical Specialty (Psychiatry)
MC HOSPITALS & REPRESENTATIVES (Voting)
- Dr. Richard Gallagher (WMC)
□ Dobbs Ferry Comm. Hospital - Dr. Mark Silberman □ EMS - Municipal
- VACANT
□ Hudson Valley Hospital Ctr - Dr. John McGurty
□ EMS – Proprietary
□ Lawrence Hospital - Dr. Carlos Flores
- VACANT
□ Mt. Vernon Hospital - Dr. Karlene Chin
□ EMS – Voluntary
□ No. Westchester Hospital Ctr - Dr. Robert Marcus
- Roland Faucher (MVFAVAC)
□ Phelps Memorial Hospital - Dr. Emil Nigro
□ Fire – Career
- VACANT
□ Sound Shore Medical Ctr - Dr. Lawrence Klecatsky
□ Fire – Volunteer
□ St. John's Riverside Hospital - Dr. Richard Marino
- VACANT
□ St. Joseph's Medical Ctr - Dr. Nicholas DeRobertis
□ Public Safety
□ Westchester Medical Ctr - Dr. David Goldwag
- Police Chief Anthony Chiarlitti
(Pleasantville PD)
□ White Plains Medical Ctr - Dr. Timothy Haydock
(As of 9/2006)
Sep 2006 Version
Westchester REMAC OLMC System Overview
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REMAC
As per NYS PHL Article 30, the REMAC is responsible for
many functions of the regional EMS system, including
the following:
□Establish prehospital standards consistent with current
emergency medical practices.
□Educate /credential physicians to provide online medical
control.
□Ensure availability / quality of EMS educational programs.
□Coordinate development of the regional medical control
system.
□Define roles/responsibilities of REMAC physicians
□Develop medical control policies / procedures / protocols for
EMS dispatch, triage, treatment and transport.
□Develop and implement research projects and studies.
□Assist in the coordination of the QI program.
Sep 2006 Version
Westchester REMAC OLMC System Overview
11
Westchester Regional
Quality Improvement (QI)
Sep 2006 Version
Westchester REMAC OLMC System Overview
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Quality Improvement (QI)
& EMS
□ QI Programs are REQUIRED for EMS
□ NYS PUBLIC HEALTH LAW ARTICLE 30 SECTION 3006.
□ ALL certified EMS agencies
□ Ambulance Services
□ Advanced First Responder (ALS FR)
□ Westchester REMAC Policy 04-05
□ Outlines committee structures
□ Lists review topics
□ Report submission criteria
Sep 2006 Version
Westchester REMAC OLMC System Overview
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Hospital Role & EMS QI
Requirements for hospital participation in pre-hospital QI can be
found in:
□ Article 28 – NYS PHL, Hospitals
□ 405 Regulations, NYS Hospital Code (Section 405.19)
□ Chapter VI of Title 10 (Health) – Part 80 – Rules and Regulations
on Controlled Substances
□ Joint Commission on Accreditation
of Healthcare Organizations (JCAHO)
□ Consolidated Omnibus Budget
Reconciliation Act (COBRA)
Sep 2006 Version
Westchester REMAC OLMC System Overview
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Hospital Role & EMS QI
In supporting EMS QI, hospitals should:
□ Ensure adequate QI training and familiarity with WREMAC QI
Guidelines of all emergency department physician and
nursing staff
□ Develop and implement an effective QI program for
continuous system and patient care improvement
□ Direct and facilitate an on-going review of the medical control
system and QI program.
□ Report any EMS personnel or
ALS agency complaint, protocol violation
or lack of cooperation with other aspects
of medical control and or quality
improvement activities
Sep 2006 Version
Westchester REMAC OLMC System Overview
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QI & EMS:
What OLMC Physicians Should Know
□ While each ED physician shouldn’t
know each and every EMS protocol
verbatim, physicians should know
some background about the protocols
in the region and where to look if
he/she has any questions.
□ Additionally, there are items that MUST
be immediately reported to the
Emergency Department Director or
EMS Liaison.
Sep 2006 Version
Westchester REMAC OLMC System Overview
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QI & EMS:
Reportable Events
□
A Medical Control Physician should advise his or
her Emergency Department Director of any
violation of prehospital protocols or standards of
care.
□ While the majority of QI issues are usually handled
on an agency level with the Service Medical
Director, reportable events should
be referred to the Regional EMS Office and
the REMAC.
Sep 2006 Version
Westchester REMAC OLMC System Overview
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QI & EMS:
Reportable Events
□ These types of protocol or treatment violations
will result in an immediate investigation by the
Regional EMS Office and REMAC:
□ Unrecognized Esophageal Intubation.
□ Practicing without NYS certification / Regional
Credentials.
□ Patient Abandonment.
□ Medication Errors.
□ Any other situation that places the patient in
danger.
Sep 2006 Version
Westchester REMAC OLMC System Overview
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Westchester Regional
Medical Control System
Sep 2006 Version
Westchester REMAC OLMC System Overview
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Perspectives on
Medical Control / Direction
□ American College Of Emergency Physicians
(ACEP)
□ Policy on Medical Direction:
□ All aspects of organizing and providing basic and
advanced emergency medical service requires
active participation and involvement of
physicians.
□ Medical Director has authority over all aspects of
the EMS System, including, but not limited to online and off-line medical direction.
□ Every service that provides advanced level life
support must have an identifiable medical director
that is a physician at the agency, region and state
levels.
Sep 2006 Version
Westchester REMAC OLMC System Overview
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Perspectives on
Medical Control / Direction
□ National Association of EMS Physicians
(NAEMSP)
□ Position Statement on Physician Medical Direction
of EMS
□ Authority and responsibilities of a medical
director will depend on the specific system
structure, community needs and resources, etc
□ Medical direction should be integrated
throughout the EMS system and have the
ability to offer prospective, concurrent and
retrospective influence
Sep 2006 Version
Westchester REMAC OLMC System Overview
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EMS Medical Direction in NYS
□ NYSDOH Policy Statement
03-07: Providing Medical
Direction
□ Reviews Agency Level Direction
□ NYSDOH Policy Statement
95-01: Medical Control
□ Clarifies roles and responsibilities in
the development and provision of
medical control in the prehospital
environment.
Sep 2006 Version
Westchester REMAC OLMC System Overview
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EMS Medical Direction in NYS
PHILOSOPHY OF MEDICAL OVERSIGHT
NYS Commissioner
of Health
SEMSCO / SEMAC
REMSCO(s) / REMAC(s)
Service
Medical Director(s)
Medical Control
Online
(Direct)
Sep 2006 Version
Westchester REMAC OLMC System Overview
Offline
(Indirect)
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Medical Direction
□ Three Parts:
□ Prospective
(Off-line medical direction)
□ Concurrent
(On-line medical direction)
□ Retrospective
(Off-line medical direction)
Sep 2006 Version
Westchester REMAC OLMC System Overview
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Prospective Direction
• Prospective Medical Direction is done
through the following:
• Training and Testing
• Continuing Medical Education (CME’s)
• Protocol Development
• Policy and Procedure
Development
• QI Programs
Sep 2006 Version
Westchester REMAC OLMC System Overview
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Concurrent Direction
□ Concurrent Medical Direction is usually
provided via the Medical Control Physician
through:
□ Telemetry
□ Radio
□ Phone
(Cellular or landline)
□ On scene
Sep 2006 Version
Westchester REMAC OLMC System Overview
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Retrospective Direction
□ Retrospective Medical Direction
is instituted via:
□ Call audits and reviews
□ “Bed-side” Call Audits
(one-on-one)
□ “Ground Rounds” Style
(group setting)
□ Remedial education
□ Corrective action
□ QI Programs
Sep 2006 Version
Westchester REMAC OLMC System Overview
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Protocols
New York State
Basic Life Support (BLS)
Sep 2006 Version
Westchester REMAC OLMC System Overview
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NYS BLS Protocols
□ Developed by State EMS Council and
NYSDOH
□ Applies to:
□ EMT-Basic
□ Advanced EMT Providers
□ Basic Standard of Care for EMS
Sep 2006 Version
Westchester REMAC OLMC System Overview
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NYS BLS Protocols
Directives to contact Medical Control:
□ Confer regarding transport decisions when
necessary
(for all protocols)
□ Swallowed poisons
(for instructions for treatment)
□ Any time EMT requires direction / advice
Sep 2006 Version
Westchester REMAC OLMC System Overview
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Protocols
Westchester Regional
Basic Life Support (BLS)
Special Procedures
Sep 2006 Version
Westchester REMAC OLMC System Overview
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BLS Special Procedure
Protocols
□ Developed by Westchester REMAC in
conjunction with protocols and polices
developed by SEMAC/SEMSCO and NYSDOH
□ EMS Agency applies to REMAC for notification
or approval (as required)
□ Only specially trained providers working within
approved agencies can perform skills:
□ Epi-Pen
□ Nebulized Albuterol
□ Mark I Kit
Sep 2006 Version
Westchester REMAC OLMC System Overview
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BLS Special Procedure
Protocols
Directives to contact Medical Control:
□ Nebulized Albuterol
□ Must contact prior to administration for Pts w/
history of angina, MI, arrhythmia, or CHF
□ Epi-Pen Administration
□ Must contact if Pt has not had an
epinephrine auto-injector previously
prescribed
□ Mark I Kit
□ Possible identification / notification of a
WMD event
□ Must have contact prior to pediatric
administration
Sep 2006 Version
Westchester REMAC OLMC System Overview
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Protocols
Westchester Regional
EMT – Intermediate (EMT-I)
Sep 2006 Version
Westchester REMAC OLMC System Overview
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EMT-I Protocols
□ Developed and revised by the REMAC.
□ Protocols establish medically sound algorithms for
provision of Intermediate Life Support (ILS) care in the
field.
□ EMT-I providers may perform limited ALS interventions
based on patient presentation (for both adult and
pediatric patients)
□ Endotracheal Intubation (ETT)
□ Intravenous (IV) catheterization for fluid resuscitation
NOTE : EMT-Is are NOT to initiate ALS care without requesting
Paramedic response
□ Protocol handbooks are available to each credentialed
EMT-I provider, and should be in each ILS equipped
vehicle and Medical Control or Special Resource Hospital
in the region.
Sep 2006 Version
Westchester REMAC OLMC System Overview
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EMT-I Protocols
Directives to contact Medical Control:
□ IV Therapy (Adult)
□ Additional fluid bolus of Normal Saline above the
1000 cc limit under standing orders.
NOTE : EMT-Is are NOT to initiate ALS care without
requesting Paramedic response. If the patient is
transported to the hospital after receiving ALS care
from an EMT-I without a Paramedic on board, THIS
IS A REPORTABLE INCIDENT AND SUBJECT TO
QI REVIEW whether or not extenuating
circumstances may have made the transport
necessary.
Sep 2006 Version
Westchester REMAC OLMC System Overview
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Protocols
Westchester Regional
EMT-Paramedic (EMT-P)
Sep 2006 Version
Westchester REMAC OLMC System Overview
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Paramedic Protocols
□ Developed and revised by the REMAC.
□ Protocols establish medically sound
algorithms for provision of Paramediclevel Advanced Life Support (ALS) care
in the field.
□ Protocol handbooks are available to
each Paramedic and Medical Control
Physician, and should be in each ALS
equipped vehicle, as well as all
Westchester Medical Control and
Special Resource Hospitals.
Sep 2006 Version
Westchester REMAC OLMC System Overview
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Paramedic Protocols
□ Paramedics ARE NOT allowed to deviate from
the protocols unless directed by a Westchester
REMAC Authorized Medical Control Physician.
□ Clinical judgment is allowed where a patient
does not exactly fit any one particular protocol.
□ OLMC may authorize alternative treatment IF it
falls within the boundaries of the NYS and/or
Regional protocols AND the scope of practice of
a paramedic in New York State.
□ All Medical Control Physicians must
pass an exam based on the
Paramedic Protocols
Sep 2006 Version
Westchester REMAC OLMC System Overview
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SPECIAL SITUATIONS
Sep 2006 Version
Westchester REMAC OLMC System Overview
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Special Situations
□ Do Not Resuscitate (DNR)
□ Termination of Resuscitation
(Paramedic Protocol 15)
□ Pronouncement of Death
(REMAC Policy 01-01)
□ Refusal of Medical Assistance (RMA)
□ “By-stander” Physician On Scene
□ Transfer of Care (ALS to BLS)
□ Specialty Care Centers
□ Transportation to an Out-of-Region Facility
Sep 2006 Version
Westchester REMAC OLMC System Overview
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Do Not Resuscitate (DNR)
□ Non-hospital DNR orders are
allowed by Chapter 370 of the
New York State Laws of 1991.
□ NYSDOH
Policy Statement 99-10:
FAQs Re DNRs
Sep 2006 Version
Westchester REMAC OLMC System Overview
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DNR
□ Non-hospital DNR – A physician signed, non-hospital DNR
order on the NYS form MUST be available to EMS on
scene to be honored.
□ NOTE: A non-hospital order may be expired, but MUST
be signed.
□ Hospital DNR - Article 28 licensed facilities (i.e. skilled
nursing homes) are required to issue, review and maintain
DNR orders. EMS providers may honor hospital DNR orders
for patient transports from the facility. The facility staff
MUST provide a copy of the order and/or patient's chart
with the recorded DNR order to the ambulance crew to
be honored.
□ NOTE: A hospital DNR order CAN NOT be expired.
□ A living will, health care proxy or other advanced care
directives ARE NOT valid in the prehospital setting.
Sep 2006 Version
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DNR
□ The following are circumstances that an EMS Provider
may DISREGARD a DNR order:
□ Reasonable evidence exists that suggests that the
DNR Order has been revoked or cancelled.
□ Patient is conscious, and states that they want
resuscitative measures, the DNR should be ignored.
□ Patient is unable to state his/her desire, a family
member present requests resuscitative measures
for the patient, and a confrontational situation is
likely to result if the request is denied.
□ A physician requests that the order be
disregarded.
□ An Out-of-Hospital DNR is NOT SIGNED by the
ordering physician
□ An Article 28 facility DNR order is EXPIRED
Sep 2006 Version
Westchester REMAC OLMC System Overview
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DNR: What can be done?
□ A DNR is ONLY an order not to perform
resuscitation in the event of cardiac or
pulmonary arrest – IT DOES NOT INFER THAT
ANY OTHER TREATMENT IS TO BE WITHHELD.
□ If a valid DNR exists, AND the patient is in
respiratory or cardiac arrest:
□ NO :
□ Chest compressions
□ Ventilations
□ Defibrillation
□ Endotracheal Intubation
□ Medication administration
Sep 2006 Version
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DNR: What can be done?
□ If a valid DNR exists, AND the patient is NOT in cardiac or
respiratory arrest:
□ Appropriate treatment for all injuries, pain, difficult or
insufficient breathing, hemorrhage and/or other
medical conditions MUST be provided.
□ Relief of choking caused by a foreign body is
appropriate, but if breathing has stopped, ventilations
should not be assisted.
□ For unusual circumstances or questions on individual
patient circumstances, the EMS provider will
contact On-line Medical Control.
Sep 2006 Version
Westchester REMAC OLMC System Overview
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Termination of Resuscitation
Paramedics may contact On-line Medical Control and
request approval to terminate resuscitation efforts if
following 20 - 30 minutes application of
ACLS to a
continuous and documented pulseless, non-traumatic adult
cardiac arrest, which includes:
□ Advanced airway control (ie ET, Combi-tube)
providing effective oxygenation and ventilation.
□ VT/VF shocked when present.
□ IV access achieved and antiarrhythmics
administered as appropriate.
□ All reversible causes or special resuscitation
circumstances have been considered,
searched for, and corrected.
Sep 2006 Version
Westchester REMAC OLMC System Overview
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Termination of Resuscitation
Termination of Resuscitation MAY NOT be
requested or conducted if:
□ Profound hypothermia is present.
□ Toxin or drug ingestion is suspected or
documented.
□ Communication failure prevents contact
with On-line Medical Control
□ An environmental situation is not
conducive to termination.
Sep 2006 Version
Westchester REMAC OLMC System Overview
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Termination of Resuscitation
□ If Medical Control provides the order to terminate
resuscitative efforts:
□ The Paramedic is to leave all ALS adjuncts in place
□ The body is left in the custody of the Police onscene, who will contact the Medical Examiner’s
Office
□ A PCR is completed by the Paramedic and brought
to the hospital to have it signed by the ordering
Medical Control Physician. A copy of the PCR
should be left at the hospital for the ED Director.
□ EMS should transport the body to the hospital if:
□ The arrest occurred in a public place.
□ No police agency is present to take custody
□ The family is requesting transport
Sep 2006 Version
Westchester REMAC OLMC System Overview
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Pronouncement of Death
□ REMAC Policy 01-01: Pronouncement of Death
□ Clarifies difference between:
□ Pronouncement of Death
□ process of recognition and documentation
of the physical signs of death - basis of the
decision not to engage in resuscitation efforts
□ Certification of Death
□ legal documentation required at the end of
a life - concise and complete statement of
the terminal event and its causes, witnessed
by the signature of a physician as per NYS
Public Health Law.
Sep 2006 Version
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Pronouncement of Death
□ REMAC Policy 01-01: Pronouncement of Death
(cont’d)
□ Reviews reporting of out of hospital deaths to
Police and Medical Examiners office
□ Directs body to remain on scene with Police
until removal has been effectuated by ME or
funeral director
NOTE: Due to special situations EMS may be
ordered to transport the body to the closest
hospital if, in the judgment of the Police,
expedient removal of the corpse is
necessary.
Sep 2006 Version
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Pronouncement of Death
□ EMS Must Document “Obvious Death” - In
addition to apnea and pulselessness, one or
more of following conditions MUST exist:
□ Tissue decomposition
□ Rigor mortis
□ Extreme dependent lividity
□ Obvious mortal injury (decapitation,
exsanguination, etc.)
□ A Valid Do Not Resuscitate (DNR) order
□ Also EMS should attempt to determine:
□ Confirmation with an AED that “No Shock
Advised” or presence of asystole in more
than one ECG lead
□ Any significant medical history or traumatic
event
□ Time lapse since patient was last seen alive
Sep 2006 Version
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Pronouncement of Death
□ As with any patient, EMS can contact OnLine Medical Control for consultation if
there are questions regarding the patient’s
presentation and the decision not to
attempt resuscitation.
Sep 2006 Version
Westchester REMAC OLMC System Overview
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Patient Refusals of Medical
Assistance/Transport (RMA)
□ Often, EMS providers are faced with
individuals that, for a number of reasons,
refuse medical care.
□ Recently, the NYS Department of Health has
updated its position on RMAs to allow for
the most appropriate use of resources.
□ EMS are no longer required to complete a refusal
on those patients that have no complaint.
□ A PCR must still be completed for that call
describing the details and interaction with the
individuals at the scene.
□ However, any incident with a mechanism of
injury (MOI) that indicates that the patient
could be injured, even without complaint,
requires that a refusal be completed.
Sep 2006 Version
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RMAs
□ RMAs MAY NOT be EMS initiated
□ “You don’t want to go to the hospital, do you?”
□ Providers are urged to make every effort to
encourage, but not force, patients to be
transported.
□ If a patient is unwilling to go, the provider may
ask family/friends to encourage the patient to go
□ If ALS care is indicated, or has been initiated, and
the patient is still refusing transport to
the hospital, OLMC MUST be contacted,
and the physician allowed the
opportunity to speak to the patient.
Sep 2006 Version
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RMAs
□ If the patient is still unwilling to be transported,
then the patient may refuse care, given the
following:
□ Patient is over the age of 18, or is an emancipated
minor, or the mother of a child.
□ Alert and oriented X 3/GCS of 15.
□ Suicide has not been attempted/threatened.
□ EMS has ruled out the potential for serious illness or
child abuse when the patient’s parent or guardian is
refusing care
Sep 2006 Version
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RMAs
□ A Patient CANNOT refuse if:
□ He or she has an altered mental status
□ He or she is suicidal
□ The potential for child abuse exists
□ If these situations exist:
□ EMS is to contact Medical Control
□ Law enforcement assistance is to be requested if
necessary.
□ EMS providers are not to let themselves be
placed in a dangerous situation attempting
to obtain a refusal, if the potential exists, the
crew is to withdraw to a safe area and await
law enforcement assistance
Sep 2006 Version
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RMAs
□ If patients meets criteria, then they can
refuse. EMS Providers must:
□ Perform and document at least 2 sets of vital
signs (with patient permission)
□ Inform patient of all possible negative
consequences of refusal AMA
□ Encourage patient to call EMS again if
anything changes or as needed.
□ Have patient read and sign PCR refusal
section
□ Have a witness sign the PCR refusal section
(not a crew member if at all possible)
□ Document any consultations with On-line
Medical Control (MD/DO name, facility)
Sep 2006 Version
Westchester REMAC OLMC System Overview
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“By-stander” Physician
On Scene
Occasionally, a physician will present at an EMS scene
offering his/her assistance and seeking to direct patient
care:
□ Personal physicians (whose relationship with the
patient can be verified at the scene) may
assume medical control if he/she desires, without
prior consultation of OLMC.
Note: EMS should still contact OLMC to advise of
the presence of this physician.
□ A “By-stander” physician (a doctor without a
professional relationship with the patient),
MAY NOT assume medical control WITHOUT
permission from OLMC.
Sep 2006 Version
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“By-stander” Physician
On-Scene
If a “By-stander” Physician on scene is seeking to direct
patient care:
□ EMS will contact On-line Medical Control and
have the physicians speak to one another.
NOTE: Direction may not be assumed if there is a
communications failure.
□ On-line Medical Control will then determine if
the “By-stander” physician will be allowed to
provide direction to the EMS on the scene
Sep 2006 Version
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“By-stander” Physician
On-Scene
□ If given permission by OLMC to direct patient care:
□ The “By-stander” physician will be required to sign the
“Physician Release Form” (found in the Paramedic Protocols),
assuming all liability for the care of the patient and
indemnifying the EMS crew from responsibility
□ Any care requested that falls outside of the protocols or
scope of practice of the EMS providers on the scene must
be completed by the “By-stander” physician with his or her
own equipment
□ The “By-stander” physician MUST accompany the EMS
crew to the hospital in the ambulance.
□ ON-LINE MEDICAL CONTROL MAY RE-ESTABLISH AUTHORITY
AT ANY TIME.
Sep 2006 Version
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Transfer of Care
ALS providers are authorized to transfer care to a lower
level provider (EMT-P to EMT-B or EMT-I; EMT-I to EMT-B)
ONLY if an ALS assessment has been performed,
AND:
□ Neither the nature of illness (NOI) or mechanism of
injury (MOI) indicates that there is a current need
OR an anticipated need for ALS.
□ The physical assessment indicates that there is
neither a current need OR an anticipated need for
ALS.
□ No invasive ALS procedures have been initiated
NOTE: Either the ALS or BLS provider may contact
OLMC to confirm this decision.
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Specialty Care Centers
□ New York State Department of Health (NYSDOH)
has designated certain hospitals as Specialty
Care Centers.
□ Some of these designations require active
diversion of patients by EMS to those facilities
based on patient presentation and onset of
illness or injury.
□ Patients who are experiencing the following
acute morbidities are must be transported to a
Specialty Care Center:
□ Trauma
□ Stroke
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Specialty Care Centers
□ Hospitals that have been designated Specialty
Care Centers in the Westchester Region are:
□ Trauma Centers
□ Regional Trauma Center (Level I)
□ Westchester Medical Center
□ Area Trauma Center (Level II)
□ Sound Shore Medical Center
□ Stroke Centers (As of 9/2006 - other regional hospitals are in the
process of seeking Stroke Center designation.)
□
□
□
□
□
□
Hudson Valley Hospital Center
Mt. Vernon Hospital
Northern Westchester Hospital Center
Sound Shore Medical Center
Westchester Medical Center
White Plains Hospital Center
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Specialty Care Centers:
Trauma Centers
Transport to a NYS designated Trauma center is
based on an algorithm using:
□ Physiological presentation
□ GCS < 13
□ BP < 90
□ RR <10 or <29
□ Anatomy of injury
□ Mechanism of injury
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Specialty Care Centers:
Trauma Centers
Automatic Criteria
□ <12 years old
□ Thoracic Injury w/shock or respiratory distress
□ Limb amputation/severe crush injury
□ Spinal Trauma w/ hemi or paraplegia
□ Unstable multi-systems trauma w/open pelvis
fracture
□ Burns – facial, airway, electrical, >15% BSA
Special Considerations
□ <5 or >55 years old
□ Cardiac / respiratory distress
□ Pregnant
□ Immuniosupressed
□ Bleeding disorder
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Specialty Care Centers:
Trauma Centers
Transport of a trauma patient meeting Trauma
Center criteria to the closest appropriate hospital is
REQUIRED if:
□ Cardiac arrest
□ Unmanageable airway
□ Transport time from injury to arrival at Trauma
Center is greater than 1 hour
□ On-line Medical Control so directs
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Specialty Care Centers:
Stroke Centers
Transport to a NYS designated Stroke Center is
REQUIRED if:
□ Positive Cincinnati Stroke Scale assessment
(1 or more signs present)
□ Facial Droop
□ Arm Drift
□ Abnormal Speech
□ Transport time from onset of symptoms to
arrival at a designated Stroke Center is less
than 2 hours
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Specialty Care Centers:
Stroke Centers
Patients meeting Stroke Center criteria MUST be
transported to closest appropriate hospital
emergency department (ED) if:
□ Cardiac arrest
□ Unmanageable airway
□ Other medical condition(s) warrant(s) transport to
the closest appropriate ED as per NYS and/ or
Regional protocol
□ Time from onset of stroke symptoms to arrival
at a Stroke Center is greater than 2 hours
□ On-line Medical Control so directs
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Transportation to
an Out-of-Region Facility
(Not a Special Resource Hospital)
□
□
Due to geographical variables and transportation concerns
around the region, there may be occasions where EMS may
transport a patient from an emergency scene to a hospital
outside of the Westchester Region that is not authorized to
provide On-line Medical Control.
If Medical Control Orders are needed for management of a
patient being transported to one of these facilities, a
Westchester based OLMC Physician must be
contacted to provide on-line direction.
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Transportation to
an Out-of-Region Facility
□
When OLMC is contacted:
□
If transport out-of-region is due to patient’s choice, OLMC
should first determine if patient's status permits transport to the
facility of choice, or if the patient should be directed to a
different, more appropriate facility, per Westchester REMAC
and NYSDOH transport policies and protocols.
□
If medical control orders are given, the Westchester OLMC
physician MUST notify the receiving hospital of the following:
□ Physician’s understanding of the patient's presenting
problem and results of EMS assessment
□ All reported BLS and/or ALS treatments
completed under standing orders
□ Patient's reported response to therapy given
□ Medical control orders given to the ALS provider
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Westchester Regional
Medical Control Physician Credentialing
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On-Line Medical Control Registry
To be credentialed as OLMC in the
Westchester Region, a physician must:
□ Be employed by a Regional Medical Control or Special
Resource Hospital
□ Be New York State Licensed MD or DO
□ Complete an OLMC Application, support section signed by
the MC or SR Hospital ED Director
□ Review the System Overview presentation and successfully
complete a test based on the material
□ Successfully complete a written OLMC test based on the
Paramedic Protocol exam (80% or better)
□ Mail the completed application package (with
attachments) to the Westchester Regional
EMS Office (may be sent via the
MC or SR ED Director)
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On-Line Medical Control Registry
To be maintained as On-line Medical Control in the
Westchester Region, a physician must:
□ Remain employed by a Regional Medical Control or
Special Resource Hospital
□ Promptly seek to change official primary MC or SR hospital
if regional affiliation changes
□ Notify Westchester Regional EMS Office of changes in
contact information (address, email, etc.)
□ Complete any required MC updates issued by the REMAC
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Contact Information:
Westchester Regional EMS Office
□ Address: 4 Dana Rd. , Valhalla, NY 10595
□ Website: www.wremsco.org
□ Main phone: 914-231-1616
□ Main fax: 914-813-4161
□ Staff:
□ Katherine O’Connor, BS, AEMT-P
Program Coordinator - [email protected]
□ Phyllis Smalley, BS, EMT-B
Administrative Assistant - [email protected]
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Please print out and complete the
short exam for this presentation.
Please submit the completed test
to your ED Director.
Thank you.
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