Operations Subcommittee of the Emergency Medical Care Committee

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1 Operations Subcommittee of the Emergency Medical Care Committee Meeting Agenda: 9 A.M., August 7, 2014 Location: Admin. Conference Room 2180 Johnson Ave., 2 nd Floor, San Luis Obispo Members CHAIR: Aaron Nix, Sheriff s Department Adam Pettit, Ambulance Providers Ron Alsop, Office of Emergency Services Rhonda Durian, Med-Com Dr. George Hansen, Hospitals Chief Riki Heath, Fire Service Chris Javine, Ambulance Providers Rob Lewin, Fire Service Dan McCrain, Ambulance Providers Steve Neumann, CHP Chief Mark Miller, Fire Service Jim Copsey, Law Enforcement Kevin Taylor, Fire Service Matt Vierra, Field Provider-Paramedic Staff STAFF LIAISON: Vicci Stone, Admin. Services Officer Stephen Lieberman, EMS Division Director Thomas Ronay, M.D., Medical Director Kathy Collins, R.N., SCS Coordinator Tracy Eby, Administrative Assistant AGENDA ITEM LEAD Call to Order Discussion/Action Items Adjourn Introductions Public Comment Approval of previous meeting minutes April 3, 2014 (attached) Trauma Triage Guideline Modifications Trauma Destination Southern San Luis Obispo County Announcements Declaration of Future Agenda Items Next Meeting October 2, 2014 at 9:00 A.M. Location: Health Agency, 2180 Johnson Ave., 2 nd Floor Aaron Nix Aaron Nix Kathy Collins / Steve Lieberman Aaron Nix

2 Operations Subcommittee of the Emergency Medical Care Committee Meeting Minutes 9 A.M. De Members CHAIR Aaron Nix Adam Pettit Ron Alsop Rhonda Durian George Hansen, MD Chief Mike Hubert Chris Javine Rob Lewin Matt Vierra Steve Neumann Chief Mark Miller Kevin Taylor Dan McCrain Jim Copsey Staff Steve Lieberman, Director Thomas Ronay, MD, Medical Director Kathy Collins RN, SCS Coordinator Vicci Stone, EMS Specialist Tracy Eby, Administrative Assistant Guests See Public Sign In Sheet AGENDA ITEM / DISCUSSION CALL TO ORDER Introductions Round table introductions were made. Public Comment APPROVAL OF MINUTES Approval of Minutes December 5,2013 meeting minutes were reviewed. ACTION / DISCUSSION ITEMS Revised Draft of Pre-approved Fire classes for CE credit Strike team leader course stays on the list Skills classes should count for hours Basic EVOC keep at 2 hours of CE credit MCI Policy Meeting with Joe and and Kevin to discuss and look over the current MCI policy for updates and clarifications. SB County completed a major overhaul of their policy which triggered us to look at our policy. Revised Policy 215 Management of Controlled Substances Proposed changes are in red. Based on getting specific and clear on what the EMSA is requiring of agencies. Suggested that the EMSA does an audit at the time when there is a change of DEA designee within agencies. QI request Airway Form 3.0 and IO Trying to track which device that is being utilized. Airway 3.0 will be going out in a memo. Trauma Destination Looking for feedback as to the direction we are going. Clarifying the matrix, moving long bone into step 2. That will be our county in line with national trauma program standards as well as falls in line with SB County s practice. This will become important in the South County and how trauma pts could end up going to Marian. Clinical committee will see the updates and proposed changes soon. Dopamine There is a national shortage. Memo went out making it a optional item for non-transporting agencies to carry. Transporting agencies will continue to carry it, used mainly on LDs. ADJOURN Announcements Ron- Dress rehearsal on April 16 th. Hositle action drill. First of its kind in the western states. Declaration of Future Agenda Items None Next Meeting June 5, 2014 at 0900 Health Campus ACTION / FOLLOW-UP Called the meeting to order at 0906 No public present Motion to approve; J. Copsey / Second A. Pettit; carried. Motion to approve; M. Hubert / Second K. Taylor; carried Will bring back to the June meeting in draft form Motion to approve; K. Taylor / Second M. Hubert None None Adjourned 0943

3 SAN LUIS OBISPO COUNTY HEALTH AGENCY Public Health Department Emergency Medical Services Agency 2156 Sierra Way, San Luis Obispo, CA FAX OPERATIONS COMMITTEE MEETING DATE August 7, 2014 STAFF CONTACT Kathy Collins, Specialty Care Systems Coordinator, SUBJECT Policy 153 Trauma Triage and Destination Integration of Marian Regional Medical Center SUMMARY Marian Regional Medical Center (MRMC) was designated as Level III trauma center by Santa Barbara County in April 2013 upon meeting California Title 22 requirements Trauma literature and guidelines recommend trauma patients meeting trauma triage criteria be transported to a trauma center. Regionalization of specialty care programs (STEMI) has demonstrated positive patient outcomes and a cooperative QI processes. A MOU with the Santa Barbara County EMS Agency has been developed and once countersigned, will ensure QI participation and system evaluation The San Luis Obispo County trauma center (Sierra Vista Regional Medical Center) shall be the base station/medical control for trauma patients originating in San Luis Obispo County meeting trauma triage criteria and transported to MMC REVIEWED BY RECOMMENDED ACTION(S) ATTACHMENT(S) Trauma Advisory Committee EMS Staff Thomas Ronay, MD, SLO County Medical Director Steve Lieberman, EMS Division Director Staff is recommending the recognition of Marian Regional Medical Center as a Level III Trauma Center and to integrate them into the San Luis Obispo trauma system. Policy 153 Trauma Triage and Destination K:\PublicData\COMMITTEES\Operations Subcommittee\2014\ \Trauma\TAC staff report to Integrate MMC into trauma system SL edit docx

4 SAN LUIS OBISPO COUNTY EMERGENCY MEDICAL SERVICES AGENCY PREHOSPITAL POLICY Policy Reference No: 153 [01/08/2013] Formerly Policy No: Effective Date: 11/01/2012 Review Date: 03/01/2014 TRAUMA PATIENT TRIAGE AND TRANSPORT PURPOSE To establish guidelines for EMS personnel to identify and transport significantly injured patients who could benefit from the rapid response and specialized services of a trauma center. AUTHORITY A. California Health and Safety Code, Division 2.5 B. California Code of Regulations, Title 22, Chapter 7 PROCEDURE A. Determine if patient condition meets trauma patient criteria. B. Contact the San Luis Obispo County trauma center immediately with trauma alert or for destination consultation. C. Make every effort to keep scene time under 10 minutes. D. Transport to the most appropriate facility. POLICY This policy applies to both adult and pediatric injured patients, unless stated otherwise. A. Trauma Patient Criteria Patients meeting any one of the Physiologic and/or Anatomic criteria following a traumatic event shall be a TRAUMA ALERT and transported to the closest trauma center. 1. Physiologic Criteria - (Step One) Adult injured patients meeting any ONE of the following criteria: Glasgow Coma Scale 13 (based on patient history and attributed to injury) POLICY REFERENCE No: 153 PAGE 1 Of 5

5 Systolic blood pressure <90 mmhg Respiratory rate <10 or >29 breaths per minute Pediatric injured patients meeting ONE of the following criteria (<34 Kg or 14 years): Glasgow Coma Scale 13 (based on patient history and attributed to injury) Evidence of poor perfusion color, temperature, etc. Respiratory rate >60 breaths per minute or respiratory distress <20 breaths per minute in infants <1year Heart rate 5 years (<22Kg) heart rate <80 beats per minute or >180 beats per minute 6 years (23-34Kg) heart rate<60 beats per minute or >160 beats per minute Blood pressure Newborn (<1 month) systolic blood pressure <60mmHg Infant (1 month -1 year) systolic blood pressure <70mmHg Child (1 year-10 years) systolic blood pressure <70mmHg + 2X age in years Child (11-14 years) systolic blood pressure <90mmHg 2. Anatomic Criteria (Step Two) Injured patients meeting any ONE of the following criteria: All significant penetrating injuries to head, neck, torso and extremities proximal to knee or elbow (excludes minor lacerations) Chest wall instability or deformity (e.g. flail chest) Open or depressed skull fracture Two proximal long bone fractures Paralysis 3. Mechanism of Injury Criteria (Step Three) For injured patients who do not meet any of the Physiologic or Anatomic Criteria but DO meet one of the following Mechanism Criteria, contact the San Luis Obispo County trauma center and initiate a TRAUMA CONSULTATION to determine patient destination. Depending on the patient presentation, the trauma center may direct the patient to a closer hospital. Falls Adults: >20 feet (one story is equal to 10 feet) Children: >10 feet or two or three times the height of the child POLICY REFERENCE No: 153 PAGE 2 Of 5

6 High-risk auto crash: Passenger Space Intrusion(PSI) of space: >12 inches occupant patient site; or >18 inches any site within the PSI including the roof/floor Ejection (partial or complete) from automobile Death in same passenger compartment Auto vs. pedestrian/bicyclist thrown, run over, or with significant (>20 mph) impact Motorcycle or unenclosed transport vehicle crash( >20 mph) 4. Special Patient or System Considerations ( Step 4 ) Age and co-morbid considerations For significantly injured patient(s) that DO NOT meet the Physiologic, Anatomic or Mechanism of Injury Criteria but DO meet one of the following special considerations and are considered at greater risk for serious injury, contact the San Luis Obispo County trauma center and initiate a TRAUMA CONSULTATION to determine patient destination. Note: EMS provider judgment Age greater than 65 o SBP <110 mmhg may represent shock Children < 14 years Pregnancy > 20 weeks Anticoagulation therapy (excluding aspirin) or other bleeding disorders with head injury (excluding minor injuries) Two or more proximal long bone fractures Burns with trauma mechanism A TRAUMA CONSULT is not required for ground level/low impact falls with GCS 14 or when the GCS is normal for patient B. Contact Trauma Center Contact the receiving San Luis Obispo County trauma center early and immediately upon determining the patient meets trauma patient triage criteria with a TRAUMA ALERT or TRAUMA CONSULTATION 1. TRAUMA ALERT A TRAUMA ALERT is initiated when an injured patient meets any one of the Step 1 (Physiologic) or Step 2 (Anatomic) Criteria. Consider early notification to the San Luis Obispo County trauma center, from the scene when possible POLICY REFERENCE No: 153 PAGE 3 Of 5

7 a) EMS personnel should provide a TRAUMA ALERT early and from the scene when possible to assist in early activation of the trauma team and determination of patient destination. b) ALS personnel shall contact the trauma center with the TRAUMA ALERT. c) A TRAUMA ALERT report should include the following: TRAUMA ALERT Unit and medic # ETA to trauma Report on individual patient: (MITV format) Age and sex Mechanism of injury Injury and complaints Vital signs including GCS Treatment Include specific triage step, findings or considerations that identify the patient as meeting TRAUMA ALERT criteria 2. TRAUMA CONSULTATION TRAUMA CONSULTATION with a the San Luis Obispo County trauma center should be obtained to determine trauma patient destination when Step 3 (mechanism(s) of injury) criteria or Step 4 (special considerations) are present and Step 1 (physiologic) and Step 2 (anatomic) criteria are NOT met. a) Only ALS personnel may request a TRAUMA CONSULTATION for patient destination b) A TRAUMA CONSULTATION report should include the following: TRAUMA CONSULTATION Unit and medic # ETA to closest trauma center and ETA to closest ED (In cases where the closest trauma center and the closest ED are the same facility, inform the San Luis Obispo County trauma center of the situation in the radio report. trauma center is both the closest trauma center and ED inform them as such in the radio report e.g. We are enroute to your facility with a patient meeting TRAUMA CONSULTATION ) Report on the individual patient: (MIVT format) o Patient age and sex o Mechanism of injury and scene o Injury and complaints o Vital signs including GCS o Treatment and response o Include specific step, findings or considerations that identify the patient as meeting TRAUMA CONSULTATION criteria POLICY REFERENCE No: 153 PAGE 4 Of 5

8 Paramedic Concerns 3. The San Luis Obispo County trauma center, when not receiving the patient, shall notify the receiving hospital of the incoming patient and provide that hospital with the prehospital care patient information. 4. Patient Updates When practical, a brief patient update should be given to include any significant changes enroute in vital signs, GCS, physical findings, symptoms or treatments. C. Exceptions to Direct Transport to a Trauma Center Trauma patients shall be transported to the closest ED in the following situations: 1. Patient condition necessitates transport to the closest ED, such as the following: a) Unmanageable airway (intubation attempts are unsuccessful and an adequate airway cannot be maintained with BVM or other device) b) Uncontrollable bleeding with rapidly deteriorating vital signs c) Traumatic cardiac arrest see SLO County EMSA Prehospital Policy [01/08/2013]: Prehospital Determination of Death 2. Trauma center physician destination order 3. Patient refusal see SLO County EMSA Prehospital Policy [01/10/2013]: Patient Refusal of Treatment and/or Transport 4. Trauma center is on complete diversion see SLO County EMSA Prehospital Policy [01/10/2013]: Hospital Diversion D. The utilization of EMS aircraft for the response and transport of trauma patients shall be in accordance with SLO County EMSA Prehospital Policy [01/10/2013]: EMS Aircraft (Helicopter) Operations. EMS Aircraft transport should be considered when ground transport is greater than 30 minutes from the trauma center and air transport would be more expeditious than ground transport. POLICY REFERENCE No: 153 PAGE 5 Of 5

9 Trauma Triage Guidelines (*) Adult Physiologic Criteria Glasgow Coma Scale 13 Systolic blood pressure <90mmHg Respiratory rate <10 or >29 breaths per minute TRAUMA TRIAGE DECISION SCHEME significantly Injured patients meeting one or more criteria activates 1 Pediatric Physiologic Criteria - <14 years or < 34Kg Glasgow Come Scale 13 Evidence of poor perfusion color, temperature, etc Respiratory Rate >60/min or respiratory distress or apnea <20/min in infants <1 yr Heart Rate 5 yrs (<22 Kg) - <80/min or >180/min 6 yrs (23-34 Kg) - <60/min or >160/min Blood Pressure - Newborn (<1mo) SBP<60 - Infant (1mo-1yr) SBP<70 - Child (1yr-10yrs) SBP <70 + (2x age in yrs) - Child (11-14yrs) SBP <90 YES TRAUMA ALERT and transport to closest TC NO Assess for anatomic injury 2 Anatomic Criteria All penetrating injuries to head, neck, torso, and extremities proximal to elbow or knee Chest wall instability or deformity (e.g. flail chest) Two proximal long bone fractures Open or depressed skull fracture Paralysis YES TRAUMA ALERT and transport to closest TC NO Assess for mechanism 3 Mechanism of Injury Criteria Falls - Adults: >20 feet (one story is equal to 10 feet) - Children: >10 feet or two or three times the height of the child High-risk auto crash - Intrusion of passenger compartment >12 inches occupant site or >18 inches any site including roof/floor - Ejection (partial or complete) from automobile - Death in same passenger compartment Auto vs. pedestrian/bicyclist thrown, run over, or with significant (>20 mph) impact Motorcycle or unenclosed transport vehicle crash >20 mph YES CONSULT TC for destination NO Assess for special patient or system considerations 4 Special Patient and System Considerations (*) EMS provider judgment Age >65 or <14 yrs Anticoagulation therapy (excluding aspirin) or other bleeding disorder with head injury (excluding minor injuries) Pregnancy >20 weeks Burns with trauma mechanism (*) Trauma Consultation is not required for ground level/low impact falls with GCS 14 (or when GCS is normal for patient) follow SLO County patient destination policy NO Follow SLO County destination policy CONSULT TC for destination Contact TC and transport to closest ED with Unmanageable airway Uncontrollable bleeding Traumatic cardiac arrest (*) Medical Control shall be with the San Luis Obispo County Trauma Center YES

10 SAN LUIS OBISPO COUNTY HEALTH AGENCY Public Health Department Emergency Medical Services Agency 2156 Sierra Way, San Luis Obispo, CA FAX OPERATIONS COMMITTEE MEETING DATE August 7, 2014 STAFF CONTACT Kathy Collins, Specialty Care Systems Coordinator, SUBJECT SUMMARY REVIEWED BY RECOMMENDED ACTION(S) Policy 153 Trauma Triage and Destination Triage Guideline Modification The current SLO County triage guideline for Step 2 Mechanism of Injury for patients with significant injuries is inconsistent with neighboring counties and CDC recommendations. Two proximal long bone fractures Crushed, de-gloved, mangled or pulseless extremity Amputation proximal to the wrist or ankle Pelvic instability/fractures In 2009, the State EMS Authority approved the SLO County Trauma Plan with direction that a QI process would review criteria that were inconsistent with the CDC recommendations. A review of the 2013 data for two long bone fractures looked at over 81,000 ED encounters and identified 11 (less the 0.01%) patients with the diagnosis of two or more proximal long bone fracture. The cases at the nontrauma centers were noted to be the result of low mechanism of injury or non-trauma related with occult findings. Additionally, the Sate EMS Authority and the Tri-County Trauma Advisory Committee (TAC) will be utilizing the CDC guidelines for data collection and quality improvement purposes. The State EMS Authority Core Measure summary for 2013 noted a future requirement that the trauma measures utilize the CDC guidelines to improve consistency. The Tri County TAC agreed to the development of performance dashboard utilizing the CDC guidelines as the markers (attached). Based on discussion at the last Trauma Advisory Committee meeting (5/7/14), EMS Agency staff followed up with the non-trauma centers to solicit comments and data related to this item. The findings are included in the 2013 summary, and the correspondence will be made available for review at the 8/6/14 TAC meeting. Clinical Advisory - recommended the addition Trauma Advisory Committee EMS Staff Thomas Ronay, MD, SLO County Medical Director Steve Lieberman, EMS Division Director Sierra Vista Trauma Advisory Staff is recommending two proximal long bone fractures be added to Step 2 ATTACHMENT(S) Policy 153 trauma triage and destination matrix Summary of 2013 Emergency Department Encounters EMS Authority Core Measures page 15 Tri- County Dash Board Correspondence Trauma Triage Feedback K:\PublicData\COMMITTEES\Operations Subcommittee\2014\ \Trauma\Long Bone TAC Staff Report docx

11 2013 Emergency Department Encounters OSHPD Data Two or More Proximal Long Bone Fractures as Reported by Facility Hospital ED Encounters Admission for 2 long bone fx AGCH 16,328 1 FHMC 11,546 1 SVRMC 21,013 8 TCCH 32,552 1 Totals 81, AGCH - (1) Non-trauma related Summary FHMC - (1) GLF Clavicle humerus and femur - D/C to care facility SVRMC (8) Total (6) Associated with other injuries (4) Transferred to higher level (3) Did not meet other triage criteria TCCH (1) Occult bilateral humerus fractures

SAN LUIS OBISPO COUNTY EMERGENCY MEDICAL SERVICES AGENCY PREHOSPITAL POLICY

SAN LUIS OBISPO COUNTY EMERGENCY MEDICAL SERVICES AGENCY PREHOSPITAL POLICY Policy Reference No: 153 [01/08/2013] Formerly Policy No: 201.3 Effective Date: 11/01/2012 Review Date: 03/01/2014 TRAUMA PATIENT