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Last updated 10.2001
TITLE: Falsification of Ambulance Run Reports NUMBER: 200.1
SECTION: Medical-Legal
EFFECTIVE DATE: 9/1/99 REVISED/REVIEWED: 10/1/06
PURPOSE: To clearly identify what would constitute falsification of patient information on an ambulance report form.POLICY: All documentation must be completed as accurately and as completely as possible. Thorough documentation of patient related information is vitally important to the further care of the patient as well as for medical-legal reasons. Altering or falsifying these documents can compromise patient care as well as system credibility. Deliberate failure to document accurately is considered an offense whereby appropriate disciplinary action can be taken against all personnel named on the ambulance report.
TITLE: Confidentiality of Medical Records NUMBER: 200.2SECTION: Medical-Legal
EFFECTIVE DATE: 9/1/99 REVISED/REVIEWED: 10/1/06
PURPOSE: In order to protect the patient's right to privacy, medical records must be kept confidential. Access to these records shall be in accordance with the laws and regulations that govern the right to either examine or copy and release confidential medical information. Guidelines for ensuring confidentiality are established in this policy.
POLICY:
1. The Loyola EMS System Ambulance Run Report is a medical-legal document.
2. The white copy of the Run Report is retained by the ambulance department responsible for and providing service to the patient.
3. The pink copy of the Run Report is retained by the receiving facility as a record of patient care and remains a permanent part of the patient’s medical record.
4. The yellow copy of the Run Report will ultimately be retained and stored at the resource hospital. However, the yellow copy should be initially left at the receiving Hospital in their designated area at the time of the emergency call. The System Associate Hospital will be responsible for forwarding these to the Resource Hospital following completion of Monthly Continuous Quality Assurance activities.
5. The Run Report may be utilized for purposes of data collection and quality assurance activities.
6. In the instance of a confirmed DOA, where the patient is not transported, the coroner/medical examiner may be provided with the pink copy of the Run Report after providing proper identification. The yellow copy should be retained and forwarded to the Loyola EMS System Office.
All requests without appropriate legal documentation by attorneys or other persons not identified above should be immediately referred to the Loyola EMS System Office. Release of ambulance report forms will be handled formally through the Loyola University Medical Center Medical Records/Risk Management Departments.
7. State data collection will be documented on designated Forms and submitted to the resource hospital. Data will be forwarded to the state by the Resource Hospital. When computer technology is available the Resource Hospital will work with system participants to work toward a mechanism for electronic data collection and reporting.
TITLE: Continuity of Care/Abandonment NUMBER: 200.3
SECTION: Medical-Legal
EFFECTIVE DATE: 9/1/99 REVISED/REVIEWED: 10/1/06
PURPOSE: To insure that the continuity of appropriate medical care is provided for each patient.
POLICY: Abandonment may occur when the EMT-patient relationship, once it has been established, is intentionally ended by the EMT. This relationship can only end when:
1. The patient ends the relationship. (See Policy regarding Consents/Refusals of Treatment).
2. The patient's care is transferred to another qualified medical professional.
Pre-hospital personnel may not leave a patient if there exists a need for continuing medical care. The only exception will be the presence and availability of individuals with comparable or higher licensure who may assume the responsibility for the care of the patient.
If competent patient refuses care an/or transportation to the hospital, the pre-hospital provider should establish communication with a communicating hospital, prior to leaving the scene, document the patient's condition and refusal of care and/or transportation. The pre-hospital provider must inform the patient of the risks of not receiving emergency care and if the individual continues to refuse ALS/BLS intervention, have the individual sign a release of services on the Ambulance Run Report.
When an ALS unit has arrived on the scene and it has been determined by ALS personnel that the patient requires BLS care and transport, the patient may be transferred to the BLS unit. This information will be relayed to a communicating hospital by the transporting unit.
If a competent patient requests transportation to a hospital outside of the ambulance's primary response area, the pre-hospital providers may make arrangements for transfer of the patient's care to a private ambulance service. The communicating hospital should be contacted to document the patient's request for transport out of the response area. Have the patient sign a release on the Ambulance Run Report stating his/her refusal to be transported to the nearest appropriate hospital. The pre-hospital providers should remain with the patient until the arrival of the private ambulance. The providers can transfer responsibility of the patient to a private ambulance service staffed with individuals of equal or higher training and with hospital communications capabilities. Consult your individual department's policy regarding transportation of patients out the response area.
If a patient requests transportation to a hospital outside of the ambulance's primary response area, and the prehospital providers determine that a need for continuing medical care does exist, the providers should make every effort to persuade the patient to consent to be transported to the closest appropriate hospital for initial evaluation and stabilization. If the patient continues to refuse transportation to the closest appropriate hospital the prehospital providers should establish communications with the hospital to document the situation.
TITLE: Personnel Immunity From Liability NUMBER: 200.4SECTION: Medical-Legal
EFFECTIVE DATE: 9/1/99 REVISED/REVIEWED: 10/1/06
PURPOSE: To define immunity from liability for Loyola Emergency Medical Services System prehospital personnel while providing infield patient medical assessment and life support services.
POLICY: As taken from the Illinois Emergency Medical Services Act
(a) Any person, agency, or governmental body licensed or authorized pursuant to this Act or its rules, who in good faith provides life support services during a Department approved training course, in the normal course of conducting their duties, or in an emergency shall not be civilly or criminally liable as a result of their acts or omissions, including the bypassing of nearby hospitals or medical facilities for the purpose of transporting a trauma patient to a designated trauma center in accordance with the protocols developed pursuant to Section 27 of this Act, are inconsistent with the person's training or constitute willful or wanton misconduct.
(b) No person, including any private or governmental organization or institution that administers, sponsors, authorizes, supports, finances, or supervises the functions of emergency medical services personnel licensed and authorized pursuant to this Act, including persons licensed under this Act and Department rules issued pursuant to this Act, or persons participating in the Department approved training program working for licensure, shall be liable for any civil damages for any act or omission in connection with administration, sponsorship, authorization, support, finance, or supervision of emergency medical services personnel, where the act or omission occurs in connection with their training or with services rendered outside a hospital unless the act or omission was the result of gross negligence or willful misconduct.
TITLE: Reportable Incidents NUMBER: 200.5SECTION: Medical-Legal
EFFECTIVE DATE: 9/1/99 REVISED/REVIEWED: 10/1/06
PURPOSE: To identify the responsibility of the EMS prehospital personnel to report any incidents harmful to the public good discovered while in the process of delivering patient care.
POLICY: There is an obligation on the part of all prehospital care providers and health care workers to report suspicious crimes. The nature of the injury should be considered in light of the history of the incident.
Examples of crimes or suspicious incidents:
1. Child abuse and/or neglect.
2. Assault with weapon or battery.
3. Elder abuse and/or neglect.
4. Domestic violence.
5. Motor vehicle accidents.
6. Suspicious deaths.
7. Abused and neglected long-term care facility residents.
8. Sexual assault.
Notify appropriate agencies as per Region 8 Standard Operating Procedures. The circumstances of the reportable incident should be communicated to the Emergency Department personnel. This can enhance the Emergency Department physician's assessment of the patient and the patient situation in order to provide appropriate care.
TITLE: Crime Scene Response NUMBER: 200.6SECTION: Medical-Legal
EFFECTIVE DATE: 9/1/99 REVISED/REVIEWED: 10/1/06
PURPOSE: It is recognized that the primary duty of any pre-hospital providers at the crime scene is to render medical assistance to the victim(s). The police are in charge of any crime scene and have an interest in preserving any physical evidence, which may assist in the prosecution of the criminal case. Pre-hospital providers should adhere to the advice and direction of police on the scene in all matters relevant to evidence collection unless doing so directly compromises patient care.
1. Assess the scene to determine if conditions permit safe performance of professional medical duties.
A. In all cases where a crime, suicide or attempted suicide, accidental death or suspicious fatality has occurred and police are not on the scene, request their services.
B. Treatment and transport should not be delayed pending police arrival unless the safety of the prehospital provider would be placed in jeopardy or the victim is obviously DNR (see # 3 below).
2. Initiate patient assessment and treatment per SOP. If access to the patient is prohibited, immediately notify medical control. Document the police officer's name and badge number on the ambulance run report.
A. Contamination of the crime scene is to be avoided. If necessity requires the alteration of the scene for the purpose of aiding the victim/patient, the police must be informed. Avoid unnecessary contact with physical objects at the scene.
B. Anything carried onto the scene, (i.e., dressing, wrapping or packages) should be removed by the medical team when they evacuate the scene. Do not remove anything from the scene other than those items.
C. If it is necessary to cut through the clothing of the victim/patient, avoid cutting through tears, bullet holes, or other damaged or stained areas of clothing.
D. Do not wash or clean the victim/patient's hands or areas, which have sustained bullet wounds.
E. In gunshot cases, be aware that expended bullets can be found in the clothing of the victim/patient (especially when heavy winter clothing is worn). These items of evidence may be lost during examination and/or transportation. Check your vehicle and stretcher after transport. Any items of evidence found should be turned over to the POLICE and documented on the run sheet.
F. In hanging or asphyxiation cases, avoid cutting through or untying knots in the hanging device or other material unless necessary to free the airway.
G. In stabbing cases, any impaled object must be left in place for both medical reasons and evidence collection.
3. If the patient does not meet the criteria for initiation of CPR. Do not remove or continue to examine the victim.
4. Document observations at the crime scene as soon as possible on the Ambulance Run Report. This should include the name and badge number(s) of Police Department personnel in charge at the scene.
5. Document all agencies assisting with the scene that may have been exposed to blood and/or body fluids on the ambulance run report.
TITLE Behavioral Emergency: Judgment of Uncooperative or Impaired Patient NUMBER: 200.7SECTION: Medical-Legal
EFFECTIVE DATE: 9/1/99 REVISED/REVIEWED: 10/1/06
PURPOSE:
To set guidelines for the care of a patient with impaired judgment or a behavioral emergency in which the patient exhibits erratic, bizarre or inappropriate behavior.
UNCOOPERATIVE IMPAIRED PATIENT/BEHAVIORAL EMERGENCY
1. Scene Safety: Assess competency and potential danger to yourself or others by observation, direct exam, and reports from bystanders including:
2. Identify yourself and attempt to gain the patient's confidence in a non-threatening manner.
3. Contact medical control, Police, and/or Fire Department backup as appropriate.
4. Consider and attempt to evaluate for possible causes of behavioral problems. Initiate treatment as situation allows. Examples include:
Hypoxia
Hypotension
Hypoglycemia
Trauma (i.e., Head Injury)
Alcohol/Drug Intoxication or Reaction
Stroke/CVA
Post-ictal states/Seizures
Electrolyte Imbalance
Infection
Dementia (i.e., acute or chronic organic brain syndrome)
Psychiatric illnesses
depression (suicidal)
severe anxiety
psychotic episodes/hallucinations
homicidal (i.e., harm to self or others)5. If the patient is judged to be either:
a. suicidal, or
b. clearly incompetent and dangerous to self or others, prehospital providers should carry out treatment and transport in the interest of the patient's welfare, employing the following guidelines:
i) At all times prehospital providers should avoid placing themselves in danger; at times this may mean a delay in the initiation of treatment until the personal safety of the provider is assured.
ii) Try to obtain cooperation through conventional means.
iii) If the patient resists, reasonable force may be used to restrain the patient from doing further harm to self or others (see -Use of Restraints).
iv) Police shall be notified prior to all involuntary removals, excluding institutionalized patients.
6. In an uncooperative patient, the requirement to initiate assessment and full ALS service may be waived if doing so may endanger the patient or pre-hospital provider. Document clearly the reasons ALS care was aborted.
7. All patients with a psychiatric history who do not have a petition completed by a Licensed Clinical Social Worker or other appropriate mental health care provider must be medically evaluated by an Emergency Department physician.
8. Patients requiring restraints for transfer should have appropriate documentation regarding the use of restraints noted in the transfer form.
9. Pharmacological restraints must be approved by medical control prior to administration.
TITLE: Use of Restraints NUMBER: 200.8SECTION: Medical-Legal
EFECTIVE DATE: 9/1/99 REVISED/REVIEWED: 10/1/06
POLICY: Use of restraints for behavioral health reasons is limited to emergencies in which there is imminent risk of an individual physically harming himself or herself, prehospital personnel, or others, and non-physical interventions are not effective.DEFINITIONS: Physical Restraint is any manual method or physical or mechanical device, material or equipment attached or adjacent to the patient’s body that he/she cannot easily remove that restricts freedom of movement or normal access to one’s body.
Emergency Situation is defined as an incident where a patient behavior becomes aggressive or violent and presents an immediate serious danger to his/her safety or that of others.
ASSESSMENT: A. Assess and document patient’s behavior that places the patient or others at risk to ensure patient meets criteria for restraint use; risk for injury to self/other and violent, aggressive behavior.
B. Attempt and document alternatives to manage patient behavior prior to application of restraints.
PROCEDURE: Restraints Application.
There are potential hazards associated with the use of restraints, and care must be taken to ensure that the restraints are applied correctly. Manufacturers of restraints provide guidelines for correct application. All pre-hospital personnel who might restrain a patient must be trained and their competency must be maintained.
GUIDELINES AND CARE OF PATIENTS IN RESTRAINTS:
1. Always offer the patient a chance to stop the behavior leading to the use of restraints.
2. Communicate clearly what behaviors will lead to the use of restraints.
3. Ensure that there are sufficient numbers of pre-hospital personnel available to restrain patient.
4. Avoid restraining only one limb; use either alternate (one hand and one leg or both hands) or four point restraints
5. Do not restrain a patient face down. Keep patient in semi-fowlers position.
6. Make sure circulation to the extremities is not impaired.
7. Re-assess patient frequently and CMS is intact.
8. Constantly re-evaluate the need for use of restraints.
9. Always document the reason for restraints, what less restrictive interventions were tried unsuccessfully, the patient’s response to restraints, and assessment of continued need for restraints.
10. The goal is to decrease agitation and violent behavior.
11. Use of additional manpower should be utilized as needed. Handcuffs are only to be applied by and at the discretion of the police officers. When the transportation of a victim/patient who is handcuffed is required, the pre-hospital provider should request that the police officer in possession of the handcuff key accompany the patient.
TITLE: Treatment of Minors NUMBER: 200.9SECTION: Medical-Legal
EFFECTIVE DATE: 9/1/99REVISED/REVIEWED: 10/1/06
PURPOSE: To insure the well being of any minor in need of medical care when the consent for treatment of the minor's legal guardian is not available.
POLICY: Under Illinois law any person under eighteen (18) years of age is considered to be a minor and not eligible to consent for treatment. In these circumstances, the consent of a parent or legal guardian is required. If, in the opinion of the physician and the pre-hospital provider, delay in obtaining consent would adversely affect the condition of the minor's health, however, emergency treatment may be rendered without first obtaining the consent. This requires a conversation between the pre-hospital provider and medical control.
This principle does not apply in the following situations:
1. A parent refuses to consent stating religious or other non-medical objections.
2. In cases of suspected child abuse or neglect.
3. When the minor is married, pregnant or emancipated.
Speciai Circumstances:
1. A pregnant minor and minors who are married are qualified to consent on their own behalf.
2. A minor parent may consent to treatment of their minor child.
3. Emancipated minors are mature minors (16 years of age and under 18 years of age) who have demonstrated the ability and capacity to manage their own affairs and live, wholly or partially, independent of parents or guardians.
4. Minors 12 years of age or older who:
a. have come into contact with a venereal disease
b. are suffering from the use of depressant or stimulant drugs
c. may be determined to be an alcoholic or intoxicated person
They may give consent to medical care related to diagnosis or treatment of such disease.
Guardianship is a legally determined role. Official court documents are issued to identify the legal guardian(s).
6. Baby-sitters and day care providers are not legally empowered to provide consent unless written parental consent is provided; however, in all cases the minor child's condition should be the deciding factor in providing care. If in doubt, contact medical control.
Document all of the circumstances and assessment on the ambulance run report and communicate with medical control.
TITLE: Consent/Refusal of Treatment NUMBER: 200.10SECTION: Medical-Legal
EFFECTIVE DATE: 9/1/99 REVISED/REVIEWED: 10/1/06
PURPOSE: To define consultation and documentation with medical control for all prehospital refusals of service for any minor, emancipated minor, or adult in need of medical attention.
DEFINITIONS:
Minor - any person under the age of 18
Emancipated minor – mature minors (16 years of age and under 18 years of age) who have demonstrated the ability and capacity to manage their own affairs and live, wholly or partially, independent of parents or guardians.
Minor - any person under the age of 18
Competent Adult - any person 18 years or older who is alert and oriented to person, place and time.
Incompetent Adult – any person 18 years or older who is disoriented (to person or place or time), is in shock, is under the influence of drugs or alcohol, and who is believed to be a danger to themselves or to others.
A minor cannot refuse treatment or transport to a hospital for medical attention. If a parent or guardian is not available for consent, the patient is treated under IMPLIED CONSENT.
A parent may refuse treatment of a child except under the following conditions:
1. Parents may not withhold consent for life-saving treatment.
2. When suspicion of abuse or neglect exists.
3. Life or limb threatening illness or injury.
4. Incompetent adult guardian.
Any person determined incompetent, cannot refuse treatment or transport to a hospital for medical attention. This patient is treated under IMPLIED CONSENT.
PROCEDURE FOR DOCUMENTATION OF REFUSAL OF TREATMENT FOR A COMPETENT PATIENT:
1. Complete ambulance run report
2. Document chief complaint and patient assessment including mental status exam, i.e., orientation to person, place and time.
3. Document that the patient/parent(s) was/were INFORMED and UNDERSTAND(S) the consequences of his/her own refusal for medical attention and/or transport.
4. Notify medical control for refusal of service.
5. Document ECRN/physician approving refusal.
6. Obtain patient's signature and signature of a witness of refusal (preferably family member) prior to communication with medical control and prior to leaving the scene.
7. Refusal to sign a refusal of service and/or transport should be documented as above.
TITLE: Release of Uninjured Students from School Bus Crash Scenes NUMBER: 200.10aSECTION: Medical-Legal
EFFECTIVE DATE: 8/1/1998 REVISED/REVIEWED: 10/1/06
PURPOSE: This policy is designed to the assist prehospital emergency medical personnel in releasing uninjured minor patients involved in low energy school bus crashes.
POLICY: Release of Uninjured Students from School Bus Crash Scenes
1. This policy does not apply to crashes in which any child suffers any type of significant injury. Neither shall this policy apply if there is a mechanism of injury that can be reasonably expected to cause significant injury.
2. It is possible that un-injured children may be released in the field while children from the same bus having minor injuries are transported.
3. Any child with any injuries should be transported. Only uninjured children may be released in the field.
4. It remains the responsibility of the emergency medical personnel on the scene to evaluate each patient to assure absence of injury.
5. Children may be released only to their permanent legal guardian or to appropriate school or school district officials. Children may not be released to bus drivers.
6. Children with special healthcare needs should not be released in the field.
7. It is recommended that EMS agencies contact the school districts in their coverage areas discuss with them the implementation of this policy.
8. Decisions regarding releasing any child should be done in consultation with on-line medical control. If the assessment done by EMS personnel on the scene indicates that that any child should be further assessed or treated at the hospital the child should be transported according to system policy.
TITLE: Release of Uninjured. Students from School Bus Crash Scenes NUMBER: 200.10bSECTION: Medical-Legal
EFFECTIVE DATE: 8/1/98 REVISED/REVIEWED: 10/1/06
TITLE: Physician/Nurse on the Scene / Use of Medications NUMBER: 200.11
SECTION: Medical-Legal
EFFECTIVE DATE: 9/1/99 REVISED/REVIEWED: 10/1/06
PURPOSE: To define the role and responsibilities of the physician/nurse on the scene.
PHYSICIAN ON SCENE:
1. In order for physician/nurse at the scene to assume patient care he/she must provide their Illinois physician’s/nurse’s license and a picture identification.
2. The pre-hospital provider will immediately contact the hospital via telemetry and the hospital shall be notified of the patient's present status and the presence of a physician/nurse at the scene.
3. If the physician/nurse on the scene decides to become involved directly in the patient's care, he/she should be informed that he/she must accompany the patient to the hospital and sign the ambulance report.
4. In the event the physician at the scene disagrees with Loyola EMS System SMOs. it is imperative that physician-to-physician communication be established from the scene to the Loyola EMS System communicating hospital. If the physician on the scene insists on deviating from the Loyola EMS System SMOs, he/she should be requested to personally carry out all orders.
5. The nurse assisting at the scene must follow EMS protocol/SMOs or as directed by Medical Control.
6. EMTs should refer to the appropriate section of the Loyola EMS System ambulance run report for documentation purposes.
USE OF MEDICATIONS:
1. Medications the physician has in his/her possession can be administered to the patient by the physician only. Use of these medications must be communicated to the System communicating hospital.
2. Medications from the ambulance ALS drug box can be administered to the patient by the physician/nurse within the limits of safe usage. Again, use must be communicated to the System communicating hospital.
3. If the physician/nurse on the scene decides to become involved directly in the patient's care, he/she should be informed that he/she must accompany the patient to the hospital and sign the ambulance report.
4. It is imperative that physician-to-physician communication be established from the scene to the communicating hospital. If the physician on the scene insists on deviating from the Region VIII SOPs, he/she should be requested to personally carry out all orders.
5. The nurse assisting at the scene must follow Region VIII protocols or provide treatment as directed by Medical Control.
USE OF MEDICATIONS:
1. Medications the physician has in his/her possession can be administered to the patient by the physician only. Use of these medications must be communicated to the communicating hospital.
2. Medications from the ambulance ALS drug box can be administered to the patient by the physician/nurse within the guidelines established by Region VIII protocols. Again, use must be communicated to the communicating hospital.
3. In both of the above situations, usual information such as time given, route, dosage and the person who administers the drug must be documented on the run report.
TITLE: Transport to Other Than the Nearest Hospital NUMBER: 200.12SECTION: Medical-Legal
EFFECTIVE DATE: 9/1/99 REVISED/REVIEWED: 10/1/06
PURPOSE: To comply with the Rules of the Department requiring System protocol for the transport of persons to a hospital other than the nearest hospital.
POLICY: As outlined in the EMS Act, Section 3.20(c)(5), all persons should be transported to the nearest hospital unless the medical benefits to the patient reasonably expected from the provision of appropriate medical treatment at a more distant facility outweigh the increased risks to the patient from transport to the more distant facility, or the transport is in accordance with the System’s protocols for patient choice or refusal.
PROCEDURE:
PROCEDURE: 1. The pre-hospital provider will establish contact with a communicating hospital and identify the closest hospital and estimated time of arrival (ETA) and the patient's requested/desired hospital and ETA.
2. Based on the information available at the time, the EMS physician/designee will approve or disapprove the transport to the more distant facility.
3. If the requested, more distant facility is not approved by the physician/designee and the patient is competent, a refusal must be signed and then transport to the more distant hospital can take place. The pre-hospital provider must document the refusal.
TITLE: Hospital Emergency Department Bypass/ Resource Limitations NUMBER: 200.13SECTION: Medical-Legal
EFFECTIVE DATE: 9/1/99 REVISED/REVIEWED: 10/1/06
POLICY: Due to resource limitations, it may be necessary for a hospital to declare bypass. The following procedures should be followed.
PROCEDURE:
1. Effective September 1, 2004 hospitals must utilize the web-based hospital bypass/state medical disaster-reporting program. When a hospital has determined the need for bypass, a representative of the hospital must notify the Resource Hospital, all other LUMC Associate Hospitals, and prehospital providers. Information that must be included is as follows:
a. Circumstances that initiated the decision for bypass
b. Estimate the time the hospital expects to resume normal activity
c. Names of contact personnel at the hospital if additional communication becomes necessary
2. The hospital shall notify the Illinois Department of Public Health, Division of Emergency Medical Systems, during the next business day following any bypass or resource limitation decision. This notification can be faxed. Faxed paper reports are not required if bypass is reported electronically.
3. Radio and telemetry calls will continue to be handled in the normal manner with the decision to divert ambulances to the next nearest hospital being approved/disapproved on a case by case basis.
4. The hospital should update the Resource Hospital of its estimated time for discontinuation of bypass status every four (4) hours.
5. When the hospital has determined that resources are available to resume care, they will again contact the Resource Hospital all prehospital providers in the System of the discontinuation of their bypass status.
TITLE: Do Not Resuscitate (DNR) Order NUMBER: 200.14SECTION: Medical-Legal
EFFECTIVE DATE: 1/03/01 REVISED/REVIEWED: 10/01/06
PURPOSE: To identify a valid DNR order and those patients in which CPR/Medical Care should not be initiated as directed by a physician's written order.
POLICY: Pre-hospital providers are permitted to withhold or withdraw medical care pursuant to a valid DNR order in pulmonary or cardiac arrest situations.
I. Do Not Resuscitate (DNR) Order.
A. A valid Do Not Resuscitate (DNR) Order shall consist of a written document, which has not been revoked, and contains the following information: Beginning July 7, 2001, a valid DNR order shall be written on a form provided by the Department and shall contain the following information. If the Department form is reproduced, brightly colored paper shall be used for ease of reference in an emergency. However, the form may be executed on any color paper and photocopies of a properly executed uniform DNR order are to be honored.
1. Name of patient
2. Name and signature of attending physician
3. Effective date
4. The Words "Do Not Resuscitate"
5. Evidence of consent - either:
a. Signature of patient or
b. Signature of legal guardian or
c. Signature of durable power of attorney for health care agent or
d. Signature of surrogate decision maker
If the Required Evidence of consent does not appear on the DNR order, the order is not valid for prehospital use.
B. Prehospital DNR Procedures:
1. Review the DNR and establish the above criteria
Make a reasonable attempt to verify the identity of the patient. for example, identification by patient ID band or identification by immediate family or by an authorized person named in a valid DNR order.
Immediately contact medical control and advise medical control of the presence of a valid DNR order, along with the description of any specific treatments to be withheld that are set forth on the DNR order. ALWAYS FOLLOW ORDERS FROM MEDICAL CONTROL, EVEN IF THEY ARE CONTRARY TO THE DNR ORDER.
Thoroughly document the circumstances surrounding the use of the DNR order, and attach a copy of the DNR order to the run report. If it is not possible to attach a copy of the DNR order, record all information from the DNR order on the run report.
IF THERE IS ANY DOUBT AS TO THE VALIDITY OF THE DNR ORDER, TREAT THE PATIENT AND TRANSPORT AS SOON AS POSSIBLE.
Revocation of a written "DNR" Order shall be made only in one or more of the following ways:
1. The Order is physically destroyed or verbally rescinded by the physician who signed the Order.
2. The Order is physically destroyed or verbally rescinded by the person who gave written informed consent to the Order (the patient or the patient's surrogate). If a surrogate had made consent, System personnel should attempt to confirm the surrogate's identity.
A member of the immediate family is present and requests initiation of resuscitation contrary to the written “DNR" Order. The family member must indicate that resuscitation would be what the patient would elect.
4. IF APPROPRIATE, NOTIFY THE CORONER/MEDICAL EXAMINER ACCORDING TO THE REQUIREMENTS OF YOUR COUNTY CORONER/MEDICAL EXAMINER NOTIFICATION POLICY.
D. "Do Not Resuscitate (DNR)" order refers to the following procedures:
1. Do not do chest compressions.
2. Do not ventilate (i.e., mouth to mouth, bag valve mask, pocket mask, endotracheal tube, esophageal obturator airway (EOA), tracheostomy site).
3. Do not treat asystole
4. Do not treat ventricular fibrillation
5. Do not treat agonal heart rhythm
6. Do not treat pulseless idioventricular rhythm
7. The attending physician may document on the DNR form other care to be withheld.
E. References to immediate family include (in descending order of priority):
1. Legal guardian
2. Spouse
3. Children
4. Family member living in the same household
F. References to patient surrogate:
1. A surrogate is an individual possessing durable power of attorney for health concerns over a specified patient.
II. When instructed by a person who is a health care agent of the patient pursuant to a power of attorney for health care.
A. Illinois law allows a person to appoint an agent to make healthcare decisions for the patient in the event that the patient is unable to make his or her own medical decisions. The person chosen by the patient to make these decisions is called the "agent". An agent is appointed by the patient via a document called a "power of attorney for health care". The agent can order you to withdraw or withhold medical care of the patients. A HEALTH CARE AGENT HAS NO AUTHORITY IF THE PATIENT HIMSELF OR HERSELF IS ALERT AND IS ABLE TO COMMUNICATE TO YOU. IF THE PATIENT IS ALERT AND CONSENTS TO TREATMENT, CONTINUE TO TREAT THE PATIENT, EVEN IF THEREAFTER, THE PATIENT IS UNABLE TO COMMUNICATE WITH YOU. IN SUCH SITUATIONS, THE HEALTH CARE AGENT HAS NO AUTHORITY OVER THE TREATMENT OF THE PATIENT.
B. If someone represents to you that they have power of attorney to make medical decisions for the patient, follow these procedures:1. BEGIN TREATMENT OF THE PATIENT. Immediately notify medical control of the possible presence of a health care agent for the patient and keep medical control advised. Follow all subsequent orders of the medical control physician, even if such orders contradict the orders you are receiving from the "agent".
2. As soon as it is practical, ask the agent for the power of attorney form and examine the form to determine if the agent's name appears on the form as agent, and ask the agent to verify that his/her signature appears on the form. Review the form to see what medical authority has been given to the agent. Notify medical control of the presence of a health care agent and follow the instructions of the agent unless instructed otherwise by medical control.
3. If you have doubt as to the identity of the agent, the extent of authority of the agent, or if communications with medical control cannot be established, CONTINUE TREATMENT OF THE PATIENT AND TRANSPORT AS SOON AS POSSIBLE.
III. When Instructed by the Medical Control Physician to Withhold or Withdraw Medical Care.
A. In certain instances, the medical control physician can order you to withdraw or withhold medical treatment of the patient. This may occur, for example, when you have started to treat a patient and a question occurs as to whether the patient's care should be governed by an advanced care directive. Medical control should then be notified and, depending on the circumstances, may order you to withhold further treatment or withdraw the treatment you have initiated.
B. In these situations, thoroughly document the circumstances surrounding the call and describe the treatment withheld or withdrawn along with the name of the medical control physician.
IV. Except in the conditions listed above, CPR is to be initiated immediately and continued until one (1) of the following occurs:
A. Effective spontaneous circulation and ventilation have been restored.
B. Resuscitation efforts have been transferred to other persons of at least equal skill, training and experience.
C. The rescuers are exhausted and physically unable to continue resuscitation.
D. A direct order from the patient's physician or the Medical Control physician is given to discontinue CPR.
V. A Loyola EMS System hospital is to be contacted over telemetry, MERCI, or cellular phone in ALL cases of cardiac arrest, whether or not they have signs of clinical death, meet the criteria for TRIPLE ZERO (Biological Death), or have a "Do Not Resuscitate" order.
VI. Living Wills and Patient Surrogates:
Illinois law allows terminally ill patients to instruct their health care provider, either directly with a living will, or indirectly through a patient surrogate, on their treatment in near death situations. However, the technical requirements of these laws make them unworkable and impractical for field use. Therefore, Loyola EMS System providers shall not follow the instructions contained in a living will or given by a person purporting to be a surrogate for the patient unless instructed otherwise by medical control or unless the Living Will is accompanied by a DNR order.
VII. Notification of Coroner/Medical Examiner:
Notification of the Coroner’s/Medical Examiner's office, in which a "DNR" order was honored on a patient with a terminal medical illness and under care of a physician, shall be by either the local police department or the EMS personnel.
The EMS MD or designee will review every “DNR" order to insure adherence to this policy.
In any case in which there is deviation from the “DNR" policy, the EMS MD will initiate a request for clarification.
TITLE: Pronouncement of Death in the Field NUMBER: 200.15SECTION: Medical-Legal
EFFECTIVE DATE: 9/1/99 REVISED/REVIEWED: 10/01/06
A patient under the care of Loyola paramedics may be pronounced dead at the scene, in the ambulance, or en route by the emergency department physician directing the care of the patient. This may be done in the following situations:
1. When, in the medical judgment of the Emergency Department Physician, the patient has died and the initiation of medical treatment by paramedics is not appropriate;
or
2. When, in the medical judgment of the Emergency Department Physician, the patient has died and continued treatment of the patient would be ineffective and, therefore, inappropriate.
WITHHOLDING OR WITHDRAWING MEDICAL CARE - PHYSICIAN RESPONSIBILITIES
The following guidelines are for use by the Emergency Department Physician in making determinations for the withdrawal or withholding of medical treatment. They are guidelines only, and each physician is responsible for using his or her own medical judgment when making a decision to withhold or withdraw medical care. Communications with field personnel should be via telemetry radio or cellular telephone. (Note: MERCI radio or private phone can be used in rare circumstances.) Disposition of the body will be in accordance with county ordinance and the wishes of the communicating physician.
1. Obviously Dead Patients ("Triple Zero" - Biological Death)
A. CPR and advanced life support procedures will not be initiated by prehospital personnel when presented with a patient who has suffered decapitation, rigor mortis without hypothermia, profound dependent lividity, decomposition, mummification, incineration or those who are in a frozen state.
B. Paramedics will expeditiously notify medical control of the presence of one of the above listed conditions by referring to the patient as a "triple zero" patient and will describe the patient's condition and the situation.
C. Confirmation of no cardiac electrical activity by ECG rhythm strip.
D. If the physician agrees that the patient meets the requirements set forth above, the physician should pronounce the patient dead. The time of pronouncement should be documented in the ECRN communication log.
2. Cardiac Arrest Patients with DNR Orders
A. The validity of the DNR order must be determined in accordance with IDPH regulations and System policy.
B. If the DNR form is valid, resuscitative efforts may be withheld or withdrawn by field personnel.
C. The patient should then be pronounced by the physician and the time of pronouncement should be recorded in the ECRN communications log.
NOTE: Resuscitation will be begun by field personnel on patients with living wills, incomplete/invalid DNR orders and/or with an agent at the scene. The communicating physician will be asked to determine how the paramedics should proceed.
3. No Response Patients (cardiac arrest patient who fails to respond to treatment)
A. Consideration should be given to withdrawing medical care from patients who have not responded to appropriate resuscitative efforts. These patients will be described as patients who remain unresponsive, asystolic and apneic despite aggressive use of Region SOPs.
B. The physician should request that the paramedics confirm that the patient remains in cardiac arrest and has not responded to resuscitation attempts guided by Region SOPs.
C. The physician should request that the paramedics reaffirm that ET tube and IV placement is correct and that treatment has been given in accordance with Region SOPs.
D. The physician may then give the order to field personnel to withdraw resuscitative efforts. In most cases, this order should be given after the patient has been removed to the ambulance (away from significant others). If, in an extraordinary situation, it is impossible or not desirable to move the body (i.e., hospice or nursing home), the physician will be informed of this situation and should give orders to the paramedics on how to proceed.
E. The physician should pronounce the patient dead and record the time of pronouncement in the ECRN communication log.
TITLE: Medical Examiner Cases NUMBER: 200.16
SECTION: Medical-Legal
EFFECTIVE DATE: 9/1/99REVISED/REVIEWED: 10/1/06
PURPOSE: To define guidelines for notification of the Coroner/Medical Examiner.
POLICY:
Personnel of the Loyola EMS System, whether operating at a Basic or Advanced Life Support level, are required to immediately initiate Cardiopulmonary Resuscitation (CPR) whenever clinical signs of a premorbid state exist.
The Medical Examiner an/or Law Enforcement Agency having jurisdiction must be notified or informed of any dead body of any person found within their respective areas.
PROCEDURE:
1. In situations where gross indications are conclusive that death has occurred, (i.e., decomposition, decapitation, etc.), the prehospital providers shall call medical control for the decision whether or not on scene care is to be initiated.
a. If medical control advises it is not necessary to initiate resuscitative measures the prehospital provider will notify the appropriate medical examiner and/or law enforcement agency.
b. If medical control advises to initiate resuscitative measures, the prehospital provider will do so in accordance with SOPs and transport to the receiving facility.
2. Whenever presented with a Do Not Resuscitate” (DNR) order, always begin BLS assessment while simultaneously contacting medical control to have the DNR order reviewed and approved by the telemetry physician.
3. In an attempt to assure preservation of possible evidence at a crime scene, the prehospital providers should avoid unnecessarily disturbing the scene, or abandoning the body or scene until proper authorities arrive. (See Crime Scene Response Policy)
4. When the police are in attendance, ambulances may return to service when, and if, a valid “Do Not Resuscitate – DNR” order for that patient is documented or resuscitation is not initiated as explicit signs biological death (triple zero) exist and confirmation has been obtained by the communicating Hospital telemetry base station personnel.
5. The hospital will be responsible for notifying the Medical Examiner for any patients received in the Emergency Department.
6. An Ambulance Run Report form or refusal must be completed on all patient contacts. This form is an official document, which must indicate all treatment and/or assessments regardless of whether or not transportation occurs.
7. Body removal should be completed by the local Police Department or Funeral Home if Medical Examiner approval is given.
TITLE: Abuse of Controlled Substances by System Participants NUMBER: 200.17SECTION: Medical-Legal
EFFECTIVE DATE: 9/1/99 REVISED/REVIEWED 1/01/06
PURPOSE: To assure a safe environment and prohibit the use of controlled substances and alcohol by System providers while on duty.
POLICY: Abuse of controlled substances, including alcohol, by System providers while on duty will be grounds for suspension. The suspension action will be consistent with the Rules of the Illinois Department of Public Health
Those observing behaviors or signs of substance abuse by providers must report their observations to the Loyola EMS Department immediately. Both the LEMSS Medical Director and LEMSS Coordinator may be reached by pager.
The EMS Medical Director or EMS Coordinator will contact the involved participant's employer and request his or her immediate removal from patient care activities and system participation suspension protocols will be initiated.
TITLE: Victims of Abuse NUMBER: 200.18SECTION: Medical-Legal
EFFECTIVE DATE: 5/1/98 REVISED/REVIEWED: 10/1/06
PURPOSE: Assure victims of abuse receive information regarding available resources.
POLICY: Pre-hospital providers will offer information regarding services available to victims of abuse, or for any person suspected to be a victim of domestic abuse.
PROCEDURE FOR SUSPECTED ABUSE CR NEGLECT:
1. Initial Medical/Trauma Care.
2. Treat obvious injuries per appropriate SOP.
3. History, physical exam, scene survey as usual - document findings on run sheet.
Suspected Child Abuse/Neglect:
4. Transport. Report your suspicion to ED staff upon arrival.
- Mandatory transport.
- Contact medical control if parent/legal guardian refusing.
5. Notify Department of Children and Family Services (DCFS) at 1-800-25-ABUSE (24-hour phone line.)
Suspected Domestic / Sexual:
4. Provide victims of suspected abuse information on services available. See Domestic Crime Victim information forms.
5. Encourage them to seek medical attention.
6. If patient is a victim of suspected sexual abuse and < 18 years of age, DCFS must be contacted.
Suspected Elder Abuse Hotline:
7. Notify one of the following (reporting is mandatory):
- resident of an extended care facility 1-800-252-4343
- not in an extended care facility 1-800-252-8966 (M - F 0830 - 1700)
after hours call local law enforcement
- mentally ill or abused 1-800-843-6154
TITLE: Run Reports NUMBER:200.19SECTION: Medical-Legal
EFFECTIVE DATE: 1/1/97 REVISED/REVIEWED 10/1/06
PURPOSE: To collect data to facilitate the tracking of case outcomes for purposes of quality control and for activities related to the improvement of pre-hospital care
POLICY: A run report (paper or electronic as appropriate) shall be completed by each vehicle service provider for every emergency prehospital or inter-hospital transport.
1. One copy shall be left with the receiving hospital emergency department, trauma center or health care facility before leaving the facility.
2. All non-transport vehicle providers shall document all medical care provided and shall submit the documentation to the EMS office.
TITLE: System-Wide Crisis Response Number: 200.20SECTION: Medical-Legal
EFFECTIVE DATE: 1/03/01 REVISED/REVIEWED 01/01/06
PURPOSE: To provide a proactive mechanism for recognition of and response to an impending or active system-wide crisis
POLICY: Recognition of evolving trends or the influx of patients with similar signs and symptoms will better prepare participating hospitals and local ambulance providers for an increased demand for EMS and emergency department resources
The following procedures outline how and when notification/recognition may occur:
PROCEDURES:
I. Recognition
a. Telemetry personnel may be made aware of a system-wide crisis by communication from the local ambulance provider (i.e., mass casualty incident) or by noting an increasing number of emergency departments requesting ambulance diversion. The telemetry personnel should report these occurrences to the attending emergency doctor or charge nurse.
b. When participating hospitals see a rapid or developing increase of patients with similar symptoms, the attending emergency doctor or the charge nurse should contact their Resource Hospital and appraise them of the situation.
c. When ambulance providers or their personnel notice that they have an increase of runs with patients complaining of similar signs and symptoms, they should report this information to their Resource Hospital.
II. Notification of Personnel
a. The Resource Hospital shall document any calls they receive from their participating hospitals or ambulance providers and identify that they are seeing numerous types of patients complaining of similar types of symptoms. The Resource Hospital should note the time the call is received and seek a detailed account of the situation.
b. If the Resource Hospital receives calls from two participating hospitals, or has reason to suspect a potential system-wide crisis, the telemetry nurse or emergency department designee will page the LEMSS Coordinator or LEMSS Medical Director to inform them of the situation. The LEMSS Coordinator or LEMSS Medical Director will contact the local ambulance provider to see if they are seeing an increase in patients with similar types of symptoms.
c. The LEMSS Coordinator or LEMSS Medical Director may also contact the Illinois Poison Control Center to see if they are receiving additional calls for similar type symptoms.
d. If there appears to be a trend, prehospital or hospital, of increased frequency of similar symptoms, the LEMSS Coordinator or LEMSS Medical Director shall page the Emergency Officer for the Illinois Department of Public Health at 1-800-782-7860. In addition, if there is a local health department medical director, that person may also be contacted.
e. The Emergency Officer for the Illinois Department of Public Health will contact the Director of Public Health, or his designee, and the Duty Officer with the Illinois Emergency Management Agency. Based on the type and magnitude of the crisis, the Director of Public Health, or his designee, may activate the Disaster POD, according to the Emergency Medical Disaster Plan.
III. Plan of Action
a. Once notified by the Illinois Department of Public Health that there may be a potential for increased utilization of resources, the LEMSS Coordinator will contact the participating hospitals and local ambulance providers within the System to inform them of the crisis. The LEMSS Coordinator will request that each participating hospital take steps to avoid ambulance diversion and alert them to the possible need of having to mobilize additional staff and resources or activate their internal disaster plans. The LEMSS Coordinator may request assistance from the Chief of Emergency Medical Services also. The participating hospitals will also be informed that requests for BLS diversion will not be accepted during this crisis.
b. The LEMSS Coordinator or designee will consult with the emergency department designees staffing telemetry to monitor transport times, while the local dispatch center/s that receives 911 calls will monitor ambulance responses. If transport times begin to exceed 10-15 minutes and ambulance response times become excessive as a result of hospitals being on diversion, the Chief of EMS will be contacted and will assist in contacting the Emergency Department Charge Nurses and Senior Administrators of the participating hospitals on diversion to advise them to activate their internal disaster plans so that they can rapidly come off diversion. They will be given a specified time frame in which to accomplish this.
c. The monitoring of transport and ambulance response times requires frequent communication and close coordination between EMS and Emergency Department personnel at the Resource Hospitals, dispatch centers and the local fire departments.
d. During an impending or actual system-wide crisis, the local municipality may request mutual aid, through pre-existing agreements, from the surrounding areas.
e. All information shall be recorded on the “System-Wide Crisis Form” developed by the Illinois Department of Public Health, which will be available upon request.
IV. All Clear
a. The Director of Public Health, or his designee, will contact the Resource Hospital when the increased demand for response to the crisis appears to be over.
TITLE: Illinois Abandoned Newborn Infant Protection ActPolicy Number: 200.21
SECTION: Medical-Legal
EFFECTIVE DATE: 1/03/01 REVISED/REVIEWED 01/01/06
PURPOSE: The intent of the procedure is to establish a consistent method of action associated with the receipt of newborn infants who, under the Abandoned Newborn Infant Protection Act (Public Act 92-0432), may be legally relinquished to the care and custody of a hospital, manned fire station or other emergency medical facility.
DEFINITIONS:
- “newborn” – an infant who a licensed physician reasonably believes is seventy-two (72) hours old or younger
- “relinquish” – leaving an infant with the personnel of a hospital, manned fire station or other emergency medical facility
- “emergency medical facility” – a freestanding emergency center or trauma center as defined in the Emergency Medical Services (EMS) Systems Act. Urgent care and convenient care centers are not included in this designation
POLICY: As directed by the Illinois Abandoned newborn Infant Protection Act, the personnel of a Loyola EMS System hospital, manned fire station or other emergency medical facility must accept a newborn infant, who a licensed physician reasonably believes is seventy-two (72) hours old or younger, presented to their facility
PROCEDURES:
1. 1. The facilities must provide appropriate and adequate medical care necessary to ensure the safety of the child.
2. If there is suspected child abuse or neglect, not based solely on the infant’s relinquishment, Loyola EMS and hospital personnel must report that to the DCFS Central Registry 1-800-25-ABUSE, using the current standing medical orders for making such a report.
3. The personnel of the Loyola EMS System provider agency must provide an information packet to the relinquishing person, which contains information on the Adoption Registry and Medical Exchange, written notice of the process to terminate parental rights, and a resource list of counselors, including grief counseling, pregnancy counseling and counseling regarding adoption and other available options. (Each agency should develop its own list of local providers of these services.) The information packet must include written notice of the following:
- “No sooner than 60 days following the date of the initial relinquishing of the infant to a hospital, manned fire station or emergency medical facility, the child placing agency or the Department of Children and Family Services (DCFS) will commence proceedings for the termination of parental rights and placement of the infant for adoption.”
- “Failure of a parent of the infant to contact the Department of Children and Family Services (DCFS) and petition for the return of custody of the infant before termination of parental rights bars any further action asserting legal rights and respect to that infant.”
4. Loyola EMS System personnel who accept a child must inform the relinquishing person that they may relinquish the child anonymously and acceptance of the information packet is completely voluntary.
5. The Loyola EMS System personnel may inquire about the maternal/child medical history, but the relinquishing person is under no obligation to provide any information.
6. If the relinquishing person declines the information packet, the relinquishing person must be verbally informed that by relinquishing the infant anonymously, he or she will have to petition the court to prevent the termination of parental rights and retain custody.
7. Loyola EMS System personnel at a manned fire station or emergency medical facility is responsible for transporting the child to the nearest hospital for further medical evaluation in compliance with established EMS System procedures.
8. The Loyola EMS System hospital must further examine the infant and call the State Central Registry (1-800-25-ABUSE) to report the relinquished infant within 12 hours of acceptance of the child.
9. If the parent or relinquishing person of a newborn infant returns to reclaim the child within 72 hours after relinquishing the child to a manned fire station or emergency medical facility, personnel must inform the parent or relinquishing person of the name and location of the hospital to which the infant was transported.
ASSUMPTIONS:
- The hospital, manned fire station or emergency medical services facility is deemed to have temporary protective custody until DCFS or a licensed child-placing agency takes physical custody of the infant.
- DCFS will contact law enforcement agencies so that an investigation may proceed to ensure that the relinquished newborn infant is not a missing child.
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