Westchester Regional Emergency Medical Services On-line Medical Control Physician Course & Regional System Overvie

1. Westchester RegionalEmergency 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

2. 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 Westchester REMAC OLMC System Overview

3. Westchester RegionalEmergency Medical Services System Westchester REMAC OLMC System Overview

4. 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. Westchester REMAC OLMC System Overview

5. 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 Westchester REMAC OLMC System Overview

6. 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 Westchester REMAC OLMC System Overview

7. 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. Westchester REMAC OLMC System Overview

8. 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. Westchester REMAC OLMC System Overview

9. 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 non-voting individuals representing the following; • Medical specialties (3) • Pediatrics • Psychiatry • Trauma • EMS organizations (3) • Municipal • Proprietary • Volunteer • Fire service (2) • Career • Volunteer • Public Safety (1) Westchester REMAC OLMC System Overview

10. REMAC OFFICERS REMAC Chair Dr. Nicholas DeRobertis SEMAC Representative Dr. Timothy Haydock SEMAC Alternate Pending MC HOSPITALS & REPRESENTATIVES (Voting) Dobbs Ferry Comm. Hospital - Dr. Mark Silberman Hudson Valley Hospital Ctr - Dr. John McGurty Lawrence Hospital - Dr. Carlos Flores Mt. Vernon Hospital - Dr. Karlene Chin No. Westchester Hospital Ctr - Dr. Robert Marcus Phelps Memorial Hospital - Dr. Emil Nigro Sound Shore Medical Ctr - Dr. Lawrence Klecatsky St. John's Riverside Hospital - Dr. Richard Marino St. Joseph's Medical Ctr - Dr. Nicholas DeRobertis Westchester Medical Ctr - Dr. David Goldwag White Plains Medical Ctr - Dr. Timothy Haydock (As of 9/2006) NON-VOTING MEMBERS Medical Specialty (Trauma)- VACANT Medical Specialty (Pediatrics)- Dr. Joli Yuknek (WPHC) Medical Specialty (Psychiatry)- Dr. Richard Gallagher (WMC) EMS - Municipal - VACANT EMS – Proprietary - VACANT EMS – Voluntary - Roland Faucher (MVFAVAC) Fire – Career- VACANT Fire – Volunteer- VACANT Public Safety- Police Chief Anthony Chiarlitti (Pleasantville PD) REMAC Westchester REMAC OLMC System Overview

11. 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. Westchester REMAC OLMC System Overview

12. Westchester RegionalQuality Improvement (QI) Westchester REMAC OLMC System Overview

13. 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 Westchester REMAC OLMC System Overview

14. 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) Westchester REMAC OLMC System Overview

15. 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 Westchester REMAC OLMC System Overview

16. 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. Westchester REMAC OLMC System Overview

17. 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 shouldbe referred to the Regional EMS Office andthe REMAC. Westchester REMAC OLMC System Overview

18. 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. Westchester REMAC OLMC System Overview

19. Westchester RegionalMedical Control System Westchester REMAC OLMC System Overview

20. 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 on-line 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. Westchester REMAC OLMC System Overview

21. 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 Westchester REMAC OLMC System Overview

22. 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. Westchester REMAC OLMC System Overview

23. EMS Medical Direction in NYSPHILOSOPHY OF MEDICAL OVERSIGHT Westchester REMAC OLMC System Overview

24. Medical Direction • Three Parts: • Prospective (Off-line medical direction) • Concurrent (On-line medical direction) • Retrospective (Off-line medical direction) Westchester REMAC OLMC System Overview

25. 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 Westchester REMAC OLMC System Overview

26. Concurrent Direction • Concurrent Medical Direction is usually provided via the Medical Control Physician through: • Telemetry • Radio • Phone(Cellular or landline) • On scene Westchester REMAC OLMC System Overview

27. 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 Westchester REMAC OLMC System Overview

28. ProtocolsNew York State Basic Life Support (BLS) Westchester REMAC OLMC System Overview

29. NYS BLS Protocols • Developed by State EMS Council and NYSDOH • Applies to: • EMT-Basic • Advanced EMT Providers • Basic Standard of Care for EMS Westchester REMAC OLMC System Overview

30. Directives to contact Medical Control: Confer regarding transport decisionswhen necessary(for all protocols) Swallowed poisons(for instructions for treatment) Any time EMT requires direction / advice NYS BLS Protocols Westchester REMAC OLMC System Overview

31. ProtocolsWestchester Regional Basic Life Support (BLS) Special Procedures Westchester REMAC OLMC System Overview

32. 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 Westchester REMAC OLMC System Overview

33. 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 aWMD event • Must have contact prior to pediatric administration Westchester REMAC OLMC System Overview

34. ProtocolsWestchester Regional EMT – Intermediate (EMT-I) Westchester REMAC OLMC System Overview

35. 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. Westchester REMAC OLMC System Overview

36. 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 REVIEWwhether or not extenuating circumstances may have made the transport necessary. Westchester REMAC OLMC System Overview

37. ProtocolsWestchester RegionalEMT-Paramedic (EMT-P) Westchester REMAC OLMC System Overview

38. Paramedic Protocols • Developed and revised by the REMAC. • Protocols establish medically sound algorithms for provision of Paramedic-level 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. Westchester REMAC OLMC System Overview

39. 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 Westchester REMAC OLMC System Overview

40. SPECIAL SITUATIONS Westchester REMAC OLMC System Overview

41. 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 Westchester REMAC OLMC System Overview

42. 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 Westchester REMAC OLMC System Overview

43. DNR • Non-hospital DNR – A physician signed,non-hospital DNR order on the NYS form MUSTbe 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. Westchester REMAC OLMC System Overview

44. 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 Westchester REMAC OLMC System Overview

45. 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,ANDthe patient is in respiratory or cardiac arrest: • NO : • Chest compressions • Ventilations • Defibrillation • Endotracheal Intubation • Medication administration Westchester REMAC OLMC System Overview

46. 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. Westchester REMAC OLMC System Overview

47. 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. Westchester REMAC OLMC System Overview

48. 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. Westchester REMAC OLMC System Overview

49. 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 on-scene, 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 Westchester REMAC OLMC System Overview

50. 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. Westchester REMAC OLMC System Overview