2019 REMSA POLICIES AND PROCEDURE OVERVIEW Overall Policy

2019 REMSA POLICIES AND PROCEDURE OVERVIEW Overall Policy Changes Misty Plumley, Senior EMS Specialist

OBJECTIVES Identify and review policy changes for 2019 Discuss CQI Review findings via Case Review High Performance CPR objectives Review education regarding needed performance standards.

POLICY CHANGES – SECTION 1000 EMS PERSONNEL REMSA 2019 Policy and Procedure Manual Overview

REMSA 1102 EMT Training: Application of training requirements for naloxone, epinephrine Training must be completed by first recertification after July 1, 2019 EMT applications updated in LMS Upcoming: Integration of glucometer in Fall 2019

REMSA 1104 - No current changes for 2019 Law enforcement partners continue to evaluate programs for use/deployment of naloxone.

REMSA 1201 Fee Schedule is under review and discussions for change occurring with stakeholder groups, anticipated changes after July 2019.

REMSA 1202 EMT Certification Application changes for post July 1, 2019. Clarification of verbiage to align with CA EMSA verbiage for National Registry completion. Title 22 CCR Chapter references updated. Applicants are required to save their materials for application in case of audit.

REMSA 1202 ADDITIONAL CHANGES Added verbiage to be consistent with CA EMSA: - EMT applicants must have completed their NR exam within 2 years of application Change from skills exam was valid for 1 year from cognitive test successful completion.

REMSA 1203 EMT Recertification Changes consistent with requirements for training that apply after July 1, 2019. Title 22 CCR Chapter references updated.

REMSA 1204 New Policy for 2019 - EMT Reinstatement - Policy adds clarifying language for applicants who are applying for recertification with an EMT certificate that has expired Consistent with CA EMSA processes and verbiage for paramedics. EMT applicants are required to maintain copies of their application documents and uploads for a period of 4 years in case of audit. Title 22 CCR reference sections updated.

REMSA 1204* (RENUMBERED TO 1205) EMT Certification by Challenge With the addition of REMSA 1204 EMT Reinstatement, EMT Certification by Challenge has become REMSA 1205. Title 22 CCR Chapter references updated.

REMSA 1205* (RENUMBERED TO 1206) Certificate Review Process With the addition of REMSA 1204 EMT Reinstatement, Certificate Review Process has become REMSA 1206.

REMSA 1206* (RENUMBERED TO 1207) Paramedic Accreditation With the addition of REMSA 1204 EMT Reinstatement, Paramedic Accreditation has become REMSA 1207.

REMSA 1207* (RENUMBERED TO 1208) Paramedic Reverification With the addition of REMSA 1204 EMT Reinstatement, Paramedic Reverification has become REMSA 1208.

REMSA 1208* (RENUMBERED TO 1209) MICN Authorization With the addition of REMSA 1204 EMT Reinstatement, MICN Authorization has become REMSA 1209.

REMSA 1209* (RENUMBERED TO 1210) MICN Reauthorization With the addition of REMSA 1204 EMT Reinstatement, MICN Reauthorization has become REMSA 1210. Changes made to reflect new reauthorization requirements: Ability to utilized either ALS SCV or preauthorized ALS Ride out time for reauthorization. Clarification of EMS CE requirements with less than 24 months initial authorization.

REMSA 1210* CHANGES CONTINUED Clarification of EMS CE requirements with less than 24 months initial authorization.

REMSA 1210* (RENUMBERED TO 1211) MICN Challenge With the addition of REMSA 1204 EMT Reinstatement, MICN Challenge has become REMSA 1211.

REMSA 1301 EMS Continuing Education No Current Changes Proposed for 2019

REMSA 1302 Skills Competency Verification Changes to the ALS SCV process to update the form for childbirth/neonatal resuscitation. All new ALS SCV courses should utilize the updated ALS SCV form, and childbirth & neonatal resuscitation be integrated into pediatric simulation or pediatric resuscitation classes offered by REMSA providers. REMSA requires that all paramedics have completed the updated ALS SCV process no later than April 1, 2020.

REMSA 1303 Continuing Education Provider No Current Changes Proposed for 2019

POLICY CHANGES – SECTION 2000 COMMUNICATIONS REMSA 2019 Policy and Procedure Manual Overview

REMSA 2101 Emergency Medical Dispatch Changes to EMD cards and LEMSA controlled items occurring as needed. No current policy changes proposed.

REMSA 2201 Radio Communications Standard Radio frequency programming will be updated as needed. No policy changes currently proposed.

POLICY CHANGES – SECTION 3000 PREHOSPITAL SERVICES REMSA 2019 Policy and Procedure Manual Overview

REMSA 3203 NEW POLICY ADDITION

REMSA 3301 Drug and Equipment List Trial study for Ketamine ended, Ketamine approved for Local Optional Scope of Practice (LOSOP), ketamine added.

REMSA 3302 Controlled Substances Trial study for Ketamine ended, Ketamine approved for Local Optional Scope of Practice (LOSOP), ketamine verbiage clarified.

REMSA 3309 Intranasal Naloxone Use by Public Safety Personnel No Current Changes Proposed for 2019

POLICY CHANGES – SECTION 4000 TREATMENT PROTOCOLS REMSA 2019 Policy and Procedure Manual Overview

REMSA 4101 Introduction to Treatment Protocols No Proposed Changes for 4101 for 2019 Implications for agencies applying for waiver of AHA training.

REMSA 4102 Universal Patient Protocol 12 lead ECG, perform when clinically indicated, when the paramedic is present

REMSA 4103 Calculation Chart Narcan Dosing Changes Ketamine Doses Added

REMSA 4103 Push Dose Epinephrine (0. 01 mg/m. L) added:

REMSA 4203 Do Not Attempt Resuscitation Added verbiage to further utilize patient’s response to therapy as a guide for withdrawal of resuscitation. Clarification of BLS Criteria to determine death

REMSA 4203 2019 Protocol 2018 Protocol

REMSA 4203 Withdrawal of resuscitative efforts: Driven by patient’s response to therapeutic interventions. Lack of response to treatment could be an strong indicator of futility of arrest. Resuscitation of patients should occur on scene Environmental and safety implications must be addressed Focus less on specific numbers as decision making points High Performance CPR should be priority after scene management Utilize criteria to discontinue, not attempt or withdraw resuscitative efforts as clinically indicated.

REMSA 4204 Ambulance Patient Offload Delay No Current Changes Proposed for 2019 Continued emphasis remains on triaging patients to appropriate care areas Limiting non-essential ALS treatments Strategy remains: When ED’s are heavily impacted, patients meeting specific BLS criteria can be placed in triage/waiting room

REMSA 4302 Traumatic Injuries Addition of Ketamine for pain control Ketamine is now LOSOP, currently pediatric administration of ketamine is not indicated. Ketamine can be used for multi-system trauma Ketamine has no SBP criterion Ketamine cannot be combined with other controlled substances without a BHPO.

REMSA 4303 Burns Addition of Ketamine for pain control Ketamine is now LOSOP, currently pediatric administration of ketamine is not indicated. Ketamine can be used for multi-system trauma Ketamine has no SBP criterion Ketamine cannot be combined with other controlled substances without a BHPO.

REMSA 4401 Shock Unrelated to Trauma Addition of push-dose epinephrine for management of hypotension associated with shock unrelated to trauma. Standing order for adult and pediatric patients, with specific SBP endpoints Used in conjunction with fluid bolus administration Creation of 0. 01 mg/m. L of epinephrine by further dilution of 0. 1 mg/m. L epinephrine.

REMSA 4402 Point of clarification: orders for nitrates in the inferior wall MI can be obtained from any BH. 12 Lead ECG performance standard also updated.

REMSA 4404 Symptomatic Tachycardia with Pulses No Current Changes Proposed for 2019

REMSA 4405 Symptomatic Bradycardia with Pulses No Current Changes Proposed for 2019

REMSA 4406 Cardiac Arrest Continued emphasis on High Performance CPR (HP CPR) Clinical data reinforces BLS strategies for resuscitation are of paramount importance and have the most impact! High performance CPR:

REMSA 4503 Suspected Stroke No Current Changes proposed. Policy verbiage adaptation may be needed with CA EMSA Stroke Regulations are final.

REMSA 4504 Nausea/Vomiting No Current Changes Proposed for 2019

REMSA 4601 Allergies/Anaphylaxis No Current Changes Proposed for 2019

REMSA 4602 Overdose Adverse Reaction: Clarification of pediatric naloxone dosing to not exceed adult doses.

REMSA 4603 Behavioral emergency with Suspected Excited Delirium Case Review Key Additions – Related to patient position

REMSA 4603 Key Additions: Monitoring of patient position, vital signs (including Respiratory Rate and Effort), and diagnostics for oxygenation and ventilation are clinically required.

REMSA 7101 CQI System EMS Core Measures will be updated by CA EMSA and REMSA strategies for their implementation discussed with CQILT and other REMSA Advisory Committees through Q 1 Q 3 2019, once released by CA EMSA.

REMSA 7401 Aligned REMSA P&P clinical care standards with standard of care for Altered Mental Status (AMS). Addition of Altered Mental Status to 12 Lead Electrocardiogram Performance Standard:

REMSA 7703 REMSIS Authorization and Security No Current Changes Proposed for 2019

REMSA 8101 Resource List Additional address and contact information was changed as requested.

REMSA 9101 Definitions This list was updated to coincide with policies as needed.

2018 RETROSPECTIVE CQI Cumulative case overview: - PPV and documentation - Pediatric ETI definition update - Excited Delirium Case Review

CASE REVIEW - 9 -1 -1 response for suspected assault Arrive to find Law enforcement on scene Agitated male patient, appears to be about 35 years old Patient is agitated, argumentative and belligerent Lacerations to his wrists Patient is combative Patient is cuffed, prone - patient is medicated with versed

CASE REVIEW

REMSA 4603 Physiologic Derangements that occur with prone positioning: Decreased chest excursion Decreased functional capacity Decreased tidal volume Increased CO 2 retention Shifts in acid/base balance Positive feedback mechanism

CASE REVIEW 35 year old male Cardiac arrest Uncuffed, placed supine, resuscitation with REMSA 4406 Determined dead in the ED

REMSA 7303 (POSITIVE PRESSURE VENTILATION) Waveform capnography is REQUIRED for all Positive Pressure Ventilation procedures Capnography waveforms and numeric results must be documented in the e. PCR.

REMSA 7303 - Documenting Positive Pressure Ventilation: Actions in e. PCR Hand Ventilation Airway Situation Tool

POWER TOOL IMPLICATIONS Utilize Airway Situation Tool:

DOCUMENTING CAPNOGRAPHY Options: - cardiac monitor data import Import captures based on configuration Only will import what is displayed on the screen Ensure waveform capnography is visible on screen. - Selection ETCO 2 digital capnography and report number in equipment size/setting - AND attach waveform strip via picture or scanned strip.

REMSA 7301 CHANGES - Clarifying: Orotracheal intubation may be performed on patients whose length exceeds the broselow tape. Patients are typically between 9 – 12 years when they meet this weight/height combination. - Clinical assessment must take into account anatomic and genetic conditions that may affect a patient’s weight and stature. Base Hospital Direction can be used to aid in decision making as needed.

REMSA OROTRACHEAL INTUBATION Esophageal Intubations? 2 unrecognized esophageal intubations occurred in 2018. - a 3 rd was suspected – continuous waveform capnography before AND after the ETI helped isolated when the tube was dislodged. But WHY? BIGGEST Question – Should an esophageal intubation go unrecognized?

REMSA 7308 Post ETI Confirmation and Monitoring: - Digital Waveform Capnography REMAINS the Gold Standard for ETT maintenance and monitoring. REMSA 7308 updated to reflect the requirement to record (and/or print) and attach the capnogram to the e. PCR: - @ placement - after every patient move - @ transfer of care

OBJECTIVES Identify and review policy changes for 2019 Discuss CQI Review findings Review applicable Performance Standards from the CQI review Review education regarding needed performance standards.

REMSA PROTOCOL UPDATE & CQI CASE REVIEW 2019 QUESTIONS?