NH Bureau of EMS & NH 2009 Patient Care Protocol

1. NH Bureau of EMS &NH 2009 Patient Care Protocol Vicki Blanchard Advanced Life Support Coordinator New Hampshire Department of Safety Division of Fire Standards and Training and EMS

2. An Overview Of The NH EMS System Division of Fire Standards and Training & Emergency Medical Services

3. The NH EMS System • EMS Laws & Rules • The Bureau of EMS • Staff Responsibilities • Advisory Boards & Associations • Resource Hospitals • Instructor/Coordinators • Regions & Districts • Units • Providers

5. Laws and Rules • Laws:Created by the House and Senate. Also known as RSAs (Revised Statutes Annotated) • Rules:Are the nuts and bolts of the day to day operation. Also known as NH Code of Administrative Rules

9. Bureau of EMS Staff • Bureau Chief • Sections • Administrative Staff • ALS Coordinator • Education • Field Services • Preparedness • Research & Data • Trauma Services

10. New Hampshire Department of Safety Division of Fire Standards and Training & Emergency Medical Services

11. Bureau Chief – Sue Prentiss • Overall Oversight & Responsibility

12. Administrative • Office Management Staff

13. ALS Coordinator – Vicki Blanchard • Protocols & Process ALS level

14. Education Coordinator – Eric Perry • Instructors/Testing/Training QA & Standards

15. Field Services Coordinator Kathy Doolan • Liaison to Units & Hospitals, Licensing, Operations

16. Research & Quality Management • To create a quality management system for New Hampshire’s EMS system that improves the customer’s experience.

17. Preparedness & Special ProjectsBill Wood • Preparedness • MCI • AEDs

18. Trauma Coordinator – Clay Odell • Statewide Trauma System and Preparedness Issues

19. Advisory Boards and Associations • Medical Control Board • Emergency Medical & Trauma Services Coordinating Board • Trauma Medical Review Committee • NH Hospital Association • Hospital EMS Coordinators • NH Association of EMT’s • NH Paramedic Association • NH Ambulance Association

20. EMS Regions V I IV III II

21. Medical Control Board • RSA 153-A:5 III…duties (c) Serving as a liaison with medical personnel throughout the state.         (e) With the concurrence of the state pharmacy board, specifying noncontrolled prescription drugs that emergency medical care providers licensed under this chapter may possess for emergency use as authorized in RSA 318:42, X.        (f) With the concurrence of the state pharmacy board, specifying controlled prescription drugs that advanced emergency medical care providers licensed under this chapter may possess for emergency use as authorized in RSA 318-B:10, V.        (g) Approving the protocols and procedures to be used by emergency medical care providers under their own licenses or through medical control.

22. Region I John Sutton Norman Yanofsky Region II Tom D’Aprix Jim Martin Region III Don Albertson Pat Lanzetta Bill Seigart Region IV Chris Fore Doug McVicar, Chairman Region V Frank Hubbell Medical Control Board

23. Medical Resource Hospitals • Catchment Area • Units • Responsibilities • Training • Quality Assurance • Medical Oversight • Medical Direction • On & Off Line

24. Education Leadership Advice Critiques Performance improvement Medications Treatment modalities Medical Director

25. The NH EMS Licensed Provider Levels • Apprentice Providers • First Responders • EMT-Basics • EMT-Intermediates • EMT-Paramedics • PA/RN/MD’s = EMT’s • Other Entities : • National Ski Patrol / Lifeguards and Search & Rescue Agencies

26. Protocol Process • MCB assigns protocol committee • Committee researches each protocol for evidence based documentation to update or change • Updates/changes brought to MCB for discussion, revisions, approval, or denial • Final approved document

27. Protocol Process • 2 year cycle • Through May 2007 – rollout of 07 protocols • May 07 – Nov 08 – research/updates • Nov 08 – Jan 09 publication/final approval • March 2009 – 09 rollouts begin

28. 2009 Protocols

29. In General • Remove IVs from each individual protocol, as it is already in Routine Patient Care. • Standardize IV fluids throughout the document to read “0.9% NaCl (normal saline) • Removed Consider ALS or paramedic intercept and oxygen administration, because this too is in Routine Patient Care

30. Standardized

31. Grammar • Examples of grammar: • Their / there • “repeated in 5 minutes, once” vs. “repeated once after 5 minutes. • Administer / give • hepa / HEPA

32. Midazolam • Concentration change for IN administration from 1 mg/ml to 5 mg/ml

33. Routine Patient Care • Added tourniquets as a last resort when all other efforts have been exhausted. • Consent section added Sept/ Nov. 07

35. Apparent Life-Threatening Event • ALTE for children under 2 years was discussed previously in pediatric assessment. It was moved to its own protocol to prevent if from being overlooked. March 08

36. Status Determination and Transport Decision • Added definitions to the status categories • Updated the examples Sept. 07

37. Before

38. After

39. No Changes • Air Medical Transport • Communication • Communication Failure Sept. 07

40. Allergic Reaction/Anaphylaxis • Adult Intermediate: albuterol/ ipratropium mix (DuoNeb) • This will require a Transition program • Adult Paramedic: Removed the epinephrine infusion Sept/ Nov. 07

41. Asthma/COPD/RAD Adult & Pediatric Basic (Adult & Pediatric) • Add levalbuterol (Xopenex) to the list of approved MDI • Change MDI assisting from • 2 puffs; every 5 minutes as needed to • 2 puffs; repeat every 5 minutes up to 3 times, as needed Intermediate (Adult only) • Albuterol/ ipratropium mix (DuoNeb) • This will require a transition program Reference: National Heart Lung and Blood Institute, NIH Publication No. 07-4051 Sept/Nov . 07

42. Asthma/COPD/RAD Adult & Pediatric Paramedic • Added to the end of paramedic’s levalbuterol, “every 20 minutes up to a total of 4 doses. • Pediatric: similar changes with appropriate dosing • Pediatric: standardized the basic bullets with the adult protocol Reference: National Heart Lung and Blood Institute, NIH Publication No. 07-4051 Sept/ Nov. 07

43. Behavioral Adult & Pediatric Paramedic • Changed Haloperidol route per FDA’s recommendation to IM only • Haloperidol 5 mg IM, may repeat once in 5 minutes • Diphenhydramine dose change to a range 25 – 50 mg IV or 50 mg IM Nov. 07

44. Diabetic Adult • Changed title to Hypoglycemia and Hyperglycemia • Added definition of hyperglycemia: glucose levels > 300 mg/dl with associated altered mental status • Added to oral glucose bullet that “the patient must be alert enough to swallow and protect airway” • Adult: Intermediate/Paramedic: • For hyperglycemia, administer 500 ml bolus 0.9% NaCl (normal saline), then 250 mL per hour, • Removed Thiamine Nov. 07

45. Diabetic Pediatric • Pediatric Paramedic: • Hypoglycemic Emergency • Administer dextrose per length-based resuscitation tape. • Hyperglycemic Emergency • 10 mL/kg bolus in addition to maintaining hemodynamic status Nov. 07

46. Stroke Adult & Pediatric • Reformatted Stroke Scale box Nov. 07

47. Hyperthermia Adult & Pediatric • Intermediate Adult: • 500 ml 0.9% NaCl (normal saline) IV fluid bolus for dehydration • Paramedic Pediatric: • 10 – 20 ml/kg 0.9% NaCl (normal saline( IV fluid bolus for dehydration • Bullet link for seizure activity Nov. 07

48. Hypothermia Adult & Pediatric • Updated Basic section to reflect AHA CPR guidelines Insert screen shot Nov. 07

49. Obstetrical Emergencies • Updated the Contact Medical control list to include • Limb presentation • Nuchal cord • Paramedic: Changed the oxytocin dose to 20 units in 1000 mL 0.9% NaCl (normal saline) to control post partum hemorrhage at a rate of 200 – 600 mL/hr. • Paramedic: Added the bullet: Tocolysis for preterm labor: 0.9% NaCl (normal saline) IV bolus 20 mL/kg prn • Contraindications: Gestation beyond 37 weeks, pre-eclampsia, vaginal bleeding • Tocolysis: Rapid intravascular expansion which can diminish contractions of an irritable uterus Nov. 07

50. Care of the Newborn • A new protocol for the uncomplicated normal delivery • In the past normal delivery was incorporated into the newborn resuscitation, which is a bit of a contraindication…normal delivery and resuscitation. Nov 08