1. Sep 2006 Version1 Westchester Regional Emergency 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 OConnor, BS, EMT-P, Regional Program Coordinator

2. Sep 2006 VersionWestchester REMAC OLMC System Overview 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

3. Sep 2006 VersionWestchester REMAC OLMC System Overview 3 Westchester Regional Emergency Medical Services System

4. Sep 2006 VersionWestchester 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.

5. Sep 2006 VersionWestchester 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

6. Sep 2006 VersionWestchester 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

7. Sep 2006 VersionWestchester 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.

8. Sep 2006 VersionWestchester 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.

9. Sep 2006 VersionWestchester 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)

10. Sep 2006 VersionWestchester REMAC OLMC System Overview 10 REMAC 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)

11. Sep 2006 VersionWestchester 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.

12. Sep 2006 VersionWestchester REMAC OLMC System Overview 12 Westchester Regional Quality Improvement (QI)

13. Sep 2006 VersionWestchester 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

14. Sep 2006 VersionWestchester 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)

15. Sep 2006 VersionWestchester 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

16. Sep 2006 VersionWestchester REMAC OLMC System Overview 16 QI & EMS: What OLMC Physicians Should Know While each ED physician shouldnt 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.

17. Sep 2006 VersionWestchester 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 should be referred to the Regional EMS Office and the REMAC.

18. Sep 2006 VersionWestchester 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.

19. Sep 2006 VersionWestchester REMAC OLMC System Overview 19 Westchester Regional Medical Control System

20. Sep 2006 VersionWestchester 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.

21. Sep 2006 VersionWestchester 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

22. Sep 2006 VersionWestchester REMAC OLMC System Overview 22 EMS Medical Direction in NYS NYSDOH Policy Statement 03-07: Providing Medical Direction NYSDOH Policy Statement 03-07: Providing Medical Direction Reviews Agency Level Direction NYSDOH Policy Statement 95-01: Medical Control NYSDOH Policy Statement 95-01: Medical Control Clarifies roles and responsibilities in the development and provision of medical control in the prehospital environment.

23. Sep 2006 VersionWestchester REMAC OLMC System Overview 23 EMS Medical Direction in NYS PHILOSOPHY OF MEDICAL OVERSIGHT

24. Sep 2006 VersionWestchester REMAC OLMC System Overview 24 Medical Direction Three Parts: Prospective (Off-line medical direction) Concurrent (On-line medical direction) Retrospective (Off-line medical direction)

25. Sep 2006 VersionWestchester REMAC OLMC System Overview 25 Prospective Direction Prospective Medical Direction is done through the following: Training and Testing Continuing Medical Education (CMEs) Protocol Development Policy and Procedure Development QI Programs

26. Sep 2006 VersionWestchester 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

27. Sep 2006 VersionWestchester 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

28. Sep 2006 VersionWestchester REMAC OLMC System Overview 28 Protocols New York State Basic Life Support (BLS)

29. Sep 2006 VersionWestchester 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

30. Sep 2006 VersionWestchester REMAC OLMC System Overview 30 NYS BLS Protocols Directives to contact Medical Control: Confer regarding transport decisions when necessary (for all protocols) Swallowed poisons (for instructions for treatment) Any time EMT requires direction / advice

31. Sep 2006 VersionWestchester REMAC OLMC System Overview 31 Protocols Westchester Regional Basic Life Support (BLS) Special Procedures

32. Sep 2006 VersionWestchester 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

33. Sep 2006 VersionWestchester 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 a WMD event Must have contact prior to pediatric administration

34. Sep 2006 VersionWestchester REMAC OLMC System Overview 34 Protocols Westchester Regional EMT – Intermediate (EMT-I)

35. Sep 2006 VersionWestchester 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.

36. Sep 2006 VersionWestchester 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 REVIEW whether or not extenuating circumstances may have made the transport necessary.

37. Sep 2006 VersionWestchester REMAC OLMC System Overview 37 Protocols Westchester Regional EMT-Paramedic (EMT-P)

38. Sep 2006 VersionWestchester 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.

39. Sep 2006 VersionWestchester 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

40. Sep 2006 VersionWestchester REMAC OLMC System Overview 40 SPECIAL SITUATIONS

41. Sep 2006 VersionWestchester 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

42. Sep 2006 VersionWestchester 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 Policy Statement 99-10 : FAQs Re DNRs

43. Sep 2006 VersionWestchester REMAC OLMC System Overview 43 DNR Non-hospital DNR – A physician signed, non-hospital DNR order on the NYS form MUST be 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.

44. Sep 2006 VersionWestchester 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

45. Sep 2006 VersionWestchester 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, AND the patient is in respiratory or cardiac arrest: NO : Chest compressions Ventilations Defibrillation Endotracheal Intubation Medication administration

46. Sep 2006 VersionWestchester 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.

47. Sep 2006 VersionWestchester 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.

48. Sep 2006 VersionWestchester 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.

49. Sep 2006 VersionWestchester 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 Examiners 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

50. Sep 2006 VersionWestchester 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.

51. Sep 2006 VersionWestchester REMAC OLMC System Overview 51 Pronouncement of Death REMAC Policy 01-01: Pronouncement of Death (contd) Reviews reporting of out of hospital deaths to Police and Medical Examiners office Directs body to remain on scene with Police until removal has been effectuated by ME or funeral director NOTE: Due to special situations EMS may be ordered to transport the body to the closest hospital if, in the judgment of the Police, expedient removal of the corpse is necessary.

52. Sep 2006 VersionWestchester REMAC OLMC System Overview 52 Pronouncement of Death EMS Must Document Obvious Death - In addition to apnea and pulselessness, one or more of following conditions MUST exist: Tissue decomposition Rigor mortis Extreme dependent lividity Obvious mortal injury (decapitation, exsanguination, etc.) A Valid Do Not Resuscitate (DNR) order Also EMS should attempt to determine: Confirmation with an AED that No Shock Advised or presence of asystole in more than one ECG lead Any significant medical history or traumatic event Time lapse since patient was last seen alive

53. Sep 2006 VersionWestchester REMAC OLMC System Overview 53 Pronouncement of Death As with any patient, EMS can contact On- Line Medical Control for consultation if there are questions regarding the patients presentation and the decision not to attempt resuscitation.

54. Sep 2006 VersionWestchester REMAC OLMC System Overview 54 Patient Refusals of Medical Assistance/Transport (RMA) Often, EMS providers are faced with individuals that, for a number of reasons, refuse medical care. Recently, the NYS Department of Health has updated its position on RMAs to allow for the most appropriate use of resources. EMS are no longer required to complete a refusal on those patients that have no complaint. A PCR must still be completed for that call describing the details and interaction with the individuals at the scene. However, any incident with a mechanism of injury (MOI) that indicates that the patient could be injured, even without complaint, requires that a refusal be completed.

55. Sep 2006 VersionWestchester REMAC OLMC System Overview 55 RMAs RMAs MAY NOT be EMS initiated You dont want to go to the hospital, do you? Providers are urged to make every effort to encourage, but not force, patients to be transported. If a patient is unwilling to go, the provider may ask family/friends to encourage the patient to go If ALS care is indicated, or has been initiated, and the patient is still refusing transport to the hospital, OLMC MUST be contacted, and the physician allowed the opportunity to speak to the patient.

56. Sep 2006 VersionWestchester REMAC OLMC System Overview 56 RMAs If the patient is still unwilling to be transported, then the patient may refuse care, given the following: Patient is over the age of 18, or is an emancipated minor, or the mother of a child. Alert and oriented X 3/GCS of 15. Suicide has not been attempted/threatened. EMS has ruled out the potential for serious illness or child abuse when the patients parent or guardian is refusing care

57. Sep 2006 VersionWestchester REMAC OLMC System Overview 57 RMAs A Patient CANNOT refuse if: He or she has an altered mental status He or she is suicidal The potential for child abuse exists If these situations exist: EMS is to contact Medical Control Law enforcement assistance is to be requested if necessary. EMS providers are not to let themselves be placed in a dangerous situation attempting to obtain a refusal, if the potential exists, the crew is to withdraw to a safe area and await law enforcement assistance

58. Sep 2006 VersionWestchester REMAC OLMC System Overview 58 RMAs If patients meets criteria, then they can refuse. EMS Providers must: Perform and document at least 2 sets of vital signs (with patient permission) Inform patient of all possible negative consequences of refusal AMA Encourage patient to call EMS again if anything changes or as needed. Have patient read and sign PCR refusal section Have a witness sign the PCR refusal section (not a crew member if at all possible) Document any consultations with On-line Medical Control (MD/DO name, facility)

59. Sep 2006 VersionWestchester REMAC OLMC System Overview 59 By-stander Physician On Scene Occasionally, a physician will present at an EMS scene offering his/her assistance and seeking to direct patient care: Personal physicians (whose relationship with the patient can be verified at the scene) may assume medical control if he/she desires, without prior consultation of OLMC. Note: EMS should still contact OLMC to advise of the presence of this physician. A By-stander physician (a doctor without a professional relationship with the patient), MAY NOT assume medical control WITHOUT permission from OLMC.

60. Sep 2006 VersionWestchester REMAC OLMC System Overview 60 By-stander Physician On-Scene If a By-stander Physician on scene is seeking to direct patient care: EMS will contact On-line Medical Control and have the physicians speak to one another. NOTE: Direction may not be assumed if there is a communications failure. On-line Medical Control will then determine if the By-stander physician will be allowed to provide direction to the EMS on the scene

61. Sep 2006 VersionWestchester REMAC OLMC System Overview 61 By-stander Physician On-Scene If given permission by OLMC to direct patient care: The By-stander physician will be required to sign the Physician Release Form (found in the Paramedic Protocols), assuming all liability for the care of the patient and indemnifying the EMS crew from responsibility Any care requested that falls outside of the protocols or scope of practice of the EMS providers on the scene must be completed by the By-stander physician with his or her own equipment The By-stander physician MUST accompany the EMS crew to the hospital in the ambulance. ON-LINE MEDICAL CONTROL MAY RE-ESTABLISH AUTHORITY AT ANY TIME.

62. Sep 2006 VersionWestchester REMAC OLMC System Overview 62 Transfer of Care ALS providers are authorized to transfer care to a lower level provider (EMT-P to EMT-B or EMT-I; EMT-I to EMT-B) ONLY if an ALS assessment has been performed, AND: Neither the nature of illness (NOI) or mechanism of injury (MOI) indicates that there is a current need OR an anticipated need for ALS. The physical assessment indicates that there is neither a current need OR an anticipated need for ALS. No invasive ALS procedures have been initiated NOTE: Either the ALS or BLS provider may contact OLMC to confirm this decision.

63. Sep 2006 VersionWestchester REMAC OLMC System Overview 63 Specialty Care Centers New York State Department of Health (NYSDOH) has designated certain hospitals as Specialty Care Centers. Some of these designations require active diversion of patients by EMS to those facilities based on patient presentation and onset of illness or injury. Patients who are experiencing the following acute morbidities are must be transported to a Specialty Care Center: Trauma Stroke

64. Sep 2006 VersionWestchester REMAC OLMC System Overview 64 Specialty Care Centers Hospitals that have been designated Specialty Care Centers in the Westchester Region are: Trauma Centers Regional Trauma Center (Level I) Westchester Medical Center Area Trauma Center (Level II) Sound Shore Medical Center Stroke Centers (As of 9/2006 - other regional hospitals are in the process of seeking Stroke Center designation.) Hudson Valley Hospital Center Mt. Vernon Hospital Northern Westchester Hospital Center Sound Shore Medical Center Westchester Medical Center White Plains Hospital Center

65. Sep 2006 VersionWestchester REMAC OLMC System Overview 65 Specialty Care Centers: Trauma Centers Transport to a NYS designated Trauma center is based on an algorithm using: Physiological presentation GCS < 13 BP < 90 RR <10 or <29 Anatomy of injury Mechanism of injury

66. Sep 2006 VersionWestchester REMAC OLMC System Overview 66 Specialty Care Centers: Trauma Centers Automatic Criteria <12 years old Thoracic Injury w/shock or respiratory distress Limb amputation/severe crush injury Spinal Trauma w/ hemi or paraplegia Unstable multi-systems trauma w/open pelvis fracture Burns – facial, airway, electrical, >15% BSA Special Considerations 55 years old Cardiac / respiratory distress Pregnant Immuniosupressed Bleeding disorder

67. Sep 2006 VersionWestchester REMAC OLMC System Overview 67 Specialty Care Centers: Trauma Centers Transport of a trauma patient meeting Trauma Center criteria to the closest appropriate hospital is REQUIRED if: Cardiac arrest Unmanageable airway Transport time from injury to arrival at Trauma Center is greater than 1 hour On-line Medical Control so directs

68. Sep 2006 VersionWestchester REMAC OLMC System Overview 68 Specialty Care Centers: Stroke Centers Transport to a NYS designated Stroke Center is REQUIRED if: Positive Cincinnati Stroke Scale assessment (1 or more signs present) Facial Droop Arm Drift Abnormal Speech Transport time from onset of symptoms to arrival at a designated Stroke Center is less than 2 hours

69. Sep 2006 VersionWestchester REMAC OLMC System Overview 69 Specialty Care Centers: Stroke Centers Patients meeting Stroke Center criteria MUST be transported to closest appropriate hospital emergency department (ED) if: Cardiac arrest Unmanageable airway Other medical condition(s) warrant(s) transport to the closest appropriate ED as per NYS and/ or Regional protocol Time from onset of stroke symptoms to arrival at a Stroke Center is greater than 2 hours On-line Medical Control so directs

70. Sep 2006 VersionWestchester REMAC OLMC System Overview 70 Transportation to an Out-of-Region Facility (Not a Special Resource Hospital) Due to geographical variables and transportation concerns around the region, there may be occasions where EMS may transport a patient from an emergency scene to a hospital outside of the Westchester Region that is not authorized to provide On-line Medical Control. If Medical Control Orders are needed for management of a patient being transported to one of these facilities, a Westchester based OLMC Physician must be contacted to provide on-line direction.

71. Sep 2006 VersionWestchester REMAC OLMC System Overview 71 Transportation to an Out-of-Region Facility When OLMC is contacted: If transport out-of-region is due to patients choice, OLMC should first determine if patient's status permits transport to the facility of choice, or if the patient should be directed to a different, more appropriate facility, per Westchester REMAC and NYSDOH transport policies and protocols. If medical control orders are given, the Westchester OLMC physician MUST notify the receiving hospital of the following: Physicians understanding of the patient's presenting problem and results of EMS assessment All reported BLS and/or ALS treatments completed under standing orders Patient's reported response to therapy given Medical control orders given to the ALS provider

72. Sep 2006 VersionWestchester REMAC OLMC System Overview 72 Westchester Regional Medical Control Physician Credentialing

73. Sep 2006 VersionWestchester REMAC OLMC System Overview 73 On-Line Medical Control Registry To be credentialed as OLMC in the Westchester Region, a physician must: Be employed by a Regional Medical Control or Special Resource Hospital Be New York State Licensed MD or DO Complete an OLMC Application, support section signed by the MC or SR Hospital ED Director Review the System Overview presentation and successfully complete a test based on the material Successfully complete a written OLMC test based on the Paramedic Protocol exam (80% or better) Mail the completed application package (with attachments) to the Westchester Regional EMS Office (may be sent via the MC or SR ED Director)

74. Sep 2006 VersionWestchester REMAC OLMC System Overview 74 On-Line Medical Control Registry To be maintained as On-line Medical Control in the Westchester Region, a physician must: Remain employed by a Regional Medical Control or Special Resource Hospital Promptly seek to change official primary MC or SR hospital if regional affiliation changes Notify Westchester Regional EMS Office of changes in contact information (address, email, etc.) Complete any required MC updates issued by the REMAC

75. Sep 2006 VersionWestchester REMAC OLMC System Overview 75 Contact Information: Westchester Regional EMS Office Address : 4 Dana Rd., Valhalla, NY 10595 Website : www.wremsco.org Main phone : 914-231-1616 Main fax : 914-813-4161 Staff : Katherine OConnor, BS, AEMT-P Program Coordinator - progcoord@wremsco.org Phyllis Smalley, BS, EMT-B Administrative Assistant - admin@wremsco.org

76. Sep 2006 VersionWestchester REMAC OLMC System Overview 76 Please print out and complete the short exam for this presentation. Please submit the completed test to your ED Director. Thank you.