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

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Presentation on theme: "NH Bureau of EMS & NH 2009 Patient Care Protocol Vicki Blanchard Advanced Life Support Coordinator New Hampshire Department of Safety Division of Fire."— Presentation transcript:

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

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


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




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

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/Trai ning 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 Projects Bill 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 II I III IV V EMS Regions

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 Medical Control Board 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

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

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

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 mLml SBP, systolic BP, BPSystolic BP 10 mg prnas needed mcgmicrograms g, gmgrams >greater than ccMl IVP, IV push, IVIV 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

51 Newborn Resuscitation This protocol assumes routine care of the newborn has been performed and reveals a newborn in need of resuscitation. Nov 08

52 Pain Management Adult & Pediatric Paramedic Adult  May consider only one of the analgesics  Fentanyl added IM and IN routes 25-50 micrograms IV, 50 micrograms IM every 5 minutes up to a total of 150 micrograms IV/IM or 1.4 micrograms/kg IN Added a caution statement regarding frail or debilitated patients. Remove abdominal call medical control references Nov. 07


54 Fever Adult & Pediatric Basic/Intermediate Adult & Pediatric  Remove the N95 bullet  Change shivering bullet to read, “Avoid inducing shivering” (previously is stated, “Do not cool to induce shivering.” Paramedic Adult  Added a bullet that states if ibuprofen has been previously been administered consider acetaminophen like in pediatric.  If ibuprofen has been given within the last 6 hours: –Consider acetaminophen 500 – 1000 mg PO. Nov. 07

55 Poisoning/Substance Abuse/Overdose Adult & Pediatric Adult & Pediatric  Consider activated charcoal 25 – 50 grams PO if ordered by Poison Control or Medical Control Reference: American Academy of Clinical Toxicology Pediatric  Added a dystonic reaction bullet same as adult and same as pediatric nausea protocol.

56 Seizure Adult & Pediatric Updated Vagus Nerve Stimulator Bullets to be more descriptive Nov. 07

57 Nausea/Vomiting Adult & Pediatric Intermediate Adult  500 ml 0.9% NaCl (normal Saline) IV fluid bolus for dehydration IV bullet to 0.9% NaCl (normal saline) IV fluid bolus 10 – 20 ml/kg for dehydration Under the Paramedic  Prochlorperazine dose increased to 5 mg – 10 mg (was 2.5 mg)  Removed Promethazine  Changed metoclopramide to just 5 mg IV or IM (was 0.1 mg/kg up to 5 mg)  Changed the repeat to: May repeat any of the above medications once after 10 minutes if nausea/vomiting persist  Added to granisetron “over 5 minutes” one dose only both adult and pediatric Nov. 07

58 Cyanide Poisoning Adult & Pediatric Intermediate/Paramedic: Created boxes to break out the Cyanide Antidote kit from the Cyanokit

59 Bradycardia Adult & Pediatric Bradycardia – Paramedic Adult  Broke out “Symptomatic and Hemodynamically Unstable” from “Symptomatic, but Hemodynamically Stable” Bradycardia – Basic/Intermediate Pediatric  added reasons for underlying causes. Jan 08

60 Tachycardia Adult & Pediatric Tachycardia – Paramedic Adult  Reordered PSVT, WPW and AF/Aflutter for better flow and added midazolam 2.5 mg IV,IM, IN under sedation Tachycardia – Paramedic Pediatric  Broke out “Symptomatic and Hemodynamically Unstable” and “Symptomatic, but Hemodynamically Stable” for continuity. Jan 08

61 ACS Adult All patients with complaints of chest pain should not automatically be treated with ASA and NTG. You should consider the likelihood of ACS based on the nature of the symptoms, the patients age, cardiac risk factors, past medical history, etc.” Grammatical changes to the Fibrinolytic Questionnaire Box and Cath Lab Activation box. Changed morphine dose to be consistent with the rest of the document. Jan 08

62 Congestive Heart Failure (Pulmonary Edema) Adult Intermediate – Added CPAP  This will require a transition module Paramedic  Reordered treatment regime CPAP (starting at Intermediate level) NTG Furosemide or bumetanide Morphine Nov 07


64 Cardiac Arrest - Adult Cardiac Arrest – Adult  Intermediates: Intraosseous infusion via a commercial IO introduction device (examples EZ-IO, B.I.G.) This will require a transition program  Paramedic: Procainimide removed Jan 08

65 Cardiac Arrest - Pediatric Basic  Updated the AED bullet to reflect recent approval of AED pads for newborns. From birth to age eight use pediatric AED pads. –If pediatric AED pads are unavailable, providers may use adult AED pads, provided the pads do not overlap. Paramedic  Reordered VFib/Pulseless VT and Asystole to be consistent with the Adult protocol. Jan 08

66 Drowning Adult & Pediatric Grammatical changes Jan 08

67 Eye & Dental Injuries Adult & Pediatric Paramedic  Tetracaine added  Proparacaine or tetracaine 2 drops to affected eye; repeat every 5 minutes as needed Nov 08

68 Burns Adult & Pediatric Merged Adult and Pediatric. Grammatical Jan 08

69 Traumatic Brain Injury Signs of hernia were placed in box to reinforce this knowledge, as recommended treatment is dependent on the presence or absence of herniation. Updated the ventilation rates and EtCO2 goals per Traumatic Brain Injury Foundation Jan 08

70 Thoracic Injuries Adult & Pediatric Added bullet stating, “Do not splint the chest” Updated signs of tension pneumothorax to include tracheal deviation March 08

71 Airway Management Protocols Airway Management – No change Gum Elastic Bougies – No change Orotracheal Intubation – No change Nasotracheal Intubation – Minor change removed pediatric redundancy March 08

72 Rapid Sequence Intubation Maximum doses added: Etomidate (40 mg) and Succinylcholine (150 mg) Cricoid pressure bullet changed to “maintained until proof of placement “ March 08

73 Blind Insertion Airways (King LT-D, Combi-tube, LMA) Created a single generic blind insertion airway protocol which states “see manufacturer’s instructions” for individual March 08


75 Cricothyrotomy Commercial device only Age-appropriate commercial devices using technique of needle and guide-wire followed by dilatation. (like the Melker) March 08 & May 08

76 No Changes Advanced Suctioning Tracheostomy Care March 08

77 Intraosseous Access Intermediate adult patients in cardiac arrest, commercial intraosseous introduction device This will require a transition program Lidocaine concentration changed to include 2% July & Nov 08

78 Umbilical Vein Cannulation Grammatical March 08

79 No Changes Vascular Access via Central Catheter Immunization March 08

80 Bloodborne/Airborne Pathogens Complete re-write incorporating updated standards from the Center of Disease Control and OSHA. CDC & OSHA’s Bloodborne pathogens Standards 29 CFR – 1910.1030 May 08

81 Crime Scene/Preservation of Evidence No Change March 08

82 Abuse and Neglect Reporting procedures section added. The reporting section strengthened by adding language from applicable NH RSA. May 08


84 Response to Domestic Violence Rewritten to heighten awareness of the potential dangers associated with domestic violence calls, and provider safety considerations. Reference section added. May 08

85 DNR Clarified the duties of the Durable Power of Attorney for Healthcare. Clarified revocation of a DNR. Procedures section made more descriptive. May 08



88 Special Resuscitation Situations and Exceptions Signs of Death” updated and “Factors of Death” Following the new AHA standard, EMS providers are not required to transport every victim of cardiac arrest to a hospital. Keeping in mind the risk involved to the EMS provider of performing resuscitation efforts in the back of a moving ambulance, the protocol was updated to reflect AHA’s recommendation that “it is expected that most resuscitations will be performed on-scene until return of spontaneous circulation or a decision to cease resuscitation efforts is made based on the criteria listed under “When to Stop””. March 08



91 No Changes Advanced Spinal Assessment On-Scene Medical Personnel March 08

92 Refusal of Care Rewrite of the competence section Added a procedural section Who is a patient?  Those people you, as an EMS provider, feel should go to the hospital, and the person is refusing to go. It is not for the person who is not hurt or injured. How can someone refuse care when no care was required. July 08



95 Pediatric Restraint NH Law reference to seatbelt use in pediatrics Updated to include 5 point restraints and isolette recommendations. Added size limits to various types of car seats Added examples of various car seats Reference: Position Statement of Association of Air Medical Services, “Improved Restraint Usage for Infant and Pediatric Patients in Ground Ambulances through Education and Policy Development, May 08

96 Pediatric Restraint Changed “Transport of Well Child” to “Non-Patient” to correctly discuss the transport of a child who is not a patient. For those ill children who need to be placed directly on the cot so that appropriate care may be rendered: Belting child directly to cot in manner to prevent ramping or sliding in a crash  Loop narrow belts over each shoulder and under arms, attaching to a non-sliding cot member  Use soft, sliding or breakaway connector to hold shoulder straps together on chest  Anchor belt to non-sliding cot member and rout over thighs, not around waist. May 08

97 Interfacility Transfers NH Protocol enables paramedics to continue medications that are not within their routine scope of practice, during an interfacility transport, provided that the medication was ordered and initiated prior to transport. The paramedic must proactively obtain working knowledge and education of any such medication –through such means as medication manuals or software, discussion with sending clinicians, discussion with medical director, etc. – prior to transporting the patient. Those medications identified by the NH EMS Medical Control Board as posing an increased risk of untoward effects such as paralytics, some sedatives, and vasoactive medications will also require completion of a NHBEMS approved education program. Paramedics must refuse to transport patients that have a level of acuity and/or medication regimen that the paramedic is not comfortable with, and work with the sending facility to acquire optimal staffing (such as sending nursing staff). Stable patients with low risk of deterioration (Intermediate level)  Any crystalloid infusion containing less than 10 meq/lt Sept & Nov 08

98 Interfacility Transfer Medications Training is available through your Medical Resource Hospital. Contact your EMS Hospital Coordinator EMS Units are required to ensure their paramedics have this training Paramedics are responsible for obtaining this training. Encourage Units to purchase a good medication reference resource

99 No Changes Hazardous Materials Exposure Mass/Multiple Casualty Triage July 08

100 Nerve Agents & Organophosphates MCI DuoDote Injectors and matrix box for ease of reading. In addition, because an MCI could involve hours or days, the albuterol dose was changed from a total of 3 nebulizers to “as needed.” July 08


102 Radiation Injuries MCI Adult and Pediatric No change July 08

103 Basic Changes Tourniquet for bleeding control as a last resort Levalbuterol added to MDI list Activated Charcoal only with advice from Poison Control or Medical Control AEDs can be used on newborns

104 Intermediate Changes Albuterol/ ipratropium mix (DuoNeb  ) for Adult Anaphylaxis and Asthma protocols  Requires transition program CPAP for CHF/Pulmonary Edema  Requires transition program Commercial Intraosseous introduction device (example: EZ-IO)  Requires transition program

105 Intermediate Changes 500 ml bolus 0.9% NaCl for hyperglycemia and dehydration (hyperthermia, fever, nausea/vomiting protocols) No more thiamine Intrafacility Transfer: Crystalloids containing less than 10 meq/lt of potassium

106 Paramedic Changes Levalbuterol maximum use: four doses Removed epinephrine infusion from adult anaphylaxis Removed the IV route of administration from haloperidol administration. Diphenhydramine dose change from 50 mg IV to 25 - 50 mg IV Pediatric dextrose dose based on length based resuscitation tape

107 Paramedic Changes Oxytocin dose change from 10 – 20 units in 1000 mL normal saline over 20 minutes to 20 unit in 1000 mL normal saline at 200 – 600 ml/hr Preterm labor tocolysis 20 mL/kg bolus IM and IN route for fentanyl  50 mcg IM up to a total of 150 mcg  1.4 mg/kg IN Prochlorperazine 5 mg – 10 mg (was 2.5 mg) Metoclopramide 5 mg (was 0.1 mg/kg to a maximum of 5 mg)

108 Paramedic Changes Granisetron IV dose changed to IV over 5 minutes Midazolam added to Tachycardia for sedation ACS – not all chest pain is cardiac Tetracaine added to Eye Injuries  2 drops every 5 minutes as needed Thiamine, Procainimide, Promethazine removed Etomidate & Succinylcholine: Maximum doses

109 Paramedic Changes IO – Lidocaine 2% added Intrafacility Transfers – paralytics, some sedative, and vasoactive medications will require completion of a NHBEMS approved program Cricothyrotomy: Age-appropriate commercial devices using technique of needle and guide-wire followed by dilatation. (like the Melker)

110 Plan Ahead As of January 2011  Continuous CO 2 monitoring for all intubated patients  Cyanide Antidote Kit (Lily kit) will be eliminated from the Cyanide Protocol  CPAP  Commercial Intraosseous introduction device  Portable suction equipment capable of adjusting from 80-300 mmHg

111 National Scope of Practice Defines and describes four levels of EMS certification/licensure nationally. Outlines the skills set and knowledge base required to competently function in the EMS system Foster greater mobility and reciprocity from state to state and other allied health disciplines

112 National Education Standards 2009 Transition Program  Procedures above and beyond the current curriculum National Education Standards  2010 – 2012  Name changes First Responder – Emergency Responder EMT Basic – EMT EMT Intermediate – Advanced EMT EMT Paramedic - Paramedic

113 Questions? Vicki Blanchard ALS Coordinator 223-4215

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