1. Region VIII EMS Systems February, 2017
Legal / Documentation
Region VIII EMS Systems
February, 2017

2. Objectives Review Region VIII SOPs for:
POLST vs Living Will
Power of Attorney for Healthcare
Initiation of ALS Care
Review Documentation Guidelines for:
POLST / Withdrawal of Resuscitation
Committals
Healthcare Surrogates / Designated Decision Makers (DDMs)
Narcotic Use and Disposition
Review NEMSIS 3 and future of EMS data

3. SME Video – Dr. Phillips

4. POLST IL – The Facts POLST:
stands for Practitioner Orders for Life-Sustaining Treatment. The POLST form is a signed medical order that documents the types of treatments seriously ill people want at end-of-life. It travels with the patient to assure that treatment preferences are honored across settings of care (hospital, nursing home, assisted living facility etc.).
is designed to help health care professionals know and honor the treatment wishes of their patients, by allowing people with advanced illness to choose the type of treatment they would want when they reach this point in their life.
is intended for people of any age who are seriously ill or have a life- limiting illnesses.
The POLST form is an advance directive in accordance with Illinois law.  It is NOT intended to replace a Power of Attorney for Health Care (POAHC) form, but to be used in addition to this form. (

5. POLST
Intended to be honored across various settings, including hospitals, nursing homes, and by emergency medical services personnel in the individual’s residence or in route to a healthcare facility
Should be used to replace the previous IDPH form
This provides individuals with choices regarding administration of CPR and other life sustaining treatments

6. POLST This takes into account: The patient’s personal views
The patient’s medical condition
Patient views regarding CPR in the event of an unforeseen accident (car crash, chocking on food)
Quality of life before and after CPR
Patient view’s regarding use of CPR during surgery or other medical procedures
Patient wishes for life sustaining treatments including mechanical ventilation, feeding tubes or other life sustaining treatments

7. General POLST Guidelines
If multiple forms are present, honor the one with the most recent date
EMS is not responsible for investigating the presence of other forms
Work with the form presented as being valid
Verbal assurances of other existing forms can not be considered valid unless give by patient or legal guardian
All copies of the form (original or duplicates) are valid
Any color paper is valid

8. Requirements to make a POLST valid
Patient Name
Resuscitation Orders - Section A
3 Signatures
Patient or Legal Representative
Witness
Practitioner (and name)
Effective Date
All other information is optional

9. POLST / DNR Documentation Tips
Narrative notes
Time of death
Physician name
Details that bolster your assessment of the validity of the POLST form
Effective date
Who consented
Name of Physician / APN / Medical Student / PA
Witness info

10. Illinois Health Care Surrogate Act
When a patient lacks decisional capacity, the health care provider must make a reasonable inquiry as to the availability and authority of a health care agent under the Power of Attorney for Health Care Law.
If no Power of Attorney, the health care provider must make a reasonable inquiry as to the availability of possible surrogates (priority order on next slide).
The surrogate decision makers, as identified by the attending physician, are then authorized to make decisions for patients who lack decisional capacity.

11. Health Care Surrogate Priority Order (755 ILCS 40/25)
Patient’s guardian of person
Patient’s spouse or partner of a registered civil union
Adult child
Parent
Adult sibling
Adult grandchild
A close friend of the patient
The patient’s guardian of the estate

12. Surrogate Decision Makers
Cannot void an existing POLST or other Advanced Directive UNLESS THEY WERE THE SIGNEE WHO GAVE ORIGINAL CONSENT, or have subsequently been appointed as Power of Attorney, without identification / authorization by the patient’s attending physician.
Would appear to be of limited use to EMS in an emergency situation where no advanced directive / POLST exists.

13. Voiding / Revoking a POLST Form
A patient with decisional capacity can void or revoke the form, and/or request alternative treatment.
Changing / modifying / revising the form requires completion of a new form.
Draw a line through sections A thru E and write “VOID” across the page of a revoked form.
Beneath the written “VOID”, re-sign and write in the date.

14. What is the risk to EMS of using POLST?
“A health care professional who in good faith complies with a do-not-resuscitate order made in accordance with this Act is not, as a result of that compliance, subject to any criminal or civil liability, except for willful and wanton misconduct, and may not be found to have committed an act of unprofessional conduct.” Illinois Health Care Surrogate Act

15. General Patient Assessment Emerging Infectious Diseases
November 2016
MERS-CoV (Middle Ease Respiratory Syndrome Coronavirus)
Saudi Arabia
Human Infection with Avian Influenza A (H7N9) Virus
China
Dengue Fever
Burkina Faso
Rift Valley Fever
Niger

16. MERS Caused by coronavirus
Symptoms include fever, cough and shortness of breath
3 to 4 out of 10 have died from the virus
Can affect anyone form 1-99 years of age
People with pre –existing medical conditions or weakened immune systems are more likely to be infected
Incubation period is usually 5-6- days
Most people who have died have had underlying medical conditions (CDC)

18. Influenza
Composition of U.S. flu vaccines are reviewed annually and updated to match circulating flu viruses
Current flu vaccine includes:
A/California/7/2009 (H1N1)virus
A/HongKong/4801/2014 (H3N2) virus
B/Brisbane/60/2008 like virus
Influenza A (H3 strain) is the predominate strain being seen currently
Flu like illnesses are currently on the increase Influenza outbreaks have been very sporadic and localized in Illinois

21. Adult Initial Medical Care - Reminders
Per Region VIII SOPs
Target SpO2 for most patients is 94-98% - administer oxygen to achieve that target
Continued use of existing central venous access devices is acceptable if initiated by RN or physician – document identity of person who initiated care, contact Medical Control before giving any medications via that access
Pain and nausea management should be considered for all patients

22. Adult Initial Medical Care - Reminders
Time Sensitive Patients – attempt to contact Medical Control as soon as practicable in the contact, to allow destinations as much time as possible to prepare / alert for your arrival. 1-2 minutes early in your encounter can save time in getting definitive treatment.
If you or the patient desire transport to other than the closest facility:
You must contact Medical Control BEFORE beginning transport
Medical Control must verify the availability of the receiving hospital before authorizing the bypass

23. Documentation Tips about AIMC
Just making a narrative note of “IMC” is inadequate.
Document :
initial patient presentation,
interventions
reassessment after each intervention
Baseline physical exam and reassessment
Baseline vital signs and reassessment
Only document blood glucose if done
Baseline (room air) SpO2, plus SpO2 with FiO2 if oxygen given

24. “What if…” – for group discussion
Per SOP, are you allowed to discontinue cardiac monitoring?
Adult Initial Medical Care
“All ALS patients do not necessarily require continuous ECG monitoring…”
Initiation of ALS Care
“Never discontinue ALS once initiated unless prior approval by Medical Control”
“What if…” – for group discussion

25. Radio Report

26. Radio Report 6. History • Signs and Symptoms • Allergies
• Medications: time and last dosage taken (bring all medications to ED)
• Past history of pertinent illness/injury
• Last oral intake (food or fluid) if known, Last Menstrual Period
• Events surrounding event
7. Clinical findings
• Assessment findings from review of systems - pertinent (+) and (-) findings
• Interpretation of ECG and vital signs
• Blood glucose for patients with altered mental status
• Body temperature when appropriate
• Cincinnati Prehospital Stroke Scale when appropriate
• Trauma score parameters if appropriate

27. How would you call this in?
How a crew member show how they would make this call As the receiving facility what would you want to know

28. EMS Documentation With every PCR you write
Imagine it enlarged on the big screen for judge and jury?
How is your spelling?
How organized are your thoughts?
Did you use creative or not approved abbreviations?

29. Documentation
To a layperson on a jury, a PCR that may be fully completed and accurate may still seem unreliable or even incomplete if it is sloppy, full of misspellings, or disorganized.
The Legal Guardian David J. Givot, Attorney EMS Documentation: The truth about Sticks and Stones September 05,2012

30. Documentation
Documentation can be used to call into question your competence as a
Provider
Your ability to render care
Your skills

31. Documentation Keep these concepts in mind when writing your report:
Make sure your spelling is correct or utilize spellcheck
If you are in doubt look it up or change a word
Use only approved recognizable medical abbreviations, otherwise spell it out!
Double check the accuracy of patient’s name, DOB, and other identifiers. If not sure document why!
Double check each box to make sure everything is covered

32. Documentation
If something is missing part of an assessment may be overlooked
Note times of any significant change in patient’s condition
When pain started?
When injury occurred?
Identify and attribute statements made by others that pertinent to the call

33. Documentation Be an Artist and Paint the picture
Organize your narrative so the reader get a sequential picture of the call from beginning to end
Do not rely on check boxes to tell the story
Every person who sees your PCR should know what you did and when you did it

36. Power of Attorney for Health Care
Does not require an attorney or physician to execute
Allows the appointed person to speak on the patient’s behalf in decisions of health care
If multiple PoA documents are executed, the one with the most recent date supercedes all previous

37. Power of Attorney for Health Care
Powers:
Talk to physicians and other health care providers about patient’s condition
See medical records and approve who else can see them
Give permission for tests, medicines, surgery, other treatments
Choose where the patient receives care
Choose who the patient receives care from
Decide to accept, withdraw or decline treatments “designed to keep you alive if you are near death or not likely to recover”
Agree or decline organ donation
Decide what happens to your remains after you have died, if not otherwise specified
Consult with your other loved ones to help come to a decision (but the Agent has final say)

38. Executing Power of Attorney
Patient name and address
Designated agent name, address and phone #
Enumerated powers

39. PoA Signatures

40. Successor Agents
In the event that the primary Agent cannot be contacted or does not wish to act during a time of need, successor agents (if specified, in the order listed) are asked to act
Only one agent at a time can act
May be more than two successors (add another page)

41. EMS interaction with PoA / Surrogates
In the absence of a POLST / DNR, Region VIII SOPs do not allow EMS to honor decisions or expressions by PoA or Surrogates in the arrest situation

42. No PoA? Living Will On the Power of Attorney form (IDPH)
WHAT IF THERE IS NO ONE AVAILABLE WHO I TRUST TO BE MY AGENT?
In this situation, it is especially important to talk to your physician and other health care providers and create written guidance about what you want or do not want, in case you are ever critically ill and cannot express your own wishes. You can complete a living will…

45. Living Wills
Not applicable to prehospital emergency care unless accompanied by a properly executed POLST / DNR
If arrest situation and family (not designated as PoA or guardian) wants to withhold or withdraw resuscitation, begin and contact Medical Control; follow orders received

46. Patients registered in hospice are almost certain to have advanced directives (Living Will, POLST / DNR)
Follow Section A (CPR) and B (Medical Interventions) of POLST

47. Documentation Tips – non-POLST
Thoroughly document all interactions with family members / surrogates / PoAHC, and all Medical Control interactions
If Living Will with no POLST, be sure to document any actions you took to attempt to locate POLST form

48. Involuntary Admission
This discussion assumes you have met the threshold for transporting the patient
The patient willingly goes with EMS
The patient is placed into protective custody by law enforcement and EMS is transporting
The patient has been ordered admitted by a court order and law enforcement / EMS collaborate to facilitate the admission

49. Illinois Admission Petition
If you are asked to enter information in a petition, you are only entering what you saw or heard, similar to what you would write in your PCR
You are participating in a request by the hospital, social services or crisis workers to allow the patient to be admitted for 24 hours for psychiatric evaluation

51. Documentation Tips – Involuntary Admissions
Be sure to write the same findings in your narrative that you write on the petition, to eliminate any perception of a conflict
Use of patient quotations is best, as well as directly quoting bystander statements
Objective observations only

52. Scenario 1
Flipped script with audio – participants play YOU ARE THE ECRN!

53. Scenario 2
Flipped script with audio – participants play YOU ARE THE ECRN!

54. Scenario 3
Flipped script with audio – participants play YOU ARE THE ECRN!

55. Medication of the Month
Atropine

56. Atropine Indications Symptomatic bradycardia
Muscarinic / organophosphate poisoning
Has not been recommended for use in cardiac arrest since the 2012 SOP revision

57. Cardiovascular / Physiologic Effects
Atropine is an indirect cardioaccelerator
Parasympathetic NS is always “dragging the brake”
Atropine blocks the parasympathetic NS / blocks the brake pedal
Inhibits the CNS from slowing the heart rate

58. Organophosphate Effects
Primary mechanism of action of organophosphate pesticides is inhibition of acetylcholinesterase (AChE)
AChE helps break down Ach for use in the CNS
When AChE is inhibited, Ach accumulates throughout the nervous system, resulting in overstimulation of muscarinic and nicotinic receptors, which causes the symptoms

59. Organophospate Patient Presentation
Muscarinic
SLUDGEBAM
Nicotinic
Muscle fasciculations
Cramping
Weakness
HTN / tachycardia
CNS
Anxiety
Mental status / mood changes
Tremors
Seizure
Coma

60. Vitals Vitals can be stimulated or depressed Depressed respirations
Bradycardia
Hypotension
Tachypnea
Hypertension
Tachycardia
Continuous pulse oximetry
Vitals can be stimulated or depressed

61. Atropine

63. Documentation Tips – Controlled Substances
Controlled substance storage / security
System / Agency specific documentation procedure
Original (now broken) tag number if tags used
New (unbroken) tag number
What is your procedure for documenting dosages given, dosages wasted, disposition?

64. Sinus Arrest / Block generically sinus node dysfunction
ECG Rhythm of the Month
Sinus Arrest / Block
generically sinus node dysfunction

65. Sinus Node Dysfunction
Sinus node is usually reliable and regular
SND is diagnosed when sinus node fails to properly generate and/or propagate impulses
Mild dysfunction usually produces no symptoms
As dysfunction increases, symptoms may include signs/symptoms of hypoperfusion and/or sensation of irregular heartbeat
1:600 cardiac patients > 65 years old

66. Etiology Intrinsic causes Extrinsic causes
Age-related sinus node changes
Coronary Artery Disease
Atherosclerotic changes in sinus node artery
Extrinsic causes
Medications
Digitalis, propranolol, verapamil, quinidine, procainamide, lidocaine, reserpine
Autonomic nervous system hyperactivity

67. Sinus Block vs Sinus Arrest

68. Sinus Block With SA block, the R-R interval for the gap:
Is usually short (only one missing beat)
Resumes cadence within ~ .08 sec (2 small boxes)

69. Sinus Arrest With SA arrest, the R-R interval for the gap:
May be short or long (> 1 missing beat, pause can be several seconds duration)
Does not usually resume previous cadence

70. Signs & Symptoms One missing beat Multiple missing beats, long pauses
Patient feels palpitation or irregularity
Usually no cardiovascular implications
Multiple missing beats, long pauses
May be decrease in cardiac output
Escape beat may be sensibly different than other heartbeats if different pacemaker site
Question – what do you call a sinus arrest that does not resume normal beats?
If sinus arrest occurs and no escape pacemaker sites kick in, the patient is in asystole.

71. Procedures of the Month
BLS – Peer Review of BLS / Refusal of Care PCRs
ALS – Peer Review of ALS / Refusal of Care PCRs
Choose three PCRs per agency per level (ALS and BLS) involving patients who refused care. Use the “student” PCR version without specific patient identifiable information. Review documentation of vitals, procedures, Medical Control contact (if any), narrative, for completeness and legibility.