CENTRAL NEW YORK - CNYEMS

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CENTRAL NEW YORK REGIONAL EMERGENCY MEDICAL SERVICES

PROGRAM

POLICY STATEMENTS

SERVING: CAYUGA, CORTLAND, ONONDAGA, OSWEGO, AND TOMPKINS COUNTIES

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INDEX

POLICY SUBJECT STATUS 96-01 REMAC Meeting Cancellation Removed: No longer applicable

96-02 Pronouncement Of Death Superseded by 14-01

96-03 Cancellation of Responding BLS and ALS Units Superseded by 06-01

97-01 Storm/Limited Transport Protocol Superseded by 14-02

97-02 School Incidents and Bus Accidents Superseded by 03-03 & BEMS 99-11

97-03 ALS Providers Transporting in BLS Vehicles Superseded by 14-03

97-04 Providing Medical Direction Superseded by 09-04

97-05 Glucometers Superseded by 08-03

97-06 Reciprocal Agreements Active 98-01 Transfer of Patients from Higher to Lower Level of Care Removed: Refer to ALS Protocols

99-01 Radio Reports and Requests for Orders Superseded by 14-12 & BEMS 11-05

99-02 Public Access Defibrillation Superseded by BEMS 09-03

99-03 Viagra ® and Nitrates Superseded by 04-01

99-04 Abbreviated ALS Clearances Removed: No longer applicable

00-01 Minimum Equipment for ALS and ALS FR Units Superseded by 09-03

00-02 Nebulized Albuterol Use by EMT-D and EMT-I Removed: Refer to ALS Protocols & NYS BLS Protocols

00-03 Dispatch Superseded by 14-04

00-04 Hospital Diversion Superseded by BEMS 06-01

00-05 Ambulance Restocking Removed: No longer applicable

00-06 Use of AED for Pediatric Patients Superseded by 03-04

01-01 Patient Refusal of Care Superseded by 03-03

01-02 Treatment and Transport of Minors Removed: Refer to BEMS 99-09

01-03 Corrective Action Superseded by 14-05

01-04 Registration, Continuing Medical Education & Reinstatement Superseded by 05-03

01-05 Interim Medical Director Superseded by 14-06

01-06 Photo Identification for EMS Providers Superseded by BEMS 12-05

02-01 ALS for Patients Receiving Medications from BLS Providers Superseded by 14-07

02-02 ALS Procedures Removed: Refer to ALS Protocols

02-03 Three Lead EKG Transmission Removed: Refer to Minimum Equip List

02-04 Biphasic Defibrillation Removed: Refer to ALS Protocols

03-01 Mark I Kits Superseded by BEMS 03-05

03-02 Certificate of Need Applications Superseded by 07-01

03-03 Patient Refusal of Care Superseded by 14-08

03-04 Use of AED for Pediatric Patients Removed: Refer to NYS BLS Protocols & SEMAC Advisory 02-02

03-05 Use of AED by ALS Services Removed: Refer to ALS Protocols & BEMS 10-01

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INDEX

03-06 Multiple Aircraft Response to a Single Scene Superseded by 14-13

04-01 Use of Erectile Dysfunction Medications and Nitrates Removed: Refer to ALS Protocols

05-01 Use of Nalbuphine Removed: No longer applicable

05-02 Use of Manual Defibrillators by Intermediate Level Services Removed: Refer to ALS Protocols


06-01 Cancellation of Responding BLS and ALS Units Active 06-02 Carbon Monoxide Monitors Active 06-03 CNYEMS BLS Protocols Removed: Refer to NYS BLS Protocols

07-01 Certificate of Need (CON) Superseded by 14-14

07-02 Hemostatic Gauze Superseded by 12-01


08-02 Blood Glucometry for BLS Agencies and Providers Superseded by 17-02

08-03 Glucometers Superseded by 17-01 & 17-02 09-01 Nitronox Requirements Active 09-02 Rapid Sequence Induction Program Superseded by 17-03 09-03 Minimum Equipment for ALS and ALS FR Units Superseded by 11-01

09-04 Providing Medical Direction Superseded by 14-12


12-01 Hemostatic Gauze and Tourniquets Removed: Refer to BEMS BLS Protocols


14-01 Pronouncement Of Death Removed: Refer to Collaborative Protocols

14-02 Storm/Limited Transport Protocol Active

14-03 ALS Providers Transporting in BLS Vehicles Active

14-04 Dispatch Superseded by 18-01

14-05 Corrective Action Active

14-06 Interim Service Medical Director Superseded by 17-13 14-07 ALS for Patients Receiving Medications from BLS Providers Active 14-08 Patient Refusals Superseded by 17-04 14-09 Registration, Continuing Medical Education & Reinstatement Active 14-10 Minimum Equipment for ALS and ALS FR Units Superseded by 17-01 14-11 Electronic PCR Data Submission to REMAC Superseded by 21-01

14-12 Providing Medical Direction – EMS Physician Active

14-13 Multiple Aircraft Response to a Single Scene Superseded by 17-10 14-14 Certificate of Need (CON) Superseded by 15-01 14-15 Clarification of Operating Territory (COT) Active

15-01 Certificate of Need (CON) Active

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INDEX


17-02 Regional Approvals Superseded by 18-02

17-03 Rapid Sequence Intubation Program Active

17-04 Patient Refusals Active

17-05 General Patient Care Active

17-06 Medication and Medical Control Active

17-07 Medical Director Discussion of Protocol Deviations Active

17-08 Transfer of Care Active

17-09 Physician on Scene and Physician on Scene Card Active

17-10 Air Medical Utilization and Multiple Aircraft Response Active

17-11 Emergency Incident Rehab Active

17-12 Trauma Center Destination Active

17-13 Interim Service Medical Director Active

18-01 Dispatch Active 18-02 Regional Approvals Active 20-01 Minimum Equipment for ALS and ALS FR Units Active 20-02 FAST-ED Stroke Scale Active 21-01 Electronic PCR Data Submission to REMAC Active

Policy: It is the policy of the REMAC that a reciprocal agreement concerning the provision of prehospital care by providers from adjacent REMAC regions is in force. Procedure: The adjoining REMACs have received and reviewed Prehospital Treatment protocols from the identified Regional Emergency Medical Advisory Committees. The REMACs find the protocols to have acceptable and expected content consistent with the current practice out of hospital care medicine. For the purposes of the agreement, an Agency’s Origination REMAC is the REMAC that has the authority over the geographic area in which the agency is physically located. The Regional Emergency Medical Advisory Committee Chairs agree that when a prehospital care provider is physically located in a REMAC region outside of their agency’s origination REMAC, that the prehospital care providers shall provide care consistent with the protocols, policies and procedures of the agency’s origination REMAC but shall accept online Medical Control from the receiving hospital, or from the institution which delivers Medical Control in the geographic area in which the provider and patient are physically located. It is specifically understood then that when a prehospital provider is providing care in an area outside their agency’s origination REMAC, the prehospital provider shall continue to provide off line medical care consistent with their agency’s origination REMAC protocols. If online Medical Control is received from outside the provider’s agency’s origination REMAC area, the providers shall accept all orders from online medical control physicians, as long as they do not exceed the provider’s and agency training.

Origination REMAC defined scope of practice. The agency will be obliged to arrange pharmaceutical and supply exchange.

Matters associated with quality improvement and or remediation will be handled REMAC to REMAC. Providers, agencies or institutions seeking resolution or action shall contact the REMAC that has authority over their geographic area.

The agreement shall remain in force until otherwise requested in writing by a participating REMAC.

Central New York Regional Emergency Medical Services

Program

Policy Statement Serving: Cayuga, Cortland, Onondaga, Oswego and Tompkins Counties

No. 97-06 Date: 12/97 Subject: Reciprocal Agreements Page 1 of 1 Supersedes/Updates: Original

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Policy: A responding Advanced Life Support unit may be canceled by a Basic Emergency Medical Technician or a higher trained pre-hospital provider on scene under the following circumstances:

• The provider has personally assessed the patient.

AND • The patient does not meet any of the major trauma criteria of the New York State

Basic Protocols. AND • The ALS unit is not the only responding transporting unit if the patient will need to

be transported. The provider canceling the ALS unit will be responsible for completing the PCR and/or all associated paperwork, including documentation of the cancellation of the ALS unit. A Certified First Responder on the scene may cancel the responding unit only if no injury or illness whatsoever exists.

Central New York Regional Emergency Medical

Services Program


No. 06-01 Date: 03/06 Subject: Cancellation of Responding BLS and ALS Units Page 1 of 1 Supersedes/Updates: 96-03

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Policy:

The use of non-invasive prehospital carbon monoxide monitors by agencies in the Central New York Region is voluntary. Agencies are required to perform an agency in-service prior to implementing such specialized equipment. Agencies are advised to use the equipment as specified by the manufacturer. When patients present with signs and symptoms of carbon monoxide poisoning, providers will notify and confer with a Resource physician to determine the most appropriate prehospital treatment and facility for transport.

Reference: Minutes of CNY REMAC meeting of November 09, 2006.


Program


No. 06-02 Date: 11/09/06 Subject: Carbon Monoxide Monitors Page 1 of 1 Supersedes/Updates: Original

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Policy:

The Central New York REMAC has established this policy to maintain consistency regarding the utilization of Nitronox throughout the region. The REMAC recognizes the importance of appropriate pain management. The Central New York Advanced Life Support Pain Management Protocol must be followed in the use of Nitronox. In an effort to minimize the potential abuse that can occur with this medication, the CNY REMAC requires the following controls be maintained by every agency that chooses to carry Nitronox.

1) The Nitronox unit is secured in such a manner that no medication can be delivered without breaking a serial numbered seal/tag.

2) The agency incorporates the CNY REMAC Nitronox Inventory Control Sheet into their routine inspection program. A separate Inventory Control Sheet will be required for each Nitronox unit.

3) All spare cylinders containing Nitrous Oxide shall be secured in such a manner that no medication can be delivered without breaking a serial numbered seal/tag. The agency must implement some method that tracks these serial numbered seals/tags.

4) The agency must assure that this medication, like all medications, is secured, accounted for and some standardized method is established to enforce this accountability. Any unexplained loss requires that an agency incident report is completed and an investigation is completed.

Any agency that wishes to carry this optional medication is required to contact the CNY office to inform them of their plan and assure that they are in compliance with the intent of this policy. All ALS providers are required to successfully complete the regional Nitronox educational program, quiz and regional contract prior to utilizing this medication. Reference: Minutes of CNY REMAC meeting of May 8, 2008.


Program


No. 09-01 Date: 09/01/09 Subject: Nitronox Requirements Page 1 of 1 Supersedes/Updates: Original

Policy: When current weather conditions or other emergencies that severely limit highway and road travel, this protocol may be used. This will allow agencies to transport stable patients whose needs can be met by an urgent care center to be transported to such a facility under the direction of medical control. Procedure: The county EMS Coordinator will contact the Medical Director* and request that he or she implement the Storm/Limited transport Protocol. When authorization has been granted, the county EMS coordinator will contact the appropriate REMAC approved Urgent Care Centers that might serve as closer facilities to determine their ability to participate. Then the ambulance services and the on-line medical control hospital will be notified of these alternate sites. The Medical Director will notify the Syracuse Office of Health Systems Management when the Storm/Limited transport protocol is in effect. The on-line medical control physician will be contacted for all patients to determine if the patient may be treated at an urgent care center or if their condition requires transport directly to the hospital. Any EMT who feels that a patient does not need transport to any facility, or whose transport may be delayed without harm to the patient is to contact medical control for permission NOT to transport. When conditions resolve sufficiently to resume normal operating procedures, the county EMS Coordinator will contact the Medical Director who will contact the Syracuse Office of Health Systems Management to inform them that normal operating procedures are in effect again PCRs for any patient not transported or transported to a REMAC approved alternate destination site should be sent to the Regional Clinical Coordinator at the CNYEMS program for review. The patient always has the right to request to go to the hospital. Patients who are critical or unstable must be transported to the nearest regionally approved hospital emergency department. *If the Medical Director is unavailable, the Resource Physician may act in his or her stead.


Program


No. 14-02 Date: 11/5/14 Subject: Storm/Limited Transports Page 1 of 1 Supersedes/Updates: 97-01

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Policy: Any paramedic or critical care technician may employ his or her skills as limited by the equipment available while working on any ambulance. For example, a paramedic may intubate a breathing patient while working on an AEMT ambulance.


Program


No. 14-03 Date: 11/5/14 Subject: ALS Providers Transporting in BLS Vehicles Page 1 of 1 Supersedes/Updates: 97-03

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Policy: It is the function of the CNYEMS Regional Continuous Quality Improvement Program to review any/all instances where there is an allegation of a patient care issue/concern, and to develop corrective action as necessary. Reference the CNYEMS Regional CQI Manual for additional information. The following must be referred to the CNYEMS Program Agency immediately.

• Esophageal Intubations • Medication Errors

a. Medication Errors only involving route and/or dose calculation errors, please consult with Agency Medical Director prior to referral. Referral to the Program Agency for these types of errors will be at the discretion of the Agency Medical Director

• Patient Abandonment Issues • Practicing Medicine without a license • Protocol Errors and Deviations • Situations that might immediately place patients in danger • Criteria for Part 800 listed below

The following must be reported to the New York State Bureau of EMS by contacting the Regional Representative in addition to notifying the CNYEMS Program Agency within twenty four hours of the agency being notified of the incident.

• Noncompliance with Part 800.15: Required Conduct • Noncompliance with Part 800.16: Suspension and Revocation • A patient dies, is injured or otherwise harmed due to actions of

commission or omission by a member of an agency. The provider and agency will be notified by the Executive Director as soon as the call review and remediation has been determined. All other situations will be handled on an individual basis depending on the severity of the complaint. The case will either be sent


Program


No. 14-05 Date: 11/5/14 Subject: Corrective Action Page 1 of 2 Supersedes/Updates: 01-03

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After notification of any patient care issue, the CNYEMS REMAC may decide the situation requires notification of the New York State Department of Health. At that time, ALS privileges may be immediately restricted. For information on the review process, hearings, acceptable remediation, and cases of providers requiring repeated corrective action, see the CNYEMS CQI manual. Reference: Central New York Emergency Medical Services Continuous Quality Improvement Manual

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Policy: Any patient receiving medication from a BLS or AEMT Provider, regardless of condition after treatment, must receive ALS care. Refer to the CNYEMS Routine Medical Care and Routine Trauma Care Protocols. Procedure: Once a basic provider has made the determination to administer a medication according to protocol, they should immediately request an ALS hook up. The arriving ALS provider must transport with the patient and initiate ALS interventions as appropriate. The only exception to this is if the hospital is closer than any ALS unit. In this case initiate transport as soon as possible.


Program


No. 14-07 Date: 11/5/14 Subject: ALS for Patients Receiving Medications from BLS Providers Page 1 of 1 Supersedes/Updates: 02-01

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Policy: This policy defines the requirements for registration, continuing medical education, and reinstatement into the regional EMS system of New York State certified providers at the following levels: Emergency Medical Technician, Advanced Emergency Medical Technician, Advanced Emergency Medical Technician-Critical Care, and Advanced Emergency Medical Technician-Paramedic. Procedure: 1. Registration of:

A. EMT:

Effective July 15, 2005 CME (Continuing Medical Education) Managers are required to create a file folder for all certified personnel, including verification of New York State certification and verification of CPR (Cardiopulmonary Resuscitation) Proficiency. CPR proficiency may be documented by a current CPR card or memorandum on file verifying personnel have demonstrated skills in the presence of a CPR Instructor. CME Managers are required to ensure newly certified EMT personnel have successfully completed a protocol exam via the www.cnyems.org website.

B. New ALS (Advanced Life Support) providers: In order to practice, the new ALS provider must become affiliated with an EMS agency. Secondly, the provider must register via the www.cnyems.org website and successfully complete a protocol exam appropriate to the provider’s level of certification. The provider must supply a copy of his or her certification and verification of CPR proficiency to both the EMS agency and to the CNYEMS Program offices.

C. Upgrading providers: Providers who attain New York State certification at a level higher than current registration must submit copies of upgraded certification card and CPR proficiency verification to both the agency and the CNYEMS Program offices. This will alert the Program offices of the provider’s new certification level and the provider’s status will be upgraded and will become visible to both the provider and the agency’s CME Manager.


Program


No. 14-09 Date: 11/5/14 Subject: Registration, Continuing Medical Education and Reinstatement Page 1 of 3 Supersedes/Updates: 05-03, 08-01

http://www.cnyems.org/


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D. Providers from other New York State EMS Regions: In order to practice in this system, providers from another region must complete the requirements of a new provider (either step A or B above). In addition, the provider is required to submit proof of good standing from the region in which the provider currently practices. Also, if applicable, the provider must demonstrate proficiency at all skills not required or evaluated by the current region and be successfully evaluated by a CNYEMS approved CME Evaluator. Lastly, the provider’s CME didactic requirements will be prorated from the time of registration.

2. Continuing Medical Education requirements for:

A. EMT:

Annual evaluation must be performed and agency CME Managers must report standing of each provider by December 31 of each year. Only providers who have completed the following will be considered in good standing:

Successful completion of one scenario-based defibrillation Verification of CPR Proficiency Demonstration of proficiency Albuterol administration proficiency in a

scenario based skill station, and approved by a CNYEMS CME Evaluator.

Demonstration of proficiency Epinephrine auto-injector administration proficiency in a scenario based skill station, and approved by a CNYEMS CME Evaluator. (if applicable)

B. AEMT:

Semi-annual, or semester, requirements must be completed and evaluations must be performed by June 30 and December 31 of each year. Agency CME Managers must report standing of each provider within five days of the conclusion of each semester in order for the provider to be considered in good standing. Only providers who have completed the following shall be deemed complete:

12 Classroom hours per year (minimum of 6 hours by June 30 and an additional minimum 6 hours by December 31).

*Semester skill maintenance as outlined in the AEMT CME Provider Handbook, approved by a CNYEMS CME Evaluator.

Annual CPR demonstration due by December 31.

C. EMT-CC: Semi-annual, or semester, requirements must be completed and evaluations must be performed by June 30 and December 31 of each year. Agency CME Managers must report standing of each provider within five days of the conclusion of each semester in order for the provider to be considered in good standing. Only providers who have completed the following shall be deemed complete:

20 Classroom hours per year (minimum of 10 hours by June 30 and an additional minimum 10 hours by December 31).*

Semester skill maintenance as outlined in the EMT-CC CME Provider Handbook, approved by a CNYEMS CME Evaluator.


D. EMT-P: Semi-annual, or semester, requirements must be completed and evaluations must be performed by June 30 and December 31 of each year. Agency CME Managers must report standing of each provider within five days of the conclusion of each semester in order for the provider to be

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considered in good standing. Only providers who have completed the following shall be deemed complete:

24 Classroom hours per year (minimum of 12 hours by June 30 and an additional minimum 12 hours by December 31). *

Semester skill maintenance as outlined in the EMT-CC CME Provider Handbook, approved by a CNYEMS CME Evaluator.


* Providers have the option of completing all classroom hours as ALS. Otherwise, a minimum or 50% must be ALS for EMT-I, EMT-CC, and EMT-P. Providers also may choose to complete all classroom hours in the first semester.

3. Reinstatement of:

A. Providers placed on inactive status at their own request:

Any provider may be placed on self-declared inactive status following a written request to the Regional Medical Director. In order to be reinstated the following must be completed or submitted to the CNYEMS Program offices:

Updated user account information via the www.cnyems.org website. Completion of a protocol exam at the appropriate level. Verification of New York State certification. CME didactic and skills requirements commensurate with certification level. Skills must be

approved by a CNYEMS CME Evaluator.

B. Providers placed on inactive status and prohibited from practice due to failure to complete CME requirements: Any provider who does not complete CME Requirements will be considered prohibited from practice until requirements are met. In order to be reinstated, the provider must:

Update user account information via the www.cnyems.org website. Completion of a protocol exam at the appropriate level. Verification of New York State certification. CME didactic hours equivalent to lesser of requirements one year or of period of time

during which provider was inactive. ** Skills demonstration commensurate with certification level, approved by a CNYEMS CME

Evaluator. ** Completion of a New York State refresher course satisfies all delinquent CME requirements. Notes: 1. After initial entry or reinstatement into the system, the agency CME Manager is

responsible for certifying the continued good standing of providers.

2. Under special circumstances, exceptions to this policy may be requested in writing to the Regional Medical Director.



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Policy: The ultimate responsibility for all prehospital care providers in the five county region known as Central New York is vested in the Regional Medical Director by the Regional Medical Advisory Committee. The Regional Medical Director extends the PRIVILEGE to practice to prehospital care providers, authorizes Physicians to provide on-line medical control as well as out of hospital medical control (below) and prescribes or directs the operation of all pre-hospital activities regardless of level of training. The Regional Medical Director delegates the responsibility to oversee advanced life support, to the Associate Medical Director and the Clinical Coordinator to review care and offer support to the ALS community. The Associate Medical Director or Clinical Coordinator is empowered to suspend, with cause, the privileges of any prehospital care provider or suspend the authority of any medical control physician, in both cases subject to peer review by the Executive CQI Committee and appeal to the REMAC. On-line Medical Control authority is delegated to the emergency physician at either the Resource or Associate hospital. Physicians who provide medical control must be oriented to the protocols used by the Central New York Region. Either the Emergency Department Director, Clinical Coordinator or Associate Medical Director must provide this orientation and the hospital must provide a list of those oriented to the Regional Medical Director. Physicians providing routine on-scene emergency medical care and contemporaneous medical direction, will be approved and / or designated by the Central New York Regional Medical Director and have met the basic minimum standards as outlined by the Regional Medical Director and the Central New York Regional Medical Advisory Committee (REMAC). These physicians may include, but not necessarily limited to, members of the EMS and Disaster Medicine Fellowship, Service Medical Directors, REMAC Physicians. The actions of these physicians will be in accordance with current accepted medical practice including medical record keeping and documentation. These physicians will pre-empt the implementation of the "Physician On Scene" policy, after appropriately identifying themselves. At no time should a request be made of a Prehospital provider to exceed his or her capabilities. Should the physician implement procedures or


Program


No. 14-12 Date: 11/5/14 Subject: Providing Medical Direction – EMS Physician Page 1 of 5 Supersedes/Updates: 97-04, 09-04

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treatments beyond the scope of current policy and practice, he/she will then be required to accompany the patient to the hospital. At no time will a provider be expected to exceed his/her scope of practice. Each ALS and BLS Agency within the Central New York EMS Region will identify a Service Medical Director. He/she shall participate in the agency CQI program and may advise the Agency regarding medical care. The Service Medical Director may speak as the advocate of the agency to the Regional Medical Director, Associate Medical Director, Clinical Coordinator, or Medical Control Physician. The following descriptions the different levels of EMS Physicians in the CNYEMS Region and the requirements for each level. On-line Medical Control Physician:

Description: • Physician whom provides on-line medical control via radio (applies to Physician

only while working at receiving hospital approved to provide orders to EMS personnel)

Requirements:

• Valid New York State medical license or appropriately credentialed Resident Physician operating under the supervision of Attending Physician

• Physician must be practicing in the emergency department when providing medical oversight

• Completion of CNYEMS Base Station Physician Course BLS Service Medical Director:

Description: • Service Medical Director or Associate/Assistant Medical Director of a BLS Agency

Requirements:

• Valid New York State medical license • Completion of New York State DOH Medical Director Verification Form (DOH-4362)

o Affirmation of responsibility for oversight of the pre-hospital quality assurance / quality improvement program for the Agency including: Provision of medical oversight on a regular and on-going basis In-service training Review of Agency policies that are directly related to medical care

o Familiarity with the applicable SEMAC and REMAC treatment protocols, policies and applicable state regulations concerning BLS care provided by the Agency

• Completion of the CNYEMS EMS Physician Application • Approval by CNYEMS REMAC

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ALS Service Medical Director:

Description: • Service Medical Director or Associate/Assistant Service Medical Director of an

AEMT (or ILS until July 2015) Agency or higher.

Requirements: • Valid New York State license • Board Certified / Board Eligible (BC/BE) Emergency Physician or Physician BC/BE

in another specialty with significant emergency medicine or critical care or EMS experience

• Valid DEA license • Completion of New York State DOH Medical Director Verification Form (DOH-4362)

o Affirmation of responsibility for oversight of the pre-hospital quality assurance / quality improvement program for the Agency including: Provision of medical oversight on a regular and on-going basis In-service training Review of Agency policies that are directly related to medical care

o Familiarity with the applicable SEMAC and REMAC treatment protocols, policies and applicable state regulations concerning AEMT/CC/Paramedic care provided by the Agency

• Completion of the CNYEMS EMS Physician Application • Approval by CNYEMS REMAC

Physician Responder – Dependent:

Description: • Physician riding on an ambulance or another emergency vehicle assigned to a

crew at all times consisting of an EMT or higher. This Physician will not be responding without an EMS crewmember with them but may provide on-scene medical control superseding the Physician-On-Scene Protocol. Physician will respond only with Agencies he or she is affiliated with and through which the Physician has been approved to act in this capacity. The Agency may revoke this privilege at any time with writing notification to the Physician and CNYEMS. This Physician does not have to be a Medical Director of the Agency but must have written approval from the Service Medical Director if that Physician is not the Service Medical Director.

Requirements:

• Valid New York State license • Board Certified / Board Eligible (BC/BE) Emergency Physician or Physician BC/BE in another specialty with significant emergency medicine or critical care or EMS experience

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• Completion of CNYEMS Base Station Physician Course • OSHA / Right To Know • HAZMAT Awareness • ICS 100/200/700 minimum • Infectious disease training • Agency specific orientation • Proof of malpractice covering EMS activities including medical direction and

direct patient care in the field. • Completion of the CNYEMS EMS Physician Application • Approval by CNYEMS REMAC • The Agency will be responsible for assuring compliance with any applicable

requirements including but not limited to OSHA/Right to Know, hazardous materials education, infectious disease preparedness, and any other agency-specific orientation.

Physician Responder – Independent:

Description: • Physician authorized to respond to an EMS call, for example, in a vehicle without

another prehospital provider present. Physician may provide on-scene medical control superseding the Physician-On-Scene Protocol. Physician will respond only with Agencies he or she is affiliated with and through which the Physician has been approved to act in this capacity (mutual aid responses are permitted). The Agency may revoke this privilege at any time with writing notification to the Physician and CNYEMS. If this Physician is driving, they must be a member of the Agency they are riding with and covered under their policies and insurance for driving. This Physician does not have to be a Medical Director of the Agency but must have written approval from the Service Medical Director if that Physician is not a Service Medical Director himself or herself.

Requirements:

• Valid New York State medical license • Board Certified / Board Eligible (BC/BE) Emergency Physician or Physician BC/BE

in another specialty with significant emergency medicine or critical care or EMS experience

• Completion of CNYEMS Base Station Physician Course • OSHA / Right To Know • HAZMAT Awareness • ICS 100/200/700 minimum • Infectious disease training • Agency specific orientation • Completion of EMS Fellowship or EMS Subspecialty Board Certification or

significant prehospital emergency care experience

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• Proof of malpractice covering EMS activities including medical direction and direct patient care in the field.

• Service Medical Director approval if Physician is not the Service Medical Director • Completion of the CNYEMS EMS Physician Application • CNYEMS REMAC approval • The Agency will be responsible for assuring compliance with any applicable

requirements including but not limited to OSHA/Right to Know, hazardous materials education, infectious disease preparedness, and any other agency-specific orientation.

• If driving: o Valid driver’s license (state-specific based on Agency requirements) o EVOC or equivalent o Proof of active membership in Agency covered and subject to Agency

policies and insurance regarding operation of emergency vehicle Reference: NYS DOH BEMS Policy Statement #11-03 Minutes of REMAC meetings dated July 16, 2009 and August 14, 2014.

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Policy: Any certified EMS agency seeking to have their operating certificate territory description changed must follow the process outlined in this policy and NYS DOH Policy Statement 11-06 Clarification of Operating Territory (COT). Reference: NYS DOH BEMS Policy Statement #11-06 Minutes of REMSCo meeting dated September 16, 2014.


Program


No. 14-15 Date: 9/16/14 Subject: Clarification of Operating Territory (COT) Page 1 of 3 Supersedes/Updates: Original

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CLARIFICATION OF OPERATING TERRITORY REQUEST

WORK SHEET To be completed and made part of the record.

1. Formal Written Request for a Clarification of Operating Territory (COT):

YES NO Written request for Clarification of Operating Territory received from

the service Written request explains why the service’s territory qualifies for the

COT Written request indicates the service has been instructed by NYS

DOH to apply to a REMSCo for a traditional CON to correct the service’s operating territory

2. Supporting Documents for the COT Request:

YES NO DOH issued Operating Certificate (DOH-4005 or DOH 3414) or

service record Contracts Maps Copies of Patient Care Reports (with patient identification removed

but geographical information included to substantiate location) Dispatch records or call logs Correspondence and/or communications with municipalities, other

EMS agencies, REMSCo or Program Agency, or the DOH relating to the territory needing clarification

Media documentation and historical records 3. Statements of Concurrence or Support:

YES NO Statements of concurrence or support, from impacted

municipalities, adjoining certified services, services holding overlapping EMS operating authority and all public-safety answering points (PSAPs) or dispatch systems having jurisdiction

Statements are less than 6 months old Statements are signed by the executive officers or elected officials

of the represented concerned parties 4. CNY REMSCo Written Acknowledgement:

YES NO Written acknowledgment by the REMSCo sent to the service Written acknowledgment by the REMSCo sent to the NYS DOH NYS DOH verification that the service’s territory concerns are

eligible for the COT process

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5. Formal Written Request and Supporting Documents Deemed Complete:

YES NO DATE REMSCo/Program Agency Staff Review and Comment Committee

6. CNY REMSCo Actions:

YES NO DATE REMSCo approval for the “Endorsement of the

need for clarification and a recommendation of the terminology and wording that will most accurately describe the applicant's existing operating territory without expansion"

Written notification sent to the NYS DOH indicating the motion and vote of the REMSCo, including a copy of the formal written request and supporting documents

7. NYS DOH Bureau of EMS Decision:

Agree Deny DATE NYS DOH issue of an amended DOH 4005 or

DOH-3414

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Policy: Every new EMS service or any seeking to expand its primary service territory must, by statute, receive the approval of the appropriate Regional EMS Council utilizing the procedure outlined in this policy. As set forth in Article 30, Section 3003 of New York State Public Health Law, the Regional Emergency Medical Services Council has set the Certificate of Need application fee for new EMS Service or Expansion of Primary Operating Territory for Ambulance Service or Advanced Life Support First Response Service at $3000.00. The application fee for Transfer of Ownership for Ambulance Service or Advanced Life Support First Response Service is $1,000.00 This fee is used to cover the costs involved in this process, including public hearings, mailings, notices and legal fees incurred by the Council. Any unused portion of this fee will be returned to the applicant after any appeals have been settled, and the Department of Health issues a certificate, or terminates the application. Procedure:

Table of Policy Contents Sample Letter of Solicitation Suggested CON Narrative Outline Checklist for all CON’s Reference: NYS DOH BEMS Policy Statement #06-06 Minutes of REMSCo meeting dated September 16, 2014.


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No. 15-1 Date: 11/17/15 Subject: Certificate of Need (CON) Applications Page 1 of 6 Supersedes/Updates: 03-02, 07-01, 14-14

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Letter of Solicitation – Outline Applying Agency Letterhead Date: RE: Letter of Solicitation for (Name of process being initiated: CON, Expansion, etc.) TO: Refer to NYSDOH Policy 06-06 for details as to who/what agencies to solicit. Opening Paragraph – Should describe the proposed service, who the service is, where it is located, the service area proposed, level of care provided (BLS, ILS, ALS, Paramedic), and type of service (transporting, ALS-FR, Aeromedical, etc.) 2nd Paragraph – Definition of Need – use definition as shown in policy 06-06. 3rd Paragraph – Should request a response from agency/person solicited, direct response to: President CNYEMS Regional Council Jefferson Tower Suite LL1 50 Presidential Plaza Syracuse, NY 13202. Request that responses be made by specific date, and be signed and dated by the Chief Operating Officer of agency solicited. Signed by CEO of agency applying for CON.

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Suggested CON Narrative Outline Agency Letterhead Address to: President

CNYEMS Regional Council Jefferson Tower Suite LL1 50 Presidential Plaza Syracuse, NY 13202

President: Narrative: Paragraph #1

Describe what your agency is applying for (New CON, Expansion of existing CON, Etc.) Explanation of history of situation, history of applying agency. Paragraph #2 Describe your service – Physical location of your agency, proposed area of service, level of care, hours of operation, numbers of personnel, and levels of certification. Paragraph #3 Describe positive and negative impacts of the proposed service on the existing services in the area, and the local EMS system, relating to: response times, level of service, staffing, mutual aid, and financial impact on existing services. Paragraph #4 Describes your agency’s medical control and quality improvement and any impact on medical control in the area, as well as the impact on the communications system in the area, and any communications improvements your agency intends to make. Also describe any planned improvements your upgrade the agency plans to make. Paragraph #5 Describe your call volume, existing and projected, as well source of data. Actual response times for the last year, and projected response times for the coming year. Paragraph #6 List existing agencies in the proposed territory, as well as hospitals, institutions, and medical facilities, etc., in the area that generate calls for the agencies in the area. Include any mutual aid agreements that are in effect or are planned. Paragraph #7 Describe area geography (rural, urban, suburban), and any special geographic considerations, and or population. Be sure to include seasonal population changes, and any special needs in your response area.

APPLICATION FOR PUBLIC NEED WORK SHEET

To be completed and made part of the record.

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1. Required DOH Applications

YES NO DOH Form 3777, Application for New EMS Service, Expansion

of Primary Operating Territory or Transfer of Ownership, completed and notarized.

DOH Form 3778, Affirmation of Fitness and Competency, competed and notarized for each person identified as an officer, director holder of greater than 10% of companies stock.

2. Narrative which includes the following operational aspects of the proposed service:

YES NO Proposed Area of Service Proposed level of care of the service Proposed hours of operation Proposed physical location(s) of the service Proposed number of employees/members. Number of ambulances/ALS FR vehicles.

3. The applicant has included financial information including:

YES NO Source of initial funds First/next years proposed operating budget. Proof of adequacy of funding sources/future revenue.

Documentation to support that the applicant has financial resources capable of support proposed service/expansion.

4. The narrative shall include documentation of the positive and negative impact of the

proposed new/expanded service to include (but not be limited to):

Impact on all existing ambulance/EMS relating to: YES NO Response times Staffing Level of service Call volume of last 12 month/proposed first 12 months of operation Mutual Aid Medical direction Quality assurance Financial impact on any existing service(s) Any adverse impact the proposed service will have on any existing

service(s). Prehospital care protocols

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5. Narrative addendum of the application lists all segments of the EMS system in the

proposed new/expanded operating territory including:

YES NO All existing EMS agencies All hospitals and other institutions generating calls (nursing homes,

adult homes, centers for independent living, community residences for the disabled. etc)

Any/ all mutual aid agreements Actual & projected response times for past and next 12 months Communications system and the impact additional/expanded

service will have on the existing communications system. Medical direction/control of system and impact additional/expanded

service will have on existing system. Any anticipated improvements the new/expanded service intends to

make in the communications system if approved. 6. The applicant shall include copies of letters showing they have advised various entities

of their proposal and solicit letters of support.

The letters sent by the applicant must:

YES NO Include a definition of public need. Include a general description of the new/expanded service. Include the type and level of service proposed. Request a response by a specific date and that the request be

signed by the CEO of the entity. Letters received back in support or opposition are not more than six

months old. 7. Applicant documents letters have been sent to:

YES NO All Ambulance and Advanced Life First Response services within

proposed operating territory. All EMS Medical Directors in Region The Chairperson(s) of any county(ies) EMS organization(s)

County EMS coordinator(s) All Hospital CEOs All Hospital Emergency Department Directors The CEOs of all municipalities All ambulance services in areas adjacent to the proposed operating

territory All hospitals in areas adjacent to the proposed operating territory The applicant submitted proof of receipt by entity letter was sent to

(copies of registered mail receipts signed by receiving agency)

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8. Required Fees

YES NO Applicant has submitted required REMSCO application fee.

9. Application Deemed Complete:

YES NO DATE Regional Council/Program Agency Staff Transportation/Ambulance Committee Full Regional EMS Council Provide Written Notification to Applicant

indicating Complete Submission

10. Dates of Action:

YES NO DATE Request for F&C review from DOH Received results of F&C review from DOH Public Hearing Officer Assigned Public Hearing Scheduled Transportation/Ambulance Committee/

REMSCO Meeting

Copy of Complete Application and Determination sent to DOH

11. Regional Council Decisions:

Agree Deny DATE Transportation/Ambulance Committee Public Hearing Officer REMSCO Determination

Overview: The Rapid Sequence Intubation (RSI) program allows Central New York Regional Emergency Medical Advisory Committee (CNY REMAC) regionally credentialed paramedics operating with approved agencies to include RSI as part of their advanced airway management options. This credential allows the provider to utilize the RSI protocol that appears in the New York State Collaborative Protocol Set adopted by the Central New York Region. The authorization of the paramedic to provide this level of care is further contingent on the approval of the agency director/manager and the agency medical director for which the provider is practicing. Authorization: In order for a provider to utilize the RSI protocol, that provider must be credentialed by the CNY REMAC as an RSI provider, be operating with an agency that has been approved by the CNY REMAC to provide RSI, and be approved to utilize the collaborative RSI protocol by that agency’s director/manager and agency medical director. Authorization of the agency and/or provider may be revoked at any time by the CNY REMAC for failure to comply with this policy. Agency Requirements: For an agency to be approved by CNY REMAC as an “RSI agency” all of the following criteria must be met:

• The agency must have unrestricted authorization from the NY State Department of Health and the CNY REMAC to provide Advanced Life Support (ALS) care at the paramedic level.

• The agency must have unrestricted authorization from the NY State Department of Health to carry and administer controlled substances to patients.

• The agency must agree to abide by the RSI protocol and the RSI policies and procedures approved by the CNY REMAC, including agreeing to provide the RSI paramedic the proper medications and equipment detailed in the protocol and following all QA requirements detailed by this policy.

• The agency must be approved by the CNY REMAC to provide RSI.

Central New York

Regional Emergency Medical Services Program

Policy Statement

Serving: Cayuga, Cortland, Onondaga, Oswego and Tompkins Counties

No. 17-03 Date: 11/10/2016 Subject: Rapid Sequence Intubation Program Page 1 of 3 Supersedes/Updates: 09-02

• The agency must have a written endorsement from their agency director/manager and agency medical director to become an RSI agency.

For an agency to maintain approval as an RSI agency after initial credentialing, the following must be met:

• The agency must maintain all of the state and regional authorizations outlined above for initial approval.

• The agency must demonstrate compliance with all of the QA requirements detailed in this policy.

• The agency must continue to provide the necessary proper medications and equipment detailed in the protocol on an ongoing basis.

• The agency must have ongoing approval from the CNY REMAC, the agency director/manager, and the agency medical director to provide RSI services.

Failure to maintain any of the above must be reported to the Central New York EMS (CNYEMS) Program Agency immediately (within one business day) and may result in suspension of the agency’s RSI approval. The CNY Regional Medical Director will notify the CNY REMAC of any provider whose RSI credentialing has been suspended. Provider Requirements: For a provider to be approved by the CNY REMAC as an RSI paramedic all of the following criteria must be met:

• The provider must have a valid NY State paramedic certification. • The provider must be credentialed and in good standing with the CNYEMS

Program Agency. • The provider must have written endorsement to attain this credentialing by the

agency director/manager and the agency medical director. • The provider must complete the credentialing application. • The provider must successfully complete the regional RSI education.

Once the requisite materials have been submitted, the provider will be reviewed by staff of the CNYEMS Program Agency, including the Executive CQI committee, CNY Regional Medical Director, and the CNY REMAC. The CNY REMAC maintains the right to deny RSI privileges to any provider for any reason. Once regionally credentialed, the RSI provider may only operate as an RSI paramedic when they are practicing with an agency that has been granted regional approval as an RSI agency and that provider has been approved by that agency to operate as an RSI paramedic within that agency. For a provider to maintain credentialing as an RSI paramedic, all of the following criteria must be met:

• The provider must maintain current NY State paramedic certification. • The provider must remain credentialed and in good standing with the CNYEMS

Program Agency.

• The provider must continue to have the support of the CNYEMS Executive CQI Committee, CNY Regional Medical Director, the CNY REMAC, and the RSI agency’s director/manager and agency medical director.

• Regional credentialing is valid for three years (until December 31st of the third year after the initial or re-credentialing course).

o RSI skills of credentialed paramedics will be reviewed twice yearly in accordance with the regional CME semesters.

• The provider must submit the CNYEMS application for re-credentialing as an RSI paramedic prior to November 1st of the year the regional credentialing expires.

o Failure to do so will require the provider to go through the initial credentialing procedure as described above in order to be considered for reinstatement as an RSI paramedic.

• The provider must successfully complete the regional re-credentialing course for RSI paramedics.

Education: Initial and ongoing RSI education in the Central New York Region will occur via regionally approved education. The content of the initial and re-credentialing classes will be determined separately. In order for the provider to meet the initial and ongoing credentialing requirements, he or she must attend and successfully complete the applicable regionally approved class. Quality Assurance: The CNYEMS RSI quality assurance form must be completed for every instance of advanced airway management performed by a regionally credentialed RSI paramedic operating with a regionally approved RSI agency (regardless of whether paralytics are administered). The RSI provider has the responsibility to complete the patient care report (PCR) and CNYEMS RSI quality assurance form by the end of the shift during which the patient was treated and notify the RSI agency that an RSI form has been completed. Agency policy may implement additional QA procedures. The RSI agency has the responsibility to forward a copy of the PCR and CNYEMS RSI quality assurance form to the CNYEMS Program Agency within one business day. The CNY Regional Medical Director will advise the CNY REMAC of any concerns identified by the QA process that may benefit from modification of this policy. Any proposed changes to the protocol will be made in accordance with the collaborative protocol governance document and state law.

Purpose: This policy outlines the evaluation of a patient refusing treatment or transport and the documentation expected when obtaining such a refusal. Policy: I. Overview A patient is defined as a person encountered by EMS personnel with an actual or potential injury or medical problem. “Encountered” refers to visual contact with the patient. These persons may have requested an EMS response or may have had an EMS response requested for them. Due to the hidden nature of some illnesses or injuries, an assessment should be performed on all patients. For patients initially refusing care, an attempt to evaluate the individual, even if only by visual assessment, is expected and must be documented. II. Evaluation The evaluation of any patient refusing medical treatment or transport should include the following:

1. Visual Assessment – To include responsiveness, level of consciousness, orientation, obvious injuries, respiratory distress, and gait.

2. Initial Assessment – Airway, breathing, circulation, and disability.

3. Vital Signs – Pulse, blood pressure, and respiratory rate and effort. Pulse

oximetry and/or blood glucose, when clinically indicated.

4. Focused Exam – As dictated by the patient’s complaint (if any).

5. Medical Decision Making Capacity Determination – As defined below. Patients at the scene of an emergency who demonstrate the ability to understand the nature and consequences of their medical care decisions shall be allowed to make


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No. 17-04 Date: 1/17/2017 Subject: Patient Refusals Page 1 of 4 Supersedes/Updates: 01-01, 03-03, 14-08

decisions regarding their medical care, including refusal of evaluation, treatment, or transport. A patient, who is evaluated and found to have any one of the following conditions shall be considered incapable of making medical decisions regarding care and/or transport and should be transported to the closest appropriate medical facility under implied consent:

1. Altered mental status from any cause.

2. Age less than 18 unless an emancipated minor or with legal guardian consent.

3. Attempted suicide, danger to self or other, or verbalizing suicidal intent.

4. Acting in an irrational manner, to the extent that a reasonable person would believe that the capacity to make medical decisions is impaired.

5. Unable to verbalize (or otherwise adequately demonstrate) an understanding of the illness and/or risks of refusing care.

6. Unable to verbalize (or otherwise adequately demonstrate) rational reasons for refusing care despite the risks.

7. No legal guardian available to determine transport decisions. Patient consent in these circumstances is implied, meaning that a reasonable and medically capable adult would allow appropriate medical treatment and transport under similar conditions. Providers who identify a patient who is refusing transportation but requires transport under implied consent (due to lack of capacity) may require medical control consultation and law enforcement involvement to ensure the patient is transported to an appropriate emergency facility for evaluation. Medical care should be provided according to the most recent edition of the collaborative protocols adopted for use in the CNYEMS Region. Once a patient assessed to lack decision-making capabilities is transported under implied consent to the appropriate emergency facility, a medical decision making capacity determination may be required for continued involuntary care and treatment. Patients exhibiting the following “higher risk” criteria should receive particular attention for an appropriate evaluation and risk/benefit discussion prior to not transporting and the EMS provider may consider medical control consultation prior to obtaining a refusal: Higher risk criteria

1. Age greater than 65 years or less than 2 months.

2. Pulse >120 or <50.

3. Systolic blood pressure >200 or <90.

4. Respirations >29 or <10.

5. Serious chief complaint (including, but not limited to chest pain, SOB, syncope,

and focal neurologic deficit).

6. Significant mechanism of injury or high index of suspicion.

7. Fever in a newborn or infant under 8 weeks old. Patients who have the ability to understand the nature and consequences of their medical care decision and wish to refuse care/transport may do so after the provider has:

1. Determined the patient exhibits the ability to understand the nature and consequences of refusing care/transport.

2. Offered transport to a hospital.

3. Explained the risks of refusing care/transport.

4. Explained that by refusing care/transport, the possibility of serious illness,

permanent disability, and death may increase.

5. Advised the patient to seek medical attention and gave instructions for follow-up care.

6. Confirmed that the patient understood these directions.

7. Ensured that the patient signed the Refusal of Treatment/ Transport Form or

documented why it was not signed.

8. Left the patient in the care of a responsible adult (when possible).

9. Advised the patient to call 911 with any return of symptoms or if they wish to be re-evaluated and transported to the hospital.

III. Medical Control: The EMS provider may consider consulting medical control, if the patient does not wish to be transported. The purpose of the consultation is to obtain a second opinion with the goal of helping the patient realize the severity of their condition and accept transportation. Medical consultation is highly recommended for the following:

1. The provider is unsure if the patient is medically capable to refuse treatment

and/or transport.

2. The provider disagrees with the patient’s decision to transport because of unstable vital signs, clinical factors uncovered by the assessment, or the provider’s judgment that the patient is likely to have a poor outcome if not transported (See higher risk criteria, above).

Medical Control consultation is required for the parent or legal guardian refusing transport of a child being evaluated for a Brief Resolved Unexplained Event (BRUE) (Previously referred to as an Acute Life Threatening Event [ALTE]). IV. Documentation: Patient refusals are the highest risk encounters in clinical EMS. Careful assessment, patient counseling, and appropriate Medical Control consultation can decrease non-transport of high-risk refusals. Paramount to the decision-making involved in a patient refusal of treatment and/or transport is the documentation of that refusal. Documentation is expected to include:

1. In the prehospital care report the provider’s assessment, treatment provided, reasons for refusal, determination of medical decision making capacity, and medical control consultation as appropriate.

2. Completion of a refusal of treatment/transport form (or electronic equivalent)

that is in some form attached to the prehospital care report, to include at a minimum, the following:

a. Agency Name b. Date of Incident c. PCR associated with the refusal d. Patient’s signature, date and time of refusal e. Witness signature, date and time of refusal

For agencies using an electronic medical record and a device capable of capturing patient and provider signatures electronically in the field, the agency may use a modified CNYEMS Region Refusal of Treatment/Transport Form for use on such an electronic device as approved by the Regional Medical Director or his/her designee. See also CNYEMS refusal form and instructions.

Central New York EMS Patient Refusal Form Instructions to Provider: Complete form for all patients who are assessed and refuse care and/or transport. Complete all fields, enter N/A if Not Applicable. Attach to paper PCR or scan for electronic attachment to ePCR. _______________________________________________________________________________

Agency Name:

Date of Service: PCR#

Determination of Decisional Capacity:

Altered mental status from any cause

Age less than 18 unless an emancipated minor or with legal guardian consent

Attempted suicide, danger to self or other, or verbalizing suicidal intent

Acting in an irrational manner, to the extent that a reasonable person would believe that the capacity to make medical decisions is impairedUnable to verbalize (or otherwise adequately demonstrate) an understanding of the illness and/or risks of refusing careNo legal guardian available to determine transport decisions

A patient, who is evaluated and found to have any one of the above conditions shall be considered incapable of making medical decisions regarding care and/or transport and should be transported to the closest appropriate medical facility under implied consent.

Medical Control Criteria:

Check to indicate if Medical Control was consulted

Physician Consulted:

Medical Control Instructions:

Medical Control consultation is required for the parent or legal guardian refusing transport of a child being evaluated for a Brief Resolved Unexplained Event (BRUE) (Previously referred to as an Acute Life Threatening Event [ALTE]).

Higher Risk Criteria:

Patients exhibiting the following “higher risk” criteria should receive particular attention for an appropriate evaluation and risk/benefit discussion prior to not transporting and the EMS provider may consider medical control consultation prior to obtaining a refusal: • Age greater than 65 years or less than 2 months • Pulse >120 or <50 • Systolic blood pressure >200 or <90 • Respirations >29 or <10 • Serious chief complaint (including, but not limited to chest pain, SOB, syncope, and focal neurologic deficit) • Significant mechanism of injury or high index of suspicion • Fever in a newborn or infant under 8 weeks old

Provider Refusal Checklist

By signing, I confirm I have done the following: • Determined the patient is able to understand the nature and consequences of the injury/illness and the risk of refusing care/transport. • Offered transport to a hospital. • Explained the risks of refusing care/transport. • Explained that by refusing care/transport, the possibility of serious illness or death may increase. • Advised the patient to seek medical attention and gave instructions for follow-up care. • Confirmed that the patient understands these directions. • Ensured that the patient signed the Patient Refusal Form or documented why it was not signed. • Left the patient in the care of a responsible adult when possible. • Advised the patient to call 911 with any return of symptoms or if they wish to be re-evaluated and transported to the hospital.

Provider Name: NYS EMT#

Provider Signature:

Reason for refusal of care and/or transport and directions for follow-up care:

Refusal of Treatment/Transport By signing the release, I agree that: • I was offered transport to a hospital. • The risks of refusing care and transport were explained to me. • By refusing the care offered to me, I may increase the possibility of serious illness or death. • I was advised to seek medical attention. • I was made aware of how to access follow-up care. • I understand the directions given to me, and the risks involved with refusing transport against the advice of EMTs. • I am being left in the care of a responsible adult when appropriate. Follow-up Care: If there is a return of symptoms or you become concerned, you should do one of the following: • Contact your primary care doctor or their on-call answering service. • Call “911” and ask for an ambulance. • Visit an Emergency Department or Medical Clinic.

Release I hereby refuse treatment and/or transport to a hospital and I acknowledge that such treatment or transportation was advised by the emergency crew or physician. I hereby release such persons from liability for respecting and following my express wishes.

Name: Date:

Signature: Time:

Witness: Patient refused to sign

General Patient Care: EMT • Assure scene safety • Request additional resources, including ALS, as needed • Take equipment and supplies to the patient and utilize, as indicated

o Communications / radio o BLS supplies, oxygen, suction, AED o BLS medications, as needed

• ABCs, major hemorrhage control, spinal motion restriction, as needed • Vital signs; blood pressure, heart rate, respirations

o Repeat, as needed, based on patient’s condition o Consider vital sign trending in the appropriate patient

• Secondary assessment and treatment, as required ADVANCED, CC, AND PARAMEDIC • Institute needed BLS care prior to ALS care • Take required ALS equipment and supplies to the patient and utilize as indicated

o Monitor, pulse oximetry, waveform capnography o Advanced airway equipment o Vascular access supplies, IV fluids o Medications (appropriate to level of training)

PHYSICIAN CONSIDERATIONS • Medical control may authorize standing orders in the event of a multiple casualty

incident (MCI).

KEY POINTS • If an MCI exists, notify 911 center or dispatch and the resource hospital as soon as

possible. • See trauma triage guidelines, as required. • Do not wait on the scene for ALS if able to initiate transport. The hospital may be

the closest ALS. • Notify the hospital of impending arrival, per regional policy. • A written report is required to be left with the patient prior to leaving the hospital

(Title 10 NYCRR Part 800.15).

Central New York


Policy Statement


No. 17-05 Date: 11/10/2016 Subject: General Patient Care Page 1 of 1 Supersedes/Updates: Original

Medication and Medical Control:

KEY POINTS - MEDICATIONS • Medications not listed in the formulary may not be carried without clearance from

the Central New York Regional Medical Advisory Committee (CNY REMAC). • Local variations in medications, concentration, and volume may exist because of

restocking necessities. • Alternative concentrations and volumes of medications must be approved by the

CNY REMAC, through the CNY Regional Medical Director, prior to use. • In cases of medication shortages, please refer to the NYS Department of Health

(NYS DOH) policy statement “Alternative Medication Formulary for Prehospital Drug Shortages.”

• Medications must be kept locked in a secured environment when not in use. Please refer to NYS DOH policy statement “Storage and Integrity of Prehospital Medications and Intravenous Fluids.”

• Medications should be protected from extremes of temperature at all times. Please refer to NYS DOH policy statement “Storage and Integrity of Prehospital Medications and Intravenous Fluids.”

• A controlled administration set (such as a drip chamber) or pump must be used for all infusions (medications given as a continuous drip).

• If controlled substances are contained in a vehicle, they must be carried in accordance with the agency’s NYS Approved Controlled Substance Plan and Title 10 NYCRR Part 80.


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No. 17-06 Date: 11/10/2016 Subject: Medication and Medical Control Page 1 of 1 Supersedes/Updates: Original

Medical Director Discussion of Protocol Deviations: The collaborative protocols currently state, “These protocols are intended to result in improved patient care by prehospital providers. They reflect the current evidence-based practice and consensus of content experts. These protocols are not intended to be absolute treatment documents; they are principles and directives, which are sufficiently flexible to accommodate the complexity of patient management. No protocol can be written to cover every situation that a provider may encounter and this set of protocols is not a substitute for the judgment and experience of providers. Providers are expected to utilize their best clinical judgment and deliver care and procedures, according to what is reasonable and prudent for specific situations. It is expected that any deviations from protocol shall be documented and reviewed, according to regional procedure.” This agreement is not a substitute for real-time medical control and consultation; however, these protocols, as explained above, must be sufficiently flexible to accommodate the complexity of patient management and a discussion with a physician may not always be practical in certain, albeit infrequent, situations. Any deviation from regional protocol will necessitate a thorough documentation of medical decision-making on the chart and a prompt discussion with the agency medical director. The provider must notify the agency medical director and agency director / manager by the end of the provider’s shift on which the deviation occurred. Following notification of the incident, a formal discussion must occur between the provider and the agency medical director. This discussion must occur within seven days of the incident and be documented according to CQI procedure. Once the case has been reviewed by the agency medical director, if there is concern regarding the deviation that requires further attention, the agency shall forward the concern to the Central New York EMS Program Agency for regional level CQI review. If corrective action for unacceptable performance or behavior (rather than the provision of education) is required, it will be handled outside of the CQI process, according to agency, regional, and/or New York State policy and procedure, as applicable.


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No. 17-07 Date: 11/10/2016 Subject: Medical Director Discussion of Protocol Deviations Page 1 of 1 Supersedes/Updates: Original

Transfer of Care:

TRANSFER BETWEEN EMS PROVIDERS • Providers are responsible for the patient while in their care. Transferring or

receiving providers will not be responsible for their counterpart’s actions. • Patients may be transferred to a provider with the same or higher level of training

and the same or higher level of on-line privileges within the region. • Patients may be transferred to a provider with a lower level of training and a lower

level of on-line privileges within the region, provided the patient is not anticipated to require advanced care.

• EMS Physicians on scene may transfer care to appropriate level of EMT, as indicated by clinical judgment and/or regional policy.

• When transferring patients, both the receiving and transferring providers should: o Ensure that all patient information is transferred to the receiving provider,

such as chief complaint, past medical history, current history, vital signs, and care given prior to the arrival of the receiving provider.

o Assist the receiving provider until they are ready to assume total patient care.

o Be willing to accompany the receiving provider to the hospital, if the patient’s condition warrants or if the receiving provider requests it, as resources allow.

• The receiving provider must briefly document patient care given prior to receiving the patient.

• Both providers will complete a Patient Care Report (PCR), as appropriate, detailing the care given to the patient while in their care.

o Providers within the same agency may utilize the same PCR (as technology and agency/regional/state policy allow).

• PCR documentation completed by an ALS provider who transferred a patient to another provider for transport must be delivered to the receiving hospital in a time frame mandated by state and regional policy.

• BLS agencies transferring a patient to a higher level of care must comply with NYS DOH BEMS policy statement 12-02 (or updated version) and provide paperwork to the transporting agency prior to the patient leaving the scene.

• Any disparity between the providers needs to be resolved by contacting a Medical Control Physician.


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No. 17-08 Date: 11/10/2016 Subject: Transfer of Care Page 1 of 2 Supersedes/Updates: Original

TRANSFER AT HOSPITAL • Documentation left at the hospital must include:

o Agency ID, Crew ID o Patient Demographics (if available): Name, Date of Birth, Address o Event/incident description o Initial assessment: chief complaint and pertinent initial vital signs o Interventions: Medications, procedures performed, and patient response

• Specimens left at the hospital: o If available, label any specimens, and ECG with hospital stickers. o Do NOT leave unlabeled specimens or ECG at the hospital.

Physician on Scene:

NON-REGIONALLY AUTHORIZED ON-SCENE MEDICAL CONTROL: • A patient’s personal physician may assume medical control responsibility for his

or her patient if he or she desires. In such circumstances, do the following: o Give the clinician the card or refer to the “Resource: Physician on Scene

Card” describing the function of the regional medical control system to the clinician.

o If the clinician still desires that the patient be transported without ALS, he or she should order, “NO ALS, TRANSPORT ONLY,” on the patient care report and sign this order.

o Notify the destination hospital of the case after initiating transport. o If the patient’s condition deteriorates during transport, contact medical

control to discuss whether or not ALS protocols should be started. o If the patient’s physician accompanies the patient in the ambulance, he or

she will be responsible for this decision. • Bystander clinicians may not circumvent standard operating procedures or

assume medical control without approval from the resource hospital physician (the resource hospital physician must be contacted and give approval before a bystander physician is authorized to assume medical control responsibility).

• Physicians only: physician assistants, nurse practitioners, etc. are excluded.

REGIONALLY AUTHORIZED ON-SCENE MEDICAL CONTROL: • Physicians authorized by the Regional Medical Director to specifically provide on-

scene medical control may supersede the restrictions outlined above. • Physician authorization to provide on-scene medical control is valid only in the

region granting that authority and must be outlined in regional policy.


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No. 17-09 Date: 11/10/2016 Subject: Physician on Scene and Physician on Scene Card Page 1 of 2 Supersedes/Updates: Original

PHYSICIAN ON SCENE CARD: Thank you for your offer of assistance. Please be advised that we are working under medical control from EMS physicians and medical control at a hospital. We are not permitted to relinquish medical control to a clinician on the scene without approval from medical control at the resource hospital. Should you wish to assume medical control, you may request to speak with the resource hospital. If you are authorized to provide medical control, you must sign the patient’s prehospital care report and accompany the patient to the hospital.

If you have any questions regarding this policy, please contact the appropriate Regional Emergency Medical Services Council. Contact information is available at www.health.ny.gov/professionals/ems/regional.htm NYSDOH BEMS PS98-05 Public Health Law, Article 30 §3004-A 10NYCRR-800, State EMS Code

http://www.health.ny.gov/professionals/ems/regional.htm

Policy:

When multiple medevac aircraft have been dispatched to the same emergency incident, optimal patient care and safety are key goals. To achieve these goals, the following procedure will be followed:

Procedure for Multiple Medevac Aircraft:

1. If the highest level EMT or EMS Physician that was dispatched and is on the scene determines that no aircraft are needed, all aircraft can be cancelled.

2. If the highest level EMT or EMS Physician determines that only one aircraft is needed, the first aircraft to arrive will handle the transport. All dispatched air services will continue until an aircraft is on scene. In the event that the first aircraft is a law enforcement agency, they may yield to other agencies, at their discretion.

3. When multiple aircraft are responding, all will communicate via radio frequency

123.025 Air to Heliport to coordinate approaches and landings.

Air Medical Utilization:

The decision of whether or not to utilize air medical services is complex and its appropriate use is the subject of an ongoing national discussion. Many factors must be considered, including proximity to the appropriate facility, need for advanced care, weather, and local resources, among many other factors. Waiting on the scene for an aircraft to arrive is not recommended. Instead, transport to the appropriate hospital should be initiated and rendezvous with the aircraft at a landing zone along the route may be considered. The use or non-use of air medical services for particular types of calls shall not be mandated. Air medical services may be requested by any emergency provider, but is considered a medical intervention and, as such, the final decision to use or not use this intervention should be made by the highest level provider on the scene. When multiple aircraft are responding, all will communicate via radio frequency 123.025


Program


No. 17-10 Date: 11/10/2016 Subject: Air Medical Utilization and Multiple Aircraft Response to a Single Scene Page 1 of 2 Supersedes/Updates: 14-13

to help coordinate approaches and landings. In the event that the highest level provider on the scene determines that only one aircraft is required after multiple aircraft were dispatched, the first aircraft to arrive will handle the transport.

Indications for consideration of air medical transport include: • Severe trauma, as defined by the latest CDC trauma triage guidelines • Confirmed STEMI when a cardiac catheterization facility capable of performing

emergent primary coronary angioplasty is not locally available • Acute stroke (after consultation with the designated stroke center) • Other time critical-process for which the expertise of the critical care transport

crew and/or rapid transport to a specialized hospital is indicated

Reference: Minutes of CNY Air Medical Services Committee & CNY REMAC meetings dated September 2003. Minutes of CNY Air Medical Services Committee dated May 8, 2014. Minutes of CNY REMSCo meeting dated September 16, 2014. Minutes of CNY REMAC meeting dated November 10, 2016.

Emergency Incident Rehab:

• Recommended for events where people are expected to be working for one hour or more, including drills, fire ground operations, hazardous materials incidents, lengthy extrications, and any other event where personnel are wearing protective gear and fluid loss is a concern.

• Emergency incident rehab should not be done by the primary EMS unit on the scene that is standing by for emergency transport.

• Incident commander or department chief (as applicable) is responsible for requesting rehab and mandating compliance of subordinates.

• When a person arrives in rehab with no significant complaints: o Encourage the person to drink at least 8 ounces of fluid o An EMT should do a visual evaluation for signs of heat- or cold-related

stress, fatigue, or signs indicative of a medical emergency. If any of these are present, evaluate vital signs.

• If any vital sign is out of the range listed below, all turnout gear should be removed to facilitate cool-down and the person should rest for at least 10 minutes with continued oral hydration:

o BP: Systolic >160 mm Hg or o BP: Diastolic > 100 mm Hg o Respirations: >24 per minute o Pulse: >110 per minute o O2 saturation < 92% o SpCO (if available) ≥5% for non-smokers and ≥ 10% in smokers o Temperature (if available) > 100.6

(Note: A normal measured temperature does not exclude heat-related illness)

• If vital signs return to within criteria limits, the person may be released. • If vital signs are still beyond the limits, continue rehab for another 15 minutes and

determine if further intervention may be needed. • If, after 30 minutes, two or more vital signs are above the limits outlined above or

the O2 saturation itself has not returned to normal, transport to the hospital should be initiated.


Program


No. 17-11 Date: 11/10/2016 Subject: Emergency Incident Rehab Page 1 of 2 Supersedes/Updates: Original

• If a person arrives at the rehab area with complaints of chest pain, shortness of

breath, or altered mental status, follow the appropriate protocol. The person may not return to duty.

• A patient with an irregular pulse should have an ALS assessment with cardiac monitoring and be removed from duty or the event, as needed.

• Names and vital signs (if measured) for each person evaluated should be recorded on a log sheet for the incident.

• A PCR should be written on any person transported to the hospital, receiving any ALS care, or refusing indicated transport (along with appropriate refusal procedures and documentation).

• More aggressive treatment should be used during extremes of temperature. • Consider carbon monoxide poisoning with any exposure to smoke. • If any questions exist regarding the treatment of a patient according to this

protocol, consult medical control physician for advice. • For any ongoing event with high potential for injury to public safety personnel,

consider requesting a physician to the scene. • Agency procedures may be used in place of these guidelines, as appropriate, if

developed from industry standard models, such as the NFPA, USFA, or others.

Trauma Center Destination:

Trauma patients meeting “step one” and “step two” (“Resource: Trauma Triage – CDC” protocol) criteria should preferentially be transported to a level I trauma center. Resources within a local trauma system, weather conditions, and other factors may influence this decision.


Program


No. 17-12 Date: 11/10/2016 Subject: Trauma Center Destination Page 1 of 1 Supersedes/Updates: Original

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Policy: Should an agency lose its medical director due to illness, relocation, or any other unforeseen event, the Central New York Regional Medical Director will serve as acting medical director for up to 90 days. After 90 days, the Central New York Regional Medical Director may choose to continue to provide medical direction for the agency past that date, appoint an alternative agency medical director, or suspend patient care operations of the agency, at his or her discretion within the limits of applicable regional and state policy. If a BLS first response agency is unable to appoint a medical director within the 90 day timeframe, the position will default to the medical director whose agency provides the majority of ALS care within the BLS first response service area. This ALS medical director reserves the right to decline the position. If no appropriate medical director is appointed within 90 days and the aforementioned ALS medical director declines to take on this position, the Central New York Regional Medical Director may choose to continue to provide medical direction for the agency past that date, appoint an alternative agency medical director, or suspend patient care function of the agency, at his or her discretion within the limits of applicable regional and state policy. Procedure: Credentialed Service Medical Directors: If the agency selects a Service Medical Director already credentialed at the appropriate level (ALS or BLS) by the CNYEMS REMAC, the agency will submit an updated Medical Director Verification Form (DOH-4362) to the CNYEMS Program Agency and forward a copy to the NYS DOH BEMS. Non-credentialed Service Medical Directors: If the agency selects a Service Medical Director not credentialed at the appropriate level (ALS or BLS) by the CNYEMS REMAC, the physician will have to submit a CNYEMS Service Medical Director Application to be considered for credentialing in the CNYEMS Region. The physician has to be credentialed by the CNYEMS REMAC at the appropriate level prior to be selected as a Service Medical Director. The CNYEMS Program Agency should be contacted by the agency to make the notification, and request the appropriate forms. The completed forms shall be returned to CNYEMS.


Program


No. 17-13 Date: 05/16/17 Re: Interim Service Medical Director Page 1 of 1 Supersedes/Updates: 01-05, 14-06

1

Policy: The CNY REMAC is responsible for the establishment and maintenance of Triage, Treatment and Transport Protocols. This includes recommended dispatch policies and protocols for the purpose of insuring patients within the CNY Region receive timely, efficient, prehospital care. This document defines and delineates the standards approved by the CNY REMAC regarding dispatch criteria and performance for the agencies under its jurisdiction. The CNY REMAC authorizes the Regional Medical Director, and its administrative agent, to promote goals and implement standards of care for EMS in the CNY Region. Definitions and Procedures: Paramedic Advanced Life Support (ALS): A vehicle that is staffed with at least a Paramedic. EMT-Critical Care Advanced Life Support (ALS): A vehicle that is staffed with at least an Emergency Medical Technician-Critical Care. Advanced Emergency Medical Technician (AEMT): A vehicle that is staffed with at least an Advanced Emergency Medical Technician (AEMT). Basic Life Support (BLS): A vehicle that is staffed with at least an Emergency Medical Technician (EMT). System Standard: A standard of performance recommended and requested by the CNY REMAC. In Service: An EMS agency shall call in service as a BLS, AEMT, EMT-Critical Care or Paramedic unit, if appropriately staffed. Appropriate staffing for an ambulance agency requires a minimum:

1. An identified (named) and scheduled crew either in house or from home that includes: a. Driver b. Minimally an EMT or higher

2. The number of rigs in service and level of each rig.


Program


No. 18-01 Date: 9/18/2018 Subject: EMS Dispatch Page 1 of 3 Supersedes/Updates: 00-03, 14-04

2

Out of Service: An EMS agency shall be deemed out of service if any of the following conditions are met:

1. No crews are identified (named) or scheduled 2. Mechanical failure of the vehicle or equipment

3. On another call

Notification: It is the responsibility of the agency to notify the dispatch or 911 center of its status at least once every 24 hours to indicate its status. The agency must also notify the dispatch or 911 center of any change in status during that time period. Automatic EMS Dispatch: System Standard

1. Upon request for EMS services, the dispatch center will dispatch the primary agency and/or the timeliest, appropriately staffed resource. If the dispatched transporting unit is not enroute within five (5) minutes of the original page, the next most timely, appropriately staffed resource will be paged and dispatched. The primary agency will also be re-paged to notify them of the secondary agency's activation.

2. If the request for service meets the criteria outlined in item 4 of this document, the

dispatcher shall dispatch the appropriate available Paramedic or EMT-Critical Care unit.

3. In the event that a BLS, or other first response unit, is available and can be reasonably expected to arrive before the ALS unit, it should be simultaneously dispatched.

4. Criteria requiring an automatic ALS dispatch:

a. If a BLS unit can transport the patient to the nearest hospital emergency department more quickly than the ALS unit can arrive at scene, they should do so.

b. If ALS has not arrived prior to the patient being ready for transport, the BLS unit should initiate transport and arrange for an ALS intercept enroute to the hospital.

c. Specific criteria that dictate EMT-Critical Care or Paramedic response are: i. Allergic reactions ii. Serious bleeding iii. Cardiac arrest iv. Chest pain and/or cardiac symptomatology v. Cerebrovascular accidents (CVA) vi. Diabetic emergencies vii. Drowning or near drowning viii. Electric shock ix. Heat stroke and/or exhaustion x. Hypothermia xi. Overdose or poisoning xii. Respiratory distress or arrest xiii. Seizures

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xiv. Serious trauma: Potential or identified airway or respiratory complications require

Paramedic dispatch. xv. Serious burns: Potential or identified airway or respiratory complications require

Paramedic dispatch xvi. Unconscious xvii. Syncope xviii. Impending delivery: Obstetrical complications require Paramedic dispatch xix. Abdominal pain xx. Dispatch discretion: Unresolved airway obstruction requires Paramedic dispatch

d. If a recognized Emergency Medical Dispatch (EMD) program is utilized, Charlie, Delta and Echo level calls of any type shall warrant EMT-Critical Care or Paramedic response. Select Alpha or Bravo level calls may be designated as requiring EMT-Critical Care or Paramedic response by counties, agencies and agency medical directors based on local resources and other factors.

5. Any of the previously listed criteria require dispatch of a PARAMEDIC unit if the victim is identified as being 5 years of age or younger.

6. An appropriately trained EMS provider that is at the scene of the call, is at least an EMT

and has completed a thorough patient assessment may request cancellation of an ALS ambulance or responding agency. a. A representative of a law enforcement agency or a representative of the responding

fire agency may request cancellation of an ALS ambulance or responding agency if there is no injured patient.

Minimum Training Requirements for EMS Call Takers and Dispatchers: System Standard All Emergency Medical Service dispatch and 911 center personnel who answer lay requests for medical help will successfully complete a recognized Emergency Medical Dispatching (EMD) curriculum that includes pre-arrival instructions to the extent allowed by law. Participation in Continuous Quality Improvement: System Standard All Emergency Medical Service dispatch and 911 centers will participate in a CQI program. Each center will send a representative to the county CQI Committee (if that county utilizes a county committee to fulfill the CNYEMS primary level CQI requirement). Participation will be for the purposes of information sharing, data collection, case review and problem resolution to the extent allowed by law. Reference:

Minutes of CNY REMAC meeting of August 9, 2018. Minutes of CNY REMSCo meeting of September 18, 2018.

1

Policy: The New York State Department of Health Bureau of Emergency Medical Services (NYS DOH BEMS) has approved the use of 12 Lead ECG transmissions, glucometers, CPAP, defibrillation, epinephrine, intranasal naloxone and nebulized albuterol by Basic Life Support (BLS) providers. An Advanced Life Support (ALS) or (BLS) agency must have approval from the Central New York Regional Emergency Medical Advisory Committee (CNY REMAC) to allow their (BLS) providers to participate in these programs. ALS and BLS agencies must comply with NYS DOH BEMS Policy Statement 09-11 Storage and Safe Guarding of Medications Administered by EMTs (or updated version). ALS and BLS agencies must complete the following items and be approved by the CNY REMAC prior to allowing their BLS providers to utilize this equipment and medication. 12 Lead ECG Transmission:

1. Submit the following properly completed form to the CNYEMS Program Agency: • DOH-4362 Medical Director Verification

2. Complete the Agency Medical Director training plan. • A signed training roster will be filed in the agency’s training files.

3. Comply with NYS DOH BEMS Policy Statement 16-01 Basic Life Support Acquisition and Transmission of 12 Lead ECGs (or updated version).

Blood Glucometry:

1. Submit the following properly completed forms to the CNYEMS Program Agency: • DOH-4362 Medical Director Verification • New York State Department of Health Limited Service Laboratory Registration

Registration Form 2. Submit updated agency standard operating procedures (SOPs) to the CNYEMS

Program Agency. The SOPs must include the following: • Training and documentation of authorized users. • Quality Assurance program, including appropriateness review by Agency

Medical Director. • Documentation of control testing process. • Storage of glucometer and proper disposal of sharps.

Central New York


Policy Statement


No. 18-02 Date: 9/18/2018 Re: Regional Approvals: 12 Lead, Blood Glucometry, CPAP, Defibrillation, Epinephrine, Naloxone, and Albuterol Page 1 of 3 Supersedes/Updates: 08-02, 08-03, 17-02

http://www.cnyems.org/lnkhdlr.aspx?lcid=0a5e4594-d23a-41f3-b569-c73ae6994737

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3. Complete a training program offered by a NYS DOH CIC, CLI or CNYEMS CME Evaluator for Emergency Medical Technicians (EMT).

• The “Blood Glucose Measuring Devices in the Pre-Hospital Setting” lecture adopted by the CNY REMAC will be utilized for the training.

• EMTs will receive training on their agency’s glucometer. • Complete the on-line blood glucometry test on the CNYEMS website. • A signed training roster will be filed in the agency’s training files.

4. Comply with NYS DOH BEMS Policy Statement 12-01 Blood Glucometry and Nebulized Albuterol for EMS Agencies (or updated version).

CPAP:


2. Complete the Agency Medical Director training plan. • A signed training roster will be filed in the agency’s training files.

3. Comply with NYS DOH BEMS Policy Statement 15-02 Continuous Positive Airway Pressure (CPAP) for BLS EMS Agencies (or updated version).

Defibrillation:

1. Submit the following properly completed forms to the CNYEMS Program Agency: • DOH-4362 Medical Director Verification • DOH-4135 Notice of Intent to Provide Public Access Defibrillation • CNYEMS Collaborative Agreement for Public Access Defibrillation

2. Complete the CNYEMS CME skill station offered by a NYS DOH CIC, CLI or CNYEMS CME Evaluator for Emergency Medical Technicians.

• The signed CME skill sheet will be filed in the provider’s training file. 3. Comply with NYS DOH BEMS Policy Statement 09-03 Public Access Defibrillation (or

updated version). Epinephrine Auto-Injectors and Syringe Epinephrine for EMTs:



• The signed CME skill sheet will be filed in the provider’s training file. 3. Comply with NYS DOH BEMS Policy Statement 17-02 Epinephrine Auto-Injector (or

updated version). 4. Comply with NYS DOH BEMS Policy Statement 17-06 Syringe Epinephrine for EMTs (or

updated version).

Intranasal Naloxone: 1. Submit the following properly completed form to the CNYEMS Program Agency:

• DOH-4362 Medical Director Verification 2. The ALS and BLS agency’s standard operating procedures (SOPs) must be updated

with the naloxone SOP template provided by the CNYEMS Program Agency.

3

3. Complete the CNYEMS naloxone training conducted by the CNYEMS Program Agency.

• Complete the on-line naloxone test on the CNYEMS website. • A signed training roster will be filed in the agency’s training files.

4. Comply with NYS DOH BEMS Policy Statement 13-10 Intranasal Naloxone for Basic Life Support EMS Agencies (or updated version).

Nebulized Albuterol:



• The signed CME skill sheet will be filed in the provider’s training file. 3. Comply with NYS DOH BEMS Policy Statement 12-01 Blood Glucometry and

Nebulized Albuterol for EMS Agencies (or updated version). Reference:

Minutes of CNY REMAC meeting of July 10, 2008 Minutes of CNY REMAC meetings dated November 10, 2016 Minutes of CNY REMAC meetings dated August 9, 2018.

Minutes of CNY REMSCo meeting of September 18, 2018.

1

Policy: Minimum required equipment for certified ambulance and advanced life support first response services. Advanced life support services are defined as those that provide prehospital Advanced Emergency Medical Technician, Critical Care, and/or Paramedic care per Title 10 of the New York Codes, Rules and Regulations – Part 800.5 and must meet the requirements of Title 10 of the New York Codes, Rules and Regulations - 800.24. Please refer to New York State Department of Health Bureau of EMS Policy Statement 10-01 (or updated version) for additional information on defibrillators and epinephrine requirements. Title 10 of the New York Codes, Rules and Regulations – Part 800.5 requires the following:

1. Advanced Emergency Medical Technician services must have the capacity for voice communication to receive medical direction.

2. Critical Care and Paramedic services must have the capacity for voice communication to receive medical direction.

VHF Radio Capability: It is recommended that all agencies have VHF Radio capability with 6-8 channels with the following channels installed: Channel 1- 155.340 Ambulance to Hospital (Primary) Channel 2 - EMS Units' own frequency for dispatch Channel 3 - 155.400 Ambulance to Hospital (Secondary) Channel 4 - 155.715 Ambulance to Public Safety Agencies Channel 5-8 - For additional current frequency and future expansion Approval of Length-Based Resuscitation Tapes: The CNY Region will approve the use of length-based resuscitation tapes for the estimation of ideal body weight in pediatric patients. While the estimation of actual weight may vary based on the child’s body habitus, the provider should use the weight that is indicated on the tape because many of the medication dosages in the protocols should be calculated using ideal body weight.

Central New York Regional Emergency Medical

Services Program


No. 20-01 Date: 02/13/20 Re: Minimum Required Equipment for Advanced Life Support Services Page 1 of 9 Supersedes/Updates: 00-01, 08-03, 09-03, 11-01, 13-01, 14-10, 16-01, 17-01

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CNY Minimum Required Equipment – Ambulance

Equipment/ Supplies Portable Bag Ambulance AEMT EMT-CC EMT-P

Cardiac Monitor/Defibrillator 0 1 X X AED 0 1 X 12-Lead Transmission (1) 0 1 X X Continuous Waveform Capnography 0 1 X X X Glucometer (2) 1 0 X X X Length-Based Resuscitation Tape 1 1 X X Protocol Book (3) 0 1 X X X Pulse Oximeter (Requirement is met if device is supplied with cardiac monitor.)

0 1 X X X

Endotracheal Tubes 3.0 1 1 X 3.5 1 1 X 4.0 1 1 X 4.5 1 1 X 5.0 1 1 X 5.5 1 1 X 6.0 1 1 X X X 6.5 1 1 X X X 7.0 1 1 X X X 7.5 1 1 X X X 8.0 1 1 X X X 8.5 1 1 X X X 9.0 1 1 X X X

Water Soluble Jelly Tube or 1 1 X X X Packets 4 4 X X X

10 cc Syringe for endotracheal tube 2 1 X X X Alternative Airway Device Adult Set 1 1 X X X Pediatric Set 1 1 X Adult Stylet (can be packaged with ETT) 1 1 X X X Pediatric Stylet (can be packaged with ETT) 1 1 X X Laryngoscope Handle 1 1 X X X Laryngoscope Blades

Curved – 2 1 1 X X X Curved – 3 1 1 X X X Curved – 4 1 1 X X X

Straight – 0 1 1 X Straight – 1 1 1 X Straight – 2 1 1 X X X Straight – 3 1 1 X X X Straight – 4 1 1 X X X

Adult Magill Forceps 1 0 X X X Pediatric Magill Forceps 1 0 X X

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Equipment/ Supplies Portable Bag Ambulance AEMT EMT-CC EMT-P End Tidal CO2 Detector – Adult 1 0 X X X End Tidal CO2 Detector – Pediatric 1 0 X X X Esophageal Detector Device 1 0 X X X Nebulizers 1 2 X X X Atomizer 1 1 X X X Gum-Elastic Bougie 1 1 X X X Pelvic Stabilizer Device (1) 0 1 X X X Arterial Tourniquet 1 1 X X X Surgical Airway Equipment (4) 1 1 X CPAP (adult set specified by the manufacturer)

0 1 Adult Set X X X

Suction Catheters 8 French 1 1 X X X

10 French 1 1 X X X 12 French 1 1 X X X Yankauer 1 1 X X X

14 gauge x 3” IV Catheter 2 2 X X Orogastric Tube 16 French 1 1 X 1000 mL Normal Saline 1 3 X X X 100 mL Normal Saline 1 1 X X Macrodrip IV Admin. Set 1 3 X X X Microdrip IV Admin. Set 1 1 X X Large Bore Saline Lock Kit 3 2 X X X Protective IV Catheter 14G X 1¼” 2 3 X X X Protective IV Catheter 16G 2 3 X X X Protective IV Catheter 18G 2 3 X X X Protective IV Catheter 20G 2 3 X X X Protective IV Catheter 22G 2 2 X X Protective IV Catheter 24G 2 2 X X Intraosseous Needle – Adult (powered device)

1 1 X X X

Intraosseous Needle – Peds 1 1 X X X 1cc Syringe with 25G Needle 2 2 X X 3cc Syringe 2 2 X X 5cc Syringe 2 2 X X 10cc Syringe 2 2 X X 18G Hypodermic Needle (If packaged with a syringe, this will count toward the minimum quantity.)

2 2 X X

22G Hypodermic Needle (If packaged with a syringe, this will count toward the minimum quantity.)

2 2 X X

Disposable Razors 2 1 X X X Disposable IV Tourniquets (If packaged with a saline lock kit, this will count toward the minimum quantity.)

2 2 X X X

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Equipment/ Supplies Portable Bag Ambulance AEMT EMT-CC EMT-P Alcohol Prep Pads (If packaged with a saline lock kit, this will count toward the minimum quantity.)

6 12 X X X

Transparent Dressings (If packaged with a saline lock kit, this will count toward the minimum quantity.)

2 2 X X X

2” x 2” Gauze Pads (If packaged with a saline lock kit, this will count toward the minimum quantity.)

6 12 X X X

Iodine Pads or Chlorhexidine Wipes 2 2 X Band-Aids 6 12 X X X 9” Padded IV Arm board 1 1 X X X Spare Patient Monitor Cables 0 1 X X EKG Electrode Set – Adult 2 4 X X EKG Electrode Set – Pediatric (5) 2 2 X X AED Pad – Adult 1 1 X AED Pad - Pediatric 1 1 X Pacing/Defibrillation Pad – Adult 1 1 X X Pacing/Defibrillation Pad – Pediatric 1 1 X X Medications:

Acetaminophen 325 mg/10.15 mL (1) 4 0 X X X Adenosine 6 mg/2 mL 3 3 X X Albuterol 2.5 mg/3 mL 4 4 X X X Amiodarone 150 mg/3 mL Ampule 3 3 X X Aspirin 81 mg Chewable Tablets 1 Bottle 0 X X X Atropine Sulfate 1 mg/10 mL Syringe 2 2 X X Calcium Chloride 100 mg/ 1 mL 1 1 X Dexamethasone 10 mg / 1 mL 1 1 X X Dextrose 10% 25 grams/unit in 250 mL 2 1 X X X Diltiazem 5 mg/1 mL 2 2 X X Diphenhydramine 50 mg/1 mL 1 1 X X Epi-Pen Autoinjector – Adult 1 0 X Epi-Pen Autoinjector – Pediatric 1 0 X Epinephrine 1:10,000 1 mg/10 mL 6 6 X X X Epinephrine 1:1,000 1 mg/1 mL Ampule 3 3 X X Etomidate 20 mg/10 mL Vial 2 1 X X Fentanyl 100 mcg/2 mL Ampule (6) 0 2 X X Glucagon 1 mg/1 mL Vial 1 0 X X X Glucose - Oral 31gm 1 0 X X X Haloperidol 5 mg/1 mL Ampule 2 0 X X Ipratropium Bromide 500 ug/2.5 mL or Ipratropium Bromide & Albuterol

3 3 X X

Ibuprofen 100mg/5mL (1) 8 0 X X X

Ketamine 100 mg/1 mL (6) 2 0 X

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Equipment/ Supplies Portable Bag Ambulance AEMT EMT-CC EMT-P Ketorolac 30 mg/1 mL Vial 2 0 X X Lidocaine 100 mg/5 mL 3 0 X X Magnesium Sulfate (Total 8gm per vehicle)

1 0 X X

Metoprolol 5 mg/5 mL Ampule 1 1 X X Midazolam 5 mg/5 mL (6) 0 4 X X Morphine Sulfate 10 mg/1 mL (6) 0 2 X X Naloxone 2 mg/2 mL 1 1 X X X Nitroglycerin 0.4mg Tablet and/or 1 Bottle 1 Bottle X X Nitroglycerin Spray (1) 1 1 X X Nitrous Oxide 50/50 (1) 0 1 X X X Norepinephrine 4 mg/4 mL 1 1 X X Ondansetron 4 mg/2 mL Vial 1 2 X X Ondansetron 4 mg Tablets or 4 mg Orally Disintegrating Tabs (ODT) (1)

1 Bottle or Unit Dose

Packs

0 X X

Rocuronium 50 mg/5 mL Vial (1) (7) 2 0 X Sodium Bicarbonate 50 meq Syringe or Vial 1 1 X Succinylcholine 100 mg/5 mL Syringe(1) (7) 2 0 X Vecuronium 10 mg/10 mL Vial (1) (7) (8) 2 0 X

(1) Optional Regional Equipment or Medication.

(2) A current New York State Department of Health Limited Service Laboratory

Registration is required for glucometers. Registration Form

(3) The agency will create a paper version of the protocol PDF provided by the CNY

Region to carry in the ambulance.

(4) Providers must be trained on this procedure prior to agency implementation. (5) Adult electrodes can be used to fulfill the minimum pediatric electrode requirements provided the electrodes are 40 mm (skin contact size) or smaller. (6) Controlled Substance License is required to carry these medications.

Fentanyl and Ketamine are optional controlled substance medications.

(7) Agency and providers must be approved by the CNY Region to perform RSI. (8) Agency Medical Director option.

Note: Agencies must have a DOH-4362 Medical Director Verification form on file with the CNY Program Agency.

The quantity of items indicated in the ambulance is in addition to what is

to be carried in the portable bag. The agency may opt to carry the entire quantity (portable bag + ambulance) in the portable bag.

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CNY Minimum Required Equipment – First Response Vehicles

Equipment/ Supplies Portable Bag AEMT EMT-CC EMT-P

Cardiac Monitor/Defibrillator 1 X X AED 1 X 12-Lead Transmission (1) 1 X X Continuous Waveform Capnography 1 X X X Glucometer (2) 1 X X X Length-Based Resuscitation Tape 1 X X Protocol Book (3) 1 X X X Pulse Oximetry Monitor (Requirement is met if device is supplied with cardiac monitor.)

1 X X X

Endotracheal Tubes 3.0 2 X 3.5 2 X 4.0 2 X 4.5 2 X 5.0 2 X 5.5 2 X 6.0 2 X X X 6.5 2 X X X 7.0 2 X X X 7.5 2 X X X 8.0 2 X X X 8.5 2 X X X 9.0 2 X X X

Water Soluble Jelly Tube or 1 X X X Packets 4 X X X

10 cc Syringe for endotracheal tube 2 X X X Alternative Airway Device Adult Set 1 X X X Pediatric Set 1 X Adult Stylet (can be packaged with ETT) 2 X X X Pediatric Stylet (can be packaged with ETT) 2 X X Laryngoscope Handle 1 X X X Laryngoscope Blades

Curved – 2 1 X X X Curved – 3 1 X X X Curved – 4 1 X X X

Straight – 0 1 X Straight – 1 1 X Straight – 2 1 X X X Straight – 3 1 X X X Straight – 4 1 X X X

Adult Magill Forceps 1 X X X Pediatric Magill Forceps 1 X X

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End Tidal CO2 Detector – Adult 1 X X X End Tidal CO2 Detector – Pediatric 1 X X X Esophageal Detector Device 1 X X X Nebulizers 3 X X X Atomizer 2 X X X Gum-Elastic Bougie 1 X X X Pelvic Stabilizer Device (1) 1 X X X Arterial Tourniquet 2 X X X Surgical Airway Equipment (4) 1 X CPAP (adult set specified by the manufacturer)

1 X X X

Suction Catheters 8 French 2 X X X

10 French 2 X X X 12 French 2 X X X Yankauer 2 X X X

14 gauge x 3” IV Catheter 2 X X Orogastric Tube 16 French 1 X 1000 mL Normal Saline 2 X X X 100 mL Normal Saline 2 X X Macrodrip IV Admin. Set 2 X X X Microdrip IV Admin. Set 2 X X Large Bore Saline Lock Kit 4 X X X Protective IV Catheter 14G X 1¼” 2 X X X Protective IV Catheter 16G 2 X X X Protective IV Catheter 18G 2 X X X Protective IV Catheter 20G 2 X X X Protective IV Catheter 22G 2 X X Protective IV Catheter 24G 2 X X Intraosseous Needle – Adult (powered device) 1 X X X Intraosseous Needle – Peds 1 X X X 1cc Syringe with 25G Needle 2 X X 3cc Syringe 2 X X 5cc Syringe 2 X X 10cc Syringe 2 X X 18G Hypodermic Needle (If packaged with a syringe, this will count toward the minimum quantity.)

2 X X

22G Hypodermic Needle (If packaged with a syringe, this will count toward the minimum quantity.)

2 X X

Disposable Razors 1 X X X Disposable IV Tourniquets (If packaged with a saline lock kit, this will count toward the minimum quantity.)

2 X X X

8



Alcohol Prep Pads (If packaged with a saline lock kit, this will count toward the minimum quantity.)

12 X X X

Transparent Dressings (If packaged with a saline lock kit, this will count toward the minimum quantity.)

2 X X X

2” x 2” Gauze Pads (If packaged with a saline lock kit, this will count toward the minimum quantity.)

12 X X X

Iodine Pads or Chlorhexidine Wipes 3 X Band-Aids 12 X X X 9” Padded IV Arm board 1 X X X Spare Patient Monitor Cables 1 X X EKG Electrode Set – Adult 2 X X EKG Electrode Set – Pediatric (5) 2 X X AED Pad – Adult 2 X AED Pad - Pediatric 2 X Pacing/Defibrillation Pad – Adult 2 X X Pacing/Defibrillation Pad – Pediatric 2 X X Medications:

Acetaminophen 325 mg/10.15 mL (1) 4 X X X Adenosine 6 mg/2 mL 6 X X Albuterol 2.5 mg/3 mL 4 X X X Amiodarone 150 mg/3 mL Ampule 4 X X Aspirin 81 mg Chewable Tablets 1 Bottle X X X Atropine Sulfate 1 mg/10 mL Syringe 2 X X Calcium Chloride 100 mg/ 1 mL 2 X Dexamethasone 10 mg / 1 mL 2 X X Dextrose 10% 25 grams/ 250 mL 2 X X X Diltiazem 5 mg/1 mL 2 X X Diphenhydramine 50 mg/1 mL 2 X X Epi-Pen Autoinjector – Adult 1 X Epi-Pen Autoinjector – Pediatric 1 X Epinephrine 1:10,000 1 mg/10 mL 6 X X X Epinephrine 1:1,000 1 mg/1 mL Ampule 3 X X Etomidate 20 mg/10 mL Vial 3 X X Fentanyl 100 mcg/2 mL Ampule (6) 2 X X Glucagon 1 mg/1 mL Vial 1 X X X Glucose - Oral 31gm 1 X X X Haloperidol 5 mg/1 mL Ampule 2 X X Ipratropium Bromide 500 ug/2.5 mL or Ipratropium Bromide & Albuterol

3 X X

Ibuprofen 100mg/5mL (1) 8 X X X

Ketamine 100 mg/1 mL (6) 2 X

9


Equipment/ Supplies Portable Bag AEMT EMT-CC EMT-P Ketorolac 30 mg/1 mL Vial 2 X X Lidocaine 100 mg/5 mL 3 X X Magnesium Sulfate (Total 8gm per vehicle)

1 X X

Metoprolol 5 mg/5 mL Ampule 1 X X Midazolam 5 mg/5 mL (6) 4 X X Morphine Sulfate 10 mg/1 mL (6) 2 X X Naloxone 2 mg/2 mL 2 X X X Nitroglycerin 0.4mg Tablet and/or 1 Bottle X X Nitroglycerin Spray (1) 1 X X Nitrous Oxide 50/50 (1) 1 X X X Norepinephrine 4 mg/4 mL 1 X X Ondansetron 4 mg/2 mL Vial 3 X X Ondansetron 4 mg Tablets or 4 mg Orally Disintegrating Tabs (ODT) (1)

1 Bottle or Unit Dose

Packs

X X

Rocuronium 50 mg/5 mL Vial (1) (7) 2 X Sodium Bicarbonate 50 meq Syringe or Vial 2 X Succinylcholine 100 mg/5 mL Syringe (1) (7) 2 X Vecuronium 10 mg/10 mL Vial (1) (7) (8) 2 X

(1) Optional Regional Equipment or Medication.

(2) A current New York State Department of Health Limited Service Laboratory

Registration is required for glucometers. Registration Form

(3) The agency will create a paper version of the protocol PDF provided by the CNY

Region to carry in the ambulance.

(4) Providers must be trained on this procedure prior to agency implementation. (5) Adult electrodes can be used to fulfill the minimum pediatric electrode requirements provided the electrodes are 40 mm (skin contact size) or smaller. (6) Controlled Substance License is required to carry these medications.

Fentanyl and Ketamine are optional controlled substance medications.

(7) Agency and providers must be approved by the CNY Region to perform RSI. (8) Agency Medical Director option. Note: Agencies must have a DOH-4362 Medical Director Verification form on file with the CNY Program Agency.

Policy:

Basic Life Support and Advanced Life Support Stroke Protocol Criteria: For patients presenting with acute focal neurologic deficits including, but not limited to, slurred speech, facial droop, and/or unilateral (one-sided) weakness or paralysis.

The protocol indicates to “perform a neurological exam, including Cincinnati Stroke Scale and other regionally approved and indicated stroke scale.”

The FAST-ED stroke scale has been approved for the Central New York EMS Region. Providers should utilize this scale upon completion of the regionally approved training.

Reference:

Minutes of CNY REMAC meeting dated November 14, 2019. Minutes of CNY REMSCo meeting dated January 21, 2020.


Program

Policy Statement

No. 20-02

Date: 1/21/2020

Subject: FAST-ED Stroke Scale

Page 1

Supersedes/Updates: Original

1

Policy:

The New York State Department of Health Bureau of Emergency Medical Services Policy Statement #12-03 (or updated version) states that "all EMS services must submit the standard NYS data file to the Regional Program Agency in a compatible format on a regular and routine schedule determined by the Program Agency." The Policy Statement states that EMS Services must receive approval from the Regional Emergency Medical Services Council (REMSCo), Regional Emergency Medical Advisory Committee (REMAC) and the New York State Department of Health Bureau of Emergency Medical Services. All EMS Services in the Central New York EMS Region using an electronic PCR (ePCR) system are required to have a signed New York State Department of Health Application and Approval for EMS Agency to Use e-PCR (DOH-5136) that is up to date and on file with the Central New York EMS Program Agency. EMS Services shall contact the Central New York EMS Program Agency in writing to obtain credentials to access the Central Elite and New York State Elite data repositories. All EMS Services in the Central New York EMS Region using an electronic PCR (ePCR) system are required to submit electronically to the Central Elite site a completed prehospital patient care report with attachments in compliance with New York State Department of Health Bureau of Emergency Medical Services Policy Statement #21-04 (or updated version). The ePCR system must be in a format compliant with NEMSIS 3 and the New York State Department of Health Bureau of Emergency Medical Services Data Dictionary. It must be a file format that is able to be exported directly to the Central Elite data repository. New York State Department of Health Bureau of Emergency Medical Services Policy Statement #12-02 (or updated version) references the documentation that must be provided to the Emergency Department Staff upon transferring the patient. The ePCR or the Central New York EMS Patient Summary form must be provided at time of transfer. Reference: Minutes of CNY REMAC meeting of August 14, 2014. Minutes of CNY REMAC meeting of September 16, 2021. Minutes of CNY REMSCo meeting of September 21, 2021. NYS DOH BEMS Policy Statement #12-02 NYS DOH BEMS Policy Statement #12-03 NYS DOH BEMS Policy Statement #21-04


Program


No. 21-01 Date: 9/21/21 Subject: Electronic PCR Data Submission to REMAC Page 1 of 1 Supersedes/Updates: 14-11

CNYEMS Patient Summary - Ambulance / ALS FR

Agency Name: Agency Code: Incident: Times: Date of Call: Unit Notified: Incident #: Enroute: Call Location: Arrived On Scene: Chief Complaint: At Patient: Unit #: Transport: Crew Member #1: At Destination: Crew Member #2: Transfer of Care: Crew Member #3: In Service: Patient Information: Patient Name: Age: DOB: Gender: SSN: Address: City: State: Zip: Telephone #: Patient History: Physician: Past Medical History:

Medications: Allergies:

Vital Signs: Time: B/P: Pulse: Respirations: GCS: BG: SpO2:

Time: B/P: Pulse: Respirations: GCS: BG: SpO2:



Narrative:

Treatment: Medications Given: □ Oxygen _____ LPM via _______ □ Cardiac Monitor/AED Medication:

Dose: Time: □ Suction Used □ 12 Lead EKG

□ Oral/Nasal Airway w BVM □ Defibrillation Medication: Dose: Time: □ ET Tube Size_____Depth_____ □ Pacing

□ End-Tidal CO2 _________ □ Cardioversion Medication: Dose: Time: □ IV #1 Catheter Size______ □ Other

Signature of Receiving Hospital Agent: Note: Acknowledges receiving patient on above date.

CNYEMS Patient Summary - BLS FR

Agency Name: Agency Code: Incident: Times: Date of Call: Unit Notified: Incident #: Enroute: Call Location: Arrived On Scene: Chief Complaint: At Patient: Unit #: Transfer of Care: Crew Member #1: In Service: Crew Member #2: Crew Member #3: Patient Information: Patient Name: Age: DOB: Gender: SSN: Address: City: State: Zip: Telephone #: Patient History: Physician: Past Medical History:

Medications: Allergies:

Vital Signs: Time: B/P: Pulse: Respirations: GCS: BG: SpO2:




Narrative:

Treatment: Medications Given: □ Oxygen _____ LPM via _______ □ AED Medication:

Dose: Time: □ Suction Used □ Splint

□ Oral/Nasal Airway w BVM □ Other: Medication: Dose: Time: □ CPAP □ Other:

Transferred Care to Agency: