Harbor:Screening EMS Patients

COVID19 Surge Mitigation for EMS Patient Offload Times(2022)

  • Per EMS Agency Directive #4 (12/23/2020) EMS providers will offload their patients to the waiting room with notification of the triage nurse for patients meeting ALL of the below criteria in an effort to reduce ambulance patient offload times (APOT). EMS Directive #4
  1. APOT estimate ≥ 30 mins
  2. Age ≥ 18 years; or pediatric patients if accompanied by an adult
  3. Normal Mental Status (GCS 15)
  4. Normal vital signs per MCG 1380 for adults or MCG 1309 for peds: SBP ≥ 90mmHg, HR 60-100 BPM, RR 12-20, SPO2 > 94% on room air
  5. Ambulatory with steady gait without assistance (as appropriate for age)
  6. No suicidal or not on psychiatric hold (5150/5585)
  7. No chest pain, syncope, or acute neurologic symptoms (focal weakness, dizziness/vertigo)

Ambulance Triage

Goals: Identify any time-sensitive, critical, or decompensating patients who arrive by ambulance, but not yet assigned a bed. This is especially important during hospital surges and staffing shortages.

General Principles: All ED Trauma and ALS patients should be triaged as soon as possible by the assigned senior resident or attending physician. The triage should include a brief history, a full set of vital signs, mental status, and pertinent physical/psychiatric exams. You may choose to perform point of care testing (blood sugar, hemocue) or breathalyzer testing. The senior resident or attending physician should clearly communicate and discuss the urgency of rooming with the AED charge and place additional orders for the patient as needed. We should all be conscious that delays in ambulance patient offload can result in longer 911 ambulance response times in our community.


General Screening Process:

  • All EMS Providers/Law Enforcement who arrive via ambulance triage with patients must check in with the AED Charge RN (unless pre-registered and going direct to preassigned room)
    • When AED Charge RN determines patient clearly needs to stay in AED:
      • If there is a room available, AED Charge will Quick Reg the patient and room immediately
        • Assign team (purple/green) based on available room
      • If no room available, AED Charge RN assigns by alternating purple/green and notify Senior Resident via Spectra - "EMS is waiting"
        • Hold EMS until physician arrives (30 min max)


Direct to main ED triage criteria*:

  • Stable Vital Signs
    • T 36-38C
    • HR 60-100
    • SBP 100-210, DBP 60-120
    • RR 12-20
  • Ambulatory
  • Cleared by Charge RN who must Quick Reg the patient AND Use the Pre-Hospital template to enter
    • VS
    • EMS unit
    • Brief statement about patient being stable and ambulatory to triage
  • If the patient meets all 3 criteria, EMS may take them directly to the physician in triage (or NP if physician is unavailable)

'*In the setting of COIVD 19 Surge, The EMS Agency Directive #4 criteria supersedes the above direct to main ED Criteria


Role of Senior Resident/Attending Physician

  • If you notice EMS patient has been waiting > 30 min for team assignment - call Charge RN
  • If your team is assigned a triage patient, report ASAP to get EMS report
  • Release ALS personnel (BLS may have to stay until patient in room)
  • If pt on wall and appears stable for triage/WR, discuss with attending
    • If attending agrees use .edambutriage note but do NOT click the "MSE"
    • Write "Triage" in the RN Comments column
  • These patients will then go to team triage
  • If the patient needs to stay in the ED, write AED in RN comments and do a brief MSE note

ED Attending should discuss any ambulance offload delays with the AED Charge RN and OCN


Role of AED Charge RN:

  • Quick Reg all patients
  • If assigned "AED" by screening MD, place in next available room (senior to remove team assignment unless they want to keep the patient on their team; if no team assignment, goes to team based on room placement/geography)
  • If assigned "Triage" by screening MD, send EMS to main triage for physician/NP in triage to perform MSE


Role of MICN (ALS Arrivals ONLY)

  • Download and print 2 copies of ePCR (aka EMS Report Form)
  • Place stickers on them
  • Leave 1st copy with patient’s RN
    • Give 2nd copy to clerk

See Also

References

Kelsey Wilhelm 1/05/22 rev Brad Chappell 1/22

EMS Agency Directive #4 [ https://file.lacounty.gov/SDSInter/dhs/1100372_Directive_4-WaitingRoomOffload.pdf]