A Guide to EMS Point-of-Entry Developed by the Metropolitan Boston EMS Council Public Information and Education Resources (PIER) Committee

Purpose To provide medical professionals with an overview of Point-of-Entry Protocols in accordance with 105 CMR

Background  There was an identified shared need (EMS providers, citizens, hospital staff) to understand, articulate, and implement the appropriate use of the Point-of-Entry system in Region IV and the Commonwealth.  As new treatment modalities have been developed and implemented in the pre-hospital arena, there has been confusion regarding where patients are transported. This presentation was developed to address these issues.

Objectives  Provide a guide to the MADPH/OEMS approved regional point-of-entry plans  Define Point-of-Entry  Define Closest Appropriate Facility ST Elevation Myocardial Infarction (STEMI) Trauma/Burns (Adult and Pediatric) Appropriate Health Care Facility Destination based on Patient’s Specific Condition and Need Stroke

Pertinent Regulations  105 CMR Point-of-Entry Plan - a plan that is designed to ensure that EMTs transport a patient(s) in their care to the closest appropriate health care facility.  105 CMR Point-of-Entry Plans - Each ambulance service shall ensure that its EMTs deliver patients in accordance with regional point- of-entry plans approved by the Department. No ambulance service shall develop a point-of- entry plan independent of a Department- approved regional point-of-entry plan. (emphasis added) ** Department refers to the Massachusetts Department of Public Health and all of its related agencies**

Pertinent Regulations cont.  105 CMR Appropriate Health Care Facility - an emergency department, either physically located within an acute care hospital licensed by the Department pursuant to 105 CMR to provide emergency services, or in a satellite emergency facility approved by the Department pursuant to 105 CMR , that is closest geographically or conforms to a Department approved point-of-entry plan.

Closest Appropriate Facility  Under EMS System Regulations (105 CMR Responsibility to Dispatch, Treat and Transport ), EMS Services are required to “transport a patient to an appropriate health care facility” which is interpreted by OEMS as being the “closest, by driving time, hospital emergency department.” Sometimes, a patient’s medical condition makes it more appropriate to take the patient to a hospital that is not the closest. Under the definition at 105 CMR , an “appropriate health care facility” can also be one designated in a Department- approved point-of-entry plan. The Department currently has approved condition-specific point-of- entry plans.  These patients require early notification to the receiving facility through the CMED network.

ST Elevation Myocardial Infarction (STEMI) Point-of-Entry  STEMI - patients with signs and symptoms of ST elevation myocardial infarction (STEMI) being managed at the paramedic level are transported to the most clinically appropriate facility.

Trauma/Burns Point-of-Entry  Trauma (traumatic injury) – Tissue or organ injury, or both, sustained by the transfer of environmental energy. (Regional Trauma Systems; Optimal Elements Integration and Assessment; Systems Consultation Guide 2008)  Levels of Trauma Centers (Centers for Disease Control and Prevention. Guidelines for Field Triage of Injured Patients. Recommendations of the National Expert Panel on Field Triage. MMWR 2009; 58 (No. RR-1) pg 5.)

Trauma/Burns Point-of-Entry  Level I - Regional resource hospital that is central to trauma care system. Provides total care for every aspect of injury, from prevention through rehabilitation. Maintains resources and personnel for patient care, education and research (usually in university-based teaching hospital). Provides leadership in education, research and system planning to all hospitals caring for injured patients in the region.

Trauma/Burns Point-of-Entry  Level II - Provides comprehensive trauma care, regardless of severity of the injury. Might be most prevalent facility in a community and manage the majority of trauma patients or supplement the activity of a Level I trauma center. Can be an academic institution or a public or private community facility located in an urban, suburban, or rural area. Where no Level I Center exists, is responsible for education and system leadership.

Trauma/Burns Point-of-Entry  Level III - Provides prompt assessment, resuscitation, emergency surgery, and stabilization and arrange transfer to a higher level facility when necessary. Maintains continuous general surgery coverage. Has transfer agreements and standardized treatment protocols to plan for care of injured patients. Might not be required in urban or suburban area with adequate Level I or II centers.

Trauma Centers in MA

Stroke Point-of-Entry  Definition Stroke - when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts. When that happens, part of the brain cannot get the blood (and oxygen) it needs, so it starts to die. (Stroke Association Definition)

Stroke Point-of-Entry Primary Stroke Service (PSS) - a hospital that must provide emergency diagnostic and therapeutic services 24 hours-a-day, seven days-a-week to patients presenting with symptoms of acute stroke. These services are needed to ensure that every patient who arrives within hours of the start of their stroke symptoms and is eligible can be treated with thrombolytics.  PSS designation requires that hospitals follow very specific stroke protocols for patient assessment and care and commit to continuous education of the public about warning signs and symptoms of stroke. (MA- DPH)

Stroke Centers in MA

Statewide Point of Entry Plan for Appropriate Health Care Facility Destination Based on Patient’s Specific Condition and Need  This point-of-entry plan addresses other circumstances when, because of the patient’s specific medical needs, the patient would clinically benefit from going to a more distant hospital emergency department. An ambulance service may transport an emergency patient not covered by a condition-specific Department approved point-of-entry plan (i.e., stroke or trauma) to a hospital other than the closest, based on the patient’s medical condition and need. However, this point-of-entry plan would not require a service and its EMTs to deviate from taking such a patient to the closest hospital emergency department, when not permitted by service policy.

Statewide Point of Entry Plan for Appropriate Health Care Facility Destination Based on Patient’s Specific Condition and Need  Unstable patients: Transport to the closest hospital emergency department, or as required under a condition-specific Department-approved point-of-entry plan. An unstable patient is one whose vital signs have significantly changed (either upwards or downwards) from normal ranges, in the absence of interventions. See EMS textbooks for normal ranges of vital signs. If there is any question about the stability of the patient, transport to the closest hospital.

 Stable patients: Based on an appropriate assessment of the patient EMTs may consider transporting a patient to a hospital other than the closest, if the more distant hospital is more appropriate to the patient’s specific medical condition and needs, based on the following factors:  The patient’s current physician and medical records are there  the patient has recently been discharged from that hospital  the patient has had previous hospitalizations there  the patient’s complex medical history is followed at the hospital  The patient’s specific medical condition needs one of the following Burn Unit, Obstetrics, STEMI (Percutaneous Coronary Intervention (PCI) capability), Pediatrics  The additional time required to transport the patient to the more distant hospital does not exceed 20 minutes*  The care capabilities of the EMTs (Paramedic, Intermediate or Basic) are appropriate to the patient’s needs during transport.  The available EMS resources in the system at the time of the call would be capable of handling the additional transport time for this unit. Statewide Point of Entry Plan for Appropriate Health Care Facility Destination Based on Patient’s Specific Condition and Need *(Multiple hospitals for which estimated transport time from the patient is less than 10 minutes are considered to be of equal transport distance.)*

Ambulance Service Levels  Basic Life Support  Intermediate Life Support  Advanced Life Support  Critical Care Transport

Levels of Pre-Hospital Provider  First Responder  Emergency First Responder (FR, BLS, ILS, ALS)  EMT - Basic  EMT -Intermediate  EMT - Paramedic

Summary  The closest hospital may not be the most appropriate destination for your particular medical condition.  The level of EMS service and provider certification may have an impact on the facility where you are initially transported.  Point–of-Entry Plans are designed to provide the most appropriate acute care facility for a patient’s medical condition, thus optimizing care and outcome.

Other Resources  STEMI –  Stroke PDF PDF  Trauma -

Questions