Delaware County EMS Medical Intervention Procedures - V. Triage & Transport Protocols T
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V. TRIAGE AND TRANSPORT PROTOCOLS
TABLE OF CONTENTS
Page Effective Date
Patient Refusal of Treatment/Transport...................................................... T 2-3 ................ (7/1/02)
Patient Restraints ........................................................................................ T 4 ................... (7/1/02)
Physician On-Scene .................................................................................... T 5.................... (7/1/02)
Receiving Hospitals (In Region)................................................................. T 5.................... (7/1/02)
Receiving Hospitals (In Region): Trauma Patients..................................... T 5.................. (11/1/01)
Receiving Hospitals (In Region): Burn Patients......................................... T 5.................. (11/1/01)
Trauma Patients: Destination Selection ...................................................... T 6-7 ............ (12/15/02)
Trauma Triage: Field Protocol and Algorithm ........................................... T 8-9 ................ (7/1/02)
Revised 12/15/02
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PATIENT REFUSAL OF TREATMENT/TRANSPORT
Paramedics: Consider the following points when dealing with a patient who is refusing needed care:
1. Talk with Patient
Assess the patient's mental status/level of consciousness/GCS. Attempt to convince the patient of the
need for treatment. Remind the patient that a trip to the emergency department does not mean that
they will have to be admitted to the hospital overnight. When applicable reinforce the gravity of the
situation;  Do you realize that you may die?
2. Talk with Family/Friends
Establish their relationship to the patient. They may be able to convince the patient to accept care.
3. If the patient agrees to treatment/transport at this time, provide BLS care and transport for BLS cases.
Call Medical Command, provide ALS care and transport for ALS cases.
4. If the patient continues to refuse care, call Medical Command.
5. Document attempts to convince the patient of needed care, items discussed, and names of
friends/family members involved in discussions.
Medical Command Physicians
7. Use techniques in points 1 & 2 above. When speaking to patient s family/friends, have them state
their name and relationship to patient.
8. Talk to Paramedics again. Have they been able to convince the patient? How do they feel about the
patient's status? GCS? Would they be physically able to handle the patient or do they feel
threatened ...a little old lady vs. a large, hostile, aggressive man.
9. Medical Command physician will review case and may repeat above steps to help determine
appropriate disposition. If the Medical Commander is able to persuade patient to accept care and/or
transport, it will be provided.
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PATIENT REFUSAL OF TREATMENT/TRANSPORT
Assess if AAO x 3, GCS = 15; and understands risks of refusal
See Patient Assessment Protocol (A.10-11)
“! “!
Yes No
“! “!
Attempted/Threatened Suicide? Yes Can not refuse care & transport
“! “!
No Are EMS personnel physically threatened?
“! At no time should EMS personnel put
Patient themselves in physical jeopardy!
or “! “!
Parent refusing care Yes No
for a minor? “! “!
(These patients cannot be Can police present assist
Treat and transport
forced to accept care/transport) in restraining patient? Yes according to
Protocols
“! “!
Contact Medical Command No
9
for assistance “!
“! Contact Medical Command
If patient still refuses: for assistance 9
“!
Educate patient/family to call back if
patient gets worse/changes mind;
Have them call their family doctor;
They may prefer a private
ambulance to a hospital of their
choosing;
Have patient sign a patient refusal
form on appropriate line;
“!
Medical Command physician will
release the paramedics to
become "available"
“!
Document everything in detail.
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Delaware County EMS Medical Intervention Procedures - V. Triage & Transport Protocols T 4
PATIENT RESTRAINTS
PURPOSE: To provide guidelines on the use of restraints in the field or during transport of patients who are
violent or potentially violent, or who may harm themselves or others.
1. The safety of the patient, community, and responding personnel is of paramount concern when following this
policy.
2. Restraints are to be used only when necessary in situations where the patient is potentially violent and is
exhibiting behavior that is dangerous to self or others. When using restraints have police present, if possible,
and also get approval from medical command, if possible.
3. Prehospital personnel must consider that aggressive or violent behavior may be a symptom of a medical
condition, such as head injury, alcohol or drug intoxication, metabolic disorders, and psychiatric disorders.
ALS interventions shall be implemented as needed, and medical command shall be obtained as usual.
4. The method of restraint used shall allow for adequate monitoring of vital signs, and shall not restrict the
ability to protect the patient's airway or compromise neurologic or vascular status.
5. If restraints are applied by police personnel, a police officer must remain available at the scene and during
transport to remove or adjust the restraint for patient safety.
6. Restraints used shall be either padded or soft, with a quick method of release that does not rely on a key
(Velcro, seat-belt type, etc.).*
7. Restrained extremities shall be evaluated for pulse quality, capillary refill, color, and nerve and motor
function at least every 15 minutes, and this evaluation shall be documented on the PaPCR.
8. The patient's position during transport shall not compromise respiration or circulation, and shall allow
necessary medical interventions to protect the airway should vomiting occur. Restrained patients should
never be transported in a prone (face down) position.
9. Documentation shall include the reason(s) for restraints, who applied the restraints (EMS, police, etc.),
monitoring of neurovascular status, and monitoring of respiratory status.
The following restraints and techniques are not permitted at any time:
1. Hard plastic ties *
2. Any device requiring a key to remove *
3. Restraining the hands or feet behind the back
4. Materials such as gauze bandages that may tighten and cause neurologic or vascular compromise
5. Restraints or transport in the prone position
* Police may apply hard restraints or restraints requiring a key, such as handcuffs, provided that the officer stay
with the patient at all times, and the restraints are applied in such a way as to allow EMS personnel to perform
their usual duties and assure patient safety.
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PHYSICIAN ON-SCENE
Response to Physician on Scene
If a physician on scene offers to provide medical command for a case requiring Advanced Life
Support, the paramedic is to give the physician one of the cards illustrated below. The physician must
speak to the Medical Command physician; the paramedic is to facilitate this via telephone
communication. This also applies to physicians who identify themselves as regularly assigned Medical
Command physicians.
Determination of Qualification
The Medical Command physician determines the identity and qualifications of the physician on
scene.
Authorization to Paramedic
Paramedics are authorized to proceed under the command of a physician on-scene only if directed to
do so by the Medical Command physician.
Requirements of Physician on Scene
Medical command may be accepted only if the physician on scene agrees to sign the Pennsylvania
Emergency Medical Services Patient Care Report (PaPCR), and agrees to accompany the patient to the
hospital. The physician on scene may not order the paramedics to provide care beyond the paramedic
scope of practice.
Absence of On-Line Medical Command (OLMC)
If communication with the Medical Command Facility cannot be established, patient treatment will
be provided according to approved Regional ALS protocols. Medical command from a physician on
scene may not be accepted.
If the physician on-scene orders you only to transport the patient, attempt to contact the Medical
Command physician (base physician) to resolve differences in patient care. If problems are not resolved,
move to a nearby stable environment, and proceed under Regional protocol.
RECEIVING HOSPITALS
Bryn Mawr Hospital
Crozer Chester Medical Center
Crozer-Springfield Division
Delaware County Memorial Hospital
Mercy Fitzgerald Hospital
Riddle Memorial Hospital
Taylor Hospital
RECEIVING HOSPITALS: TRAUMA PATIENTS
Crozer Chester Medical Center
RECEIVING HOSPITALS: BURN PATIENTS
Crozer Chester Medical Center
Revised 11/1/01
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TRAUMA PATIENTS: DESTINATION SELECTION
Patients meeting the criteria of the Delaware County Emergency Medical Services System Trauma Triage Field
Protocol should be transported to an Accredited Trauma Center under the following guidelines:
I. PATIENT TRANSPORT PROTOCOL
A. Trauma (Adult)
Patients meeting the pre-hospital trauma triage criteria should be transported to the nearest Accredited
Trauma Center when ground transport time is twenty minutes or less. In the event that transport time to
an Accredited Trauma Center exceeds twenty minutes and Medical Command is available and has been
established, the medical command physician shall determine whether the patient should be transported to
the Accredited Trauma Center or to the nearest hospital accepting trauma patients. Patients who are
more than twenty minutes from an Accredited Trauma Center should be considered candidates for aero-
medical transport  PER MEDICAL COMMAND AUTHORIZATION.
B. Trauma (Pediatric)
Pediatric patients, identified as patients 16 years and under, meeting the Prehospital trauma triage criteria
should be transported to the Accredited Trauma Center that is determined appropriate by MEDICAL
COMMAND AUTHORIZATION. Patients who are more than twenty minutes from the appropriate
facility should be considered candidates for aero-medical transport - PER MEDICAL COMMAND
AUTHORIZATION.
C. Burns (Adult)
Patients who have isolated burn injuries and meet Burn Center criteria (see Burns Protocol, A.12-13)
should be transported to a Burn Center respective of their geographic location when ground transport
time is twenty minutes or less:
Crozer Chester Medical Center: Burn Center
In the event that transport time exceeds 20-minutes and/or the patient presents with extraordinary case
management difficulties, the patient should be transported to the closest accredited Trauma Center.
D. Burns (Pediatric)
Pediatric patients, identified as patients 16 years and under, who meet Burn Center criteria (see Burns
Protocol, P.12-13) should be transported to:
Crozer Chester Medical Center: Burn Center
when ground transport time is twenty minutes or less. In the event that transport time to a pediatric burn
center exceeds twenty minutes, pediatric burn patients should be transported to the nearest Pediatric
Trauma Center, in accordance with the guidelines for pediatric trauma patients.
E. Spinal Cord Injury
Patients with isolated spinal cord injuries should be transported under medical command direction.
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II. Determination of Receiving Hospital for Trauma Patients
Trauma patients are to be transported to a Trauma Center when ground transport time is equal to or less
than 20 minutes:
ADULT (> 16 years)
Cardiac Arrest Closest Emergency Department
Trauma Closest Accredited Trauma Center
Burn Crozer Chester Medical Center: Burn Center
Spinal Cord Injury Per medical command direction
PEDIATRIC (d" 16 years)
Cardiac Arrest Closest Emergency Department
Trauma Closest Accredited Trauma Center
Burns Crozer Chester Medical Center: Burn Center
Spinal Cord Injury Per medical command direction
III. Medical Command
In all cases involving Trauma Patients who meet the criteria of Trauma Triage Field Protocol T8-9,
including serious burns, medical command must be established.
Revised 12/15/02
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TRAUMA TRIAGE: FIELD PROTOCOL
PATIENTS WITH ANY OF THE FOLLOWING CONDITIONS
RELATED TO A TRAUMATIC INJURY
SHOULD BE TRANSPORTED TO A TRAUMA CENTER:
Vital Signs (PHYSIOLOGY)
" Abnormal Pulses
" Glasgow Coma Scale less than 15
" Systolic Blood Pressure less than 90 (Pediatric less than 80)
" Respiratory Rate less than 10 or greater than 29 (Pediatric less than 15 or greater than 36)
Anatomy of Injury:
" Penetrating injury to head, neck, torso and extremities proximal to elbow and knee
" Flail chest
" Combination trauma with burns of 10% or inhalation injuries
" Two or more proximal long-bone fractures
" Pelvic fractures
" Limb paralysis
" Amputation proximal to wrist and ankle
Mechanism of Injury:
" Ejection from automobile
" Death in same passenger compartment
" Extrication time > 20 minutes
" Falls from > 20 feet
" Rollover
" High-speed auto crash (initial speed greater than 40 mph, velocity change greater than 20 mph,
major auto deformity greater than 20 inches, intrusion into passenger compartment greater than 12 inches)
" Auto/pedestrian injury with significant (greater than 5 mph) impact
" Pedestrian thrown or run over
" Motorcycle crash greater than 20 mph or with separation of rider and motorcycle
Evaluate case with Medical Command physician as available, especially for patients younger than 5 years of
age or older than 55 years of age, or those with cardiac or respiratory disease. If in doubt, transport to a trauma
center
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TRAUMA TRIAGE FIELD PROTOCOL ALGORITHM
Measure vital signs and level of consciousness
“!
STEP 1 Abnormal Pulses or
Glasgow Coma Scale < 15 or
Systolic Blood Pressure < 90 (Pediatric < 80) or
Respiratory rate < 10 or > 29 (Pediatric < 15 or > 36)
“! “!
NO YES
“! “!
Assess anatomy of injury Transport to Trauma Center
and mechanism of injury
STEP 2 “!
Anatomy of Injury:
" Penetrating injury to head, neck, torso and extremities proximal to elbow and knee
" Flail chest
" Combination trauma with burns of 10% or inhalation injuries
" Two or more proximal long-bone fractures
" Pelvic fractures
" Limb paralysis
" Amputation proximal to wrist and ankle
Mechanism of Injury:
" Ejection from automobile
" Death in same passenger compartment
" Extrication time > 20 minutes
" Falls from > 20 feet
" Rollover
" High-speed auto crash (initial speed > 40 mph, velocity change > 20 mph,
major auto deformity > 20 inches, intrusion into passenger compartment > 12 inches)
" Auto/pedestrian injury with significant (>5 mph) impact
" Pedestrian thrown or run over
" Motorcycle crash > 20 mph or with separation of rider and motorcycle
“! “!
NO YES
“! “!
Transport to Trauma Center
Re-evaluate with Medical Command as available,
especially if: age < 5 or > 55, known cardiac disease,
respiratory disease, cirrhosis, malignancy, obesity,
coagulopathy, psychotics taking medication, or
diabetics taking insulin. When in doubt, transport
to a Trauma Center.
Revised 7/1/02
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Revised 7/1/02