A Guide to EMS Point-of-Entry

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A Guide to EMS Point-of-Entry

• Developed by the Metropolitan Boston EMS Council
  Public Information and Education Resources (PIER)
  Committee

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Purpose

• To provide medical professionals with an
  overview of Point-of-Entry Protocols in
  accordance with 105 CMR 170.000.

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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.

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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 Patients Specific Condition and Need
• Stroke

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Pertinent Regulations

• 105 CMR 170.020 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 170.357 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

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Pertinent Regulations cont.

• 105 CMR 170.020 - Appropriate Health Care
  Facility - an emergency department, either
  physically located within an acute care hospital
  licensed by the Department pursuant to 105 CMR
  130.000 to provide emergency services, or in a
  satellite emergency facility approved by the
  Department pursuant to 105 CMR 130.821, that is
  closest geographically or conforms to a
  Department approved point-of-entry plan.

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Closest Appropriate Facility

• Under EMS System Regulations (105 CMR 170.355
  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 patients medical condition makes it
  more appropriate to take the patient to a
  hospital that is not the closest. Under the
  definition at 105 CMR 170.020, 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.

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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.
• http//www.mbemsc.org/provider_info_items/view/113

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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.)

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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.

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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.

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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.

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Trauma Centers in MA
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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)

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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)

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Stroke Centers in MA
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Statewide Point of Entry Plan forAppropriate
Health Care Facility DestinationBased on
Patients Specific Condition and Need

• This point-of-entry plan addresses other
  circumstances when, because of the patients
  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 patients 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.

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Statewide Point of Entry Plan forAppropriate
Health Care Facility DestinationBased on
Patients 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.

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Statewide Point of Entry Plan forAppropriate
Health Care Facility DestinationBased on
Patients Specific Condition and Need

• 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
  patients specific medical condition and needs,
  based on the following factors
• The patients current physician and medical
  records are there
• the patient has recently been discharged from
  that hospital
• the patient has had previous hospitalizations
  there
• the patients complex medical history is followed
  at the hospital
• The patients 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
  patients 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.

(Multiple hospitals for which estimated
transport time from the patient is less than 10
minutes are considered to be of equal transport
distance.)
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Ambulance Service Levels

• Basic Life Support
• Intermediate Life Support
• Advanced Life Support
• Critical Care Transport

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Levels of Pre-Hospital Provider

• First Responder
• Emergency First Responder (FR, BLS, ILS, ALS)
• EMT - Basic
• EMT -Intermediate
• EMT - Paramedic

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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.
• Pointof-Entry Plans are designed to provide the
  most appropriate acute care facility for a
  patients medical condition, thus optimizing care
  and outcome.

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Other Resources

• STEMI
• http//www.mbemsc.org/provider_info_items/view/11
  3
• Stroke -http//www.mbemsc.org/files/provider_info_
  items/rstrokepointofentryplan20050.PDF
• Trauma -http//www.mbemsc.org/files/provider_info_
  items/TraumaPOE0.PDF

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Questions
?