ems base station meetings fall 2013
DESCRIPTION
EMS Base Station Meetings Fall 2013. What, How and Why. Objectives – What, How and Why. State EMS Authority Quality Core Measures Project Review – where do you fit in… Review 2012-2013 STEMI Benchmarks Review six months data from 2013 cardiac arrest study. Objectives – continued. - PowerPoint PPT PresentationTRANSCRIPT
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WHAT, HOW AND WHY
EMS Base Station MeetingsFall 2013
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Objectives – What, How and Why
State EMS Authority Quality Core Measures Project Review – where do you fit in…
Review 2012-2013 STEMI Benchmarks
Review six months data from 2013 cardiac arrest study
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Objectives – continued
Trauma system- the first 12 monthsDiscuss opportunities of improvement through case studies
Communication M- mechanism I - injuries V - vital signs T – treatment Documentation Destination
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State Core Measures
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State Quality Core Measures
Why…California first to establish statewide standard set of core measures
Purpose: increase accessibility and accuracy of prehospital data
Measures process data vs. outcome data
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System Core Quality Measures include: Trauma Acute coronary syndrome Cardiac Arrest Stroke Respiratory Pediatric EMS Provider skill performance EMS response and transport Public education/by-stander CPR
State Quality Core Measures
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STATE CORE MEASURES
ACS-1 “ASA Administration for Chest Pain” Year Percent
2010 72.2%
2011 70.9%
2012 71.9%
STATE 2010 66%
STATE 2011 43%
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Core Measures
How can you help?Challenges
Consistent data reporting – check your charts Acquiring data from non-transporting agencies
including: First responders Dispatch agencies Hospitals
Understand we only ask for information that we need
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STEMI
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STEMI Benchmarks
(Time in Minutes by Quarter) Q1 Q2Number of STEMI Activations 13 12
Average time on scene (15 min)14 min 9 min
Time from 911 to Pt. Contact (10 Min) 8 min 8 minTime from Pt Contact to ECG (5min) 4 min 2 minTime from ECG to SRC Contact (10 min)
12 min 8 min
Time from Pt Contact to Arrival at SRC
27 min
25 min
False Positive % (<30%) 30% 50%Time EMS to Intervention (E2B) (90-120min)
78 min
77 min
Time from Door to Intervention (D2B) (<90 min)
56 min
41 min
(Time in Minutes by Quarter 2013) Q1 Q2
Number of STEMI Activations 13 12
Average time on scene (15 min) 14 min 9 min
Time from 911 to Pt. Contact (10 Min) 8 min 8 min
Time from Pt. Contact to ECG (5min) 4 min 2 min
Time from ECG to SRC Contact (10 min) 12 min 8 min
Time from Pt. Contact to Arrival at SRC 27 min 25 min
False Positive % (<30%) 30% 50%
Time EMS to Intervention (E2B) (90-120min) 78 min 77 minTime from Door to Intervention (D2B) (<90 min) 56 min 41 min
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STEMI Feedback
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Cardiac Arrest 6 Month Review
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Cardiac Arrest Study
Four time sensitive links to survival:Early recognition of the emergency and activation of the local emergency response system
Early bystander CPR
Early delivery of a shock with a defibrillatorEarly, advanced life support followed by post resuscitation care
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Data Overview
Arrests and Outcomes
Total number of cardiac arrest transported to a hospital
52
Number survived to hospital admission 21 40%
Number survived to discharge 8 15%
Number discharged with normal/functional neurologic status
7 13.5%
Number of organ donors 4 8%
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CPR/AED
CPR/AED Summary
Number of witnessed arrests 37 71%
Number receiving CPR prior to EMS arrival 23 44%
Number of times AED was applied 16 31%
Number of patients where AED shocked was indicated
11 21%
Number of patients surviving to discharge with CPR prior to FR) 6/8)
6 75%
Number of patients surviving to discharged with AED use (4/8)
4 50%
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Cardiac Arrest Rhythms
First Cardiac Rhythms Identified by ALS Providers
Sinus Tachycardia 2 4%
V-Fib 14 27%
Asystole 23 44%
PEA 12 23%
Sinus Arrhythmia 1 2%
ROSC at some point in resuscitation 26 50%
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Survivor Rhythms
First ALS Rhythm of the (8) Patients that survived to discharge
Sinus Tachycardia 1 12.5%
V-Fib 6 75%
Asystole ( resulted in poor neurologic outcome)
1 12.5%
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Times
Notification and EMS Times
Times obtained from First Responders (40/52) 40 77%
Average time from notification to FR on scene 6 min (1-17 min)
Average time from notification to first responder CPR (30 /52 CPR times recorded)
7 min (2-13 min)
Average time from notification to ALS on scene 8 min (1-25 min)
Average time from notification to ROSC 24 min (7-50 min)
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What Now? (Goals)
Data collection – request PCR from all providers (BLS and ALS) for cardiac arrest that are transported
Obtain dispatch information – pre-arrival instructions etc.
Improve by-stander CPR from 44% - classes and public education
AED access – identify locations and add to CADImprove out of hospital survival – “Pit-crew
CPR”
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Trauma 2012-13
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Trauma Call Volume
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Consults - MOI and GLF
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2013 – Quarter 2 Consults
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MOI – Step 3 Criteria
Falls Adults: >20 feet (one story is equal to 10 feet) - Children:
>10 feet or two or three times the height of the child High-risk auto crash
Intrusion of passenger compartment >12 inches occupant site or >18 inches any site including roof/floor
Ejection (partial or complete) from automobile Death in same passenger compartment ·
Auto vs. pedestrian/bicyclist thrown, run over, or with significant (>20 mph) impact
Motorcycle or unenclosed transport vehicle crash >20 mph
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Special Considerations - Step 4
EMS provider judgment –Anything not listedAge >65 or <14 yrs. Two or more proximal long bone fracturesAnticoagulation therapy (excluding aspirin) or
other bleeding disorder with head injury (excluding minor injuries)
Pregnancy >20 weeks Burns with trauma mechanism (*) Trauma Consultation is not required for ground
level/low impact falls with GCS ≥ 14 (or when GCS is normal for patient) – follow SLO County patient destination policy
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PCR Missing After 24 HoursSVRMC Fax line for all PCRs - 805-596-7509
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Prehospital Performance
Transports > 30 minResponses > 20 minScene time > 10 without extrication
MCI/Multiple Patients Law Enforcement Questioning
Total call times
Fall outs are reviewed with the providers to determine if there is a system issue that needs further attention.
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EMS Helicopter Resource
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High Risk SituationsConsider EMS Air Resources
High risk motor vehicle accidents Major damage to vehicle e.g. head-on/entrapment Patients ejection (partial or complete) from an automobile Multiple injured patients/reported death
Auto vs. pedestrian/bicyclist – thrown or run over with significant injuries
Motorcycle (or like vehicle) crash > 20 mph with significant injuries
Falls – adults greater than 20 feet or children greater than 10 feet or 2-3 times their height with injuries
Unconscious person(s) Penetrating (stabbing or gunshot) injuries to head, neck or torso Paralysis Amputations and/or mangled limbs Burns to face or major portion of the body Multi Other situations not covered but dispatcher/FR believes
condition of patient is critical
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Scene considerations
Questions to ask yourself Do you think this patient requires specialty care? Is this a time sensitive injury or illness? Does the county have this capability, i.e. intubated
pediatric patient Is the patient inaccessible by ground? Are ground resources maxed out? Is this a MPI? Should these patients be dispersed over
a larger area?
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Time Considerations
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Trauma Center
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SVRMC Trauma Registry Data
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SVRMC Trauma Registry Volume by Age
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SVRMC Trauma Registry Volume by MOI
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Trauma Center Quality and Performance
Quality Indicators ED through hospital discharge GCS < 14, no head CT GCS >8, no definitive airway Under and Over Triage rates Surgeon response times to activation ED/Resuscitation: ED throughput, CT tech + tat,
ATLS/TNCC standards, time on the backboard, IR, transfer OR- room- team- anesthesia ICU: transfer to, readmission to, reintubation, monitoring Blood Bank: MTP, blood availability All transfers, All mortalities
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Trauma Center Quality and Performance
Transfers IN Trauma Transfer Line- 1-877-903-0003 One central point of contact for all transfer decisions,
recorded and reviewed
Transfers OUT All recorded and reviewed by the TPM/TMD/TOPPIC Relationships with tertiary centers Reasons for transfer:
Complex pelvic fractures, acetabular fractures, reimplantation, aortic injuries, pediatric patients needing PICU level of care
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Communication
Points to remember TC prefers Med Channel 3 - overhead PA TC point of medical control - even if with change in
destination iPhone app – its free
Tools include: GCS calculator Time and distance to TC and other hospitals Trauma Guidelines Drug formulary Other protocols
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Case #1- Friday night @ 1915-”The Good”
Medic 52 “ SV Base this is Medic 52 calling in with a Trauma Alert”
“Medic 52 this is SV Base MICN 844 go ahead” “SV Base this is Paramedic 007, we have a 17 yo male patient
meeting Step 1 trauma criteria” M:”Pt is a football player from a local HS was tackled by another
player, taking a hard hit to his head” I: “pt. walked off the field c/o severe headache and then
collapsed” V: 97/50- 52- 10- GCS- 4 –decer posturing, R pupil is 5mm nr, L is
2 mm and sluggish T: Pt is in full C-spine precautions, 1 IV right AC, our ETA to you
is 8 minutes” Medic 52 this is SV Base, we copy that report, we’ll see you
in 8 minutes, proceed to room 8A on arrival”
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“The Bad & Ugly”
What if you don’t have the information….
What is
the …?
Really…..
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Trauma Radio Report
Include the trauma step criteria at the beginning of the call
“Trauma Alert- patient meeting… Step 1 – MVC- Driver with GCS 8” Step 2 – Stabbing to upper chest with SOB
“Trauma Consult- patient meeting…. Step 3 - Auto vs. tree with >18” intrusion (meets
MOI) Step 4 – Auto vs. tree with major front end
damage, no PSI (paramedic judgment, + seat belt sign)
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Communication
Paint the picture
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Case #2 “Non-Stat Trauma”
0118: 911 TC car into telephone pole at 50 mph- 2 pts0123: PM arrival to 25 yo female passenger, + restrained, sitting up in seat with SLOFD holding C-Spine. Vehicle had front end damage, no PSI. Pt admitted to ETOH. Denies any c/o. 0125: 90/P-110-22-GCS 14. PE- bleeding form nose, L eye hematoma, L shoulder hematoma from seatbelt, stable chest wall, no pain on palpation, RUQ/RLQ painful on palpation, hematoma RUQ, pelvis stable, no neuro deficit0146: Report to the TC 8 minute ETA- BP 110/46- 108-14- GCS- 14
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Case # 2 Outcome
Tier 2 activation- no documentation of criteria metStable in ED, FAST neg, CT, admitted to trauma
service/surgeon on SDUDX- Basilar skull fracture, orbital fx, L ptx- small,
small liver laceration, fx sacrum, coccyx, metatarsal fx
TX: NPO, serial hgb, serial examW/in 24 hours developed increasing abdominal pain
and distentionTo OR next am- laceration + repair to sigmoid
colon, adm to ICU
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SB PositionSB Position Driver or Passenger?Driver or Passenger?
Paramedic Evaluation + Assessment
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Penetrating Mechanisms
Stabbings and GSW – Step 2 Not always what you see High risk - “killer zone” head, neck, torso, proximal
extremities Patterns – female vs male Caliber and distance
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MOI Predictors
Motorcycle crashes> 20 mph ATV – dunes vs ranchFalls from > 20ft adults or > 10 feet or 2-3
times the height in childrenConsiderationsLower speed with sudden deceleration ( MC vs
wall)Landing surface impactedProtective gearAge
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MOI Predictors
Bicycle Crashes Bike Crash Auto vs bike
??
Yes!
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Injuries
Expose the injuries – clothes off!Signs + symptoms suggestive of injury
Seat belt marks Steering wheel or other impression on the chest or abdomen Pain in any of the abdominal quadrants Chest pain with air bag deployment or steering wheel
damage Pelvic deformity, instability, pain
Special considerations Pediatric patients Older adults AMS
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I-Injuries
Isolated Orthopedic Injury?
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Pelvic fractures
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Injuries- Pelvic
o Challenging to assesso Index of Suspicion
o Patient w/o distracting injuries that c/o of pain in pelvis, back or groin
o History – a marker for considerable transfer of energyFront seat head-onVehicle impact on their side with intrusionPedestrian accidentsMotorcycleFall from great heights
• Uneven landing
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I - Injuries
Pelvic Injuries – s/s of significant injury
Deformity, bruising, swelling over bony prominences, pubis, perineum or scrotum
Leg - shortening or rotation w/o fractureWounds/bruising over pelvisBleeding from rectum, vagina or urethraNeurologic abnormalities distally (rare)
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Case # 3
0947- 911 call for an 80 year old female involved in an MVC. Pt states she lost control of her vehicle on a curve and hit a tree head on
1000-Pt contact- awake, alert, c/o headache, neck pain, back pain, chest pain, abdominal pain, R ankle pain. Single occupant, no PSI. 186/108-80-18-GCS-15
1038- arrival at TCIs this a trauma patient? What step criteria is
met, if any?
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V- Vital Signs
Important to share with TCBP < 90 at anytime - First Responders need to communicate with transporting providers
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V- Vital Signs- Geriatric
VS in the elderly More often under triaged Elderly = > 65 locally but really > 55 Significant increase in mortality after 55 with
greatest > 70 Confounders in the elderly Pre-existing conditions and medications BP< 110 should be considered equal to <90 GLF with head injury or change of GSC on
thinners
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V- Vital Signs- Pediatric
Pediatric Physiologic Criteria for children < 14 years or < 34 kg GCS ≤ 13 Evidence of poor perfusion- color, temperature, etc. Respiratory Rate
• > 60/min or respiratory distress or apnea• <20/min in infants < 1 year
Heart Rate• ≤ 5 years (<22kg) - < 80/min or > 180/min• ≥ 6yrs (22-34KG) - < 60/min or > 160/min
Blood Pressure• Newborn (<1mo) SBP < 60• Infant (1mo-1yr) SBP < 70• Child (1yr-10 yrs) SBP < 70 +(2x age in years)• Child (11-14 yrs) SBP < 90
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Pediatric GCS
Pediatric Glasgow Coma Score Infant < 1 yr Child 1-4 yrs Age 4-Adult
EYES4 Open Open Open3 To voice To voice To voice2 To pain To pain To pain1 No response No response No response
VERBAL5 Coos, babbles Oriented, speaks, interacts,
socialOriented and alert
4 Irritable, cry, consolable Confused speech, disoriented, consolable
Disoriented
3 Cries persistently to pain Inappropriate words, inconsolable
Nonsensical speech
2 Moans to pain Incomprehensible , agitated Moans, unintelligible 1 No Response No Response No Response
Motor6 Normal, spontaneous
movementNormal, spontaneous movement
Follows commands
5 Withdraws to touch Localizes pain Localizes pain4 Withdraws to pain Withdraws to pain Withdraws to pain3 Decorticate flexion Decorticate flexion Decorticate flexion2 Decerebrate extension Decerebrate extension Decerebrate extension1 No response No response No response
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Treatment Plan
1. ALL trauma patients need O2 until proven otherwise
2. ALL trauma patients are bleeding until proven otherwise
3. ALL trauma patients have cervical spine injury until proven otherwise
4. ALL unconscious trauma patients have a brain unjury until proven otherwise
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Treatment Priorities
A- airwayB- breathing
High flow O2 for all
C- circulation Control bleeding if possible- direct pressure/pressure
dsg Take a note of EBL Tourniquets if needed Bind the pelvis if hypotensive
D- Get a baseline neuro + communicate early Avoid hypotension + hypoxia
E- strip, flip, keep warm!
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Treatment
Fluid resuscitation Single IV – leave an arm for the hospital Add extensions when possible – helpful for TC to add
blood warmers Fluid – none or controlled – boluses (250-500cc)
Rapid infusion may increase bleeding/dilutional Maintain BP of 90mmHg or radial pulse (elderly >110
mmHg) Patient needs: transport and blood/TXA
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T-Treatment- Suspected Pelvic Fractures
Signs/symptomsPhysical exam often unreliableDo not rock or aggressively palpateAvoid excessive log rolling Consider splinting if obviousBind the pelvis if hypotensive
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T-Treatment- Splint Fractures
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Transfer of Care
Team ReadyTransfer the patient to the stretcher firstParamedic bedside report- to the team
“Moment of Silence” Additional details to the trauma scribe
More details of the MOI Restraints? Field photos?
PCR at time of drop off it all possible
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Documentation
Real examples….Patient became alert to person, place and presidentDefibrinatedLou Garritt's DiseaseDrug Attichimlich maneuverpatient trapped under steeringlingUpper rear biceps femoris areaFound actively sieving
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Documentation
More…..orbital region of the headlight headlessnessanginal respirationshead contraindicate to mechanical fall100 y/o -- ATV roll-over Pt does have a gauge reflexPt. experienced year lasting just less than 5 min.
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Documentation
What, how and why
Review the for accuracy Fax all SVRMC PCRs to 805-596-7509
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Destination
Considerations with in destination decisions
Unmanageable airway CPR with trauma
Blunt vs penetrating
Notifying SVRMCStabilization with rapid re-triage
Transfer process and Phone # 805-596-7509
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Destination
Multi-PatientMulti-IncidentMass-Casualty
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Destination
MMC – status No Change – Step 1 and 2 to SVRMC Remote areas consider EMS Air early Step 3 and 4 consult SVRMC for destination
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Summary
Communication Add the Triage Step to the radio report Information to make a destination decision or
treatmentMOI
Paint the picture Predictors
Injury Expose – clothes off Injury patterns Paramedic judgment Not included in guidelines
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Summary
VS BP< 90 at any time (<110 elderly) Pediatric and Geriatric considerations Communicate why essential VS cannot be obtained
Treatment - Field considerations Single IV with extension Small fluid volumes unless hypotensive O2 Warm Pelvic binder - consider with pelvic pain and low BP
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Summary
Transfer of care to TC Move to bed Lead RN to ask for silence and filed report Fax chart to 805-596-7509
Documentation Narrative should match check boxes Accuracy PCR addition coming
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Summary
Destination Early medical air resource No change to current policy Contact SVRMC for destination on Step 3 and 4 Inform SVRMC with any change in destination
Multi-patient Incident 3 or more critical Polling of hospitals for status by MedCom SVRMC still point of contact for trauma patients
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Questions