Section 600 - Operations

prupose: define when BLS/ALS may be withheld or discontinued by EMS personnel to avoid unnecessary or prolonged resus of persons for whom recovery is not possible/probable

A. Obvious Death:
1. decaptiation
2. total incineration of body
3. decomp of the body
4.. rigor mortis
5. pulseless pt w/ total sepration or obvious destruction of heart, brain &/or lungs

B. pulseless/apneic ot with a valid DNR

C. pulseless/apneic pt who has exercised their right to die unter the End of Life Option Act

A. same as BLS

B. provider may conosider termination of resuscitative efforts after at least 20 mins if all following apply:
1. pt is in asystole
2. arrest was not witnessed by the EMS provider
3. no return of ROSC prior to transport
4. pt does not have a functioning ventircular assist device (VAD)

A. actions: if all criteria are met, the EMS personnel will
1. discontinue/withhold resuscitative efforts
2. cancel any prehosp personnel still enroute
3. provied appropriate comfor & care to family & bystanders
4. complete PCR documentin care/actions taken, including reasons for pronouncing death & all comms made with necessary time stamps.

B. notifications
1. In the event of a death, it is important to notify the appropriate authorities and remain on the scene until released.
2. If the deceased is at home or in a public place, contact the local law enforcement agency.
3. If the deceased is at an acute or residential care facility, the staff of the facility will handle the necessary arrangements.

C. Exceptions
1. the scc ultiple casualty incident pla, (MCIP), including simple triage & rapid transport triage, will be used at all MCI events

purpose: provide a procedure for prehosp personnel & physicians (MD & DO) to follow whenever a physician is on the scen of an EMS incident, including a physician's office, hops, clinic, or other emergency or non-emergency response or transfer scene where a physician may be present

A. identification:
1.Prehospital personnel must request proper identification from individuals claiming to be physicians, verifying their California medical license. If a person claiming to be a physician refuses to provide identification or communicate with the Base Hospital physician when requested, prehospital personnel should limit their involvement in patient care to that of a layperson.

B. physician involvement
1. relinquish pt care
2. assist in pt care
3. manage pt care

C. conflict resolution

D. documentation
1. physician's name
2. CA medica license number
3. business tel number
4. level of pt care involvement
5. all procedure(s) & treatment(s) by the physician at scene (or obtain a copy of the pt's medical record to accompany the PCR if applicable)

purpose: ensure that all pts who requrie emergency ambulance service are transported to the approved facility most appropriate for their emergency medical condition

Patients have the right to choose their transport destination if it meets policy requirements, regardless of payment ability; however, during EMS System surge periods, such as multiple patient events or local emergencies, patients may be assigned to hospitals and may not have the option to select a specific destination.

A. Patients are typically transported to basic or comprehensive emergency departments in acute care hospitals or federally owned and operated hospitals listed in Table B.

B. Patients should be transported to routine destinations unless they meet criteria for "In-Extremis," "Specialty Care," or "Special Circumstances."

C. If no preference is given by the patient:
1. They are transported to the closest hospital based on total emergency ambulance transport time.
2. The hospital must be accepting emergency ambulance patients as listed in Table B.

A. "In-Extremis" patients require immediate transport to the nearest hospital.

B. Characteristics of In-Extremis patients include one or more of the following:
1. Breech presentation or protruding limb during delivery.
2. visible, uncontrollable external bleeding despite EMS intervention.
3. Inadequate ventilation despite advanced airway interventions.

C. In-Extremis patients should be taken to the closest hospital not affected by internal disaster.
1.the closest to the incident location as determined by total emergency ambulcance transport time AND
2. that is NOT on internal disaster

A. In certain cases, specialized services may be required based on the EMS provider's initial assessment and policy criteria.

B. The "most appropriate hospital" for specialty care patients should meet the following criteria:
1. Closest to the incident location based on total ambulance transport time.
2. Designated to provide the required specialty service AND
3. Accepting emergency ambulance patients.

A. trauma pts that don't meet criteria shall be transported per 'routine pt destination'

B. trauma alerts shall be transported to a trauma center

C. if ALL trauama centers are not accepting emergency ambulance pts, the pt shall be transported:
1. closest emergency dptm to the incident location per total emergency amb transport time AND
2. that is accepting emergneyc amb pts

D. a pediatric pt (less than 15) who meets trauma alert criteria shall be transported to:
1. closest pediatric trauma center to the incident location per total emg amb transport time AND
2. that is accepting emg amb pts

E. a pregnant pt beyond 20 weeks gestation who meets trauam alert criteria, shall be transported:
1. closest Labor & Delivery center that is also a trauma center per total emg amb time AND
2. that is accepting emg amb pts

- Patients not on a Welfare and Institutions Code, Section 5150 hold:
- a. Psychiatric patients in need of medical evaluation should receive a medical care assessment as per Policy #700-S04 or Policy #700-S05 and be transported to an approved emergency department listed in Table B: Approved In-County Services.

- b. If a psychiatric patient's medical condition requires immediate attention, they should be transported to the nearest emergency department or specialty care center listed in Table B: Approved In-County Services.

A. Patients on a Welfare and Institutions Code (WIC), Section 5150 hold:
1. Psychiatric patients needing medical evaluation should undergo a medical care assessment per Policy #700-S04 or Policy #700-S05 and be transported to an approved emergency department or psychiatric receiving facility listed in Table B: Approved In-County Services.

2. The destination for the patient listed on the WIC 5150 Form should be discussed between the form's writer and the 911 ambulance transport crew.
- i. If the form was completed before the ambulance arrival and conflicts with the patient's best interest or EMS policy, the crew should consult with the form's writer for an appropriate destination.
- ii. The form needs to be rewritten entirely if the destination changes from the original.

3. Psychiatric patients without medical complaints, transported by a BLS ambulance, may be taken to the destination set by the authorized writer responsible for executing the 5150 hold.

A. pts meeting major burn criteria per SCC prehosp care policy shall be transported to the Burn Center at SC Valley Med Center (VMC) via the trauma center
1. if VMC is not accepting, pt shall be transported to
a. closest trauma center ID-ed to the incident location per the total emg amb transport time AND
b. that is accepting BURN emg amb pts

2. pts meeting major burn criterai & having additonal concurrent trauma, & if the later pose greater risk or morbidity or mortality, shall be transporter:
a. closest trauma center ID-ed to the incident location by the total emg amb transport time AND
b. that is accepting BURN emg amb pts

A. pts meeting comprehensive stroke alert criteria shall be transported to:
1. closest comprehensive stroke center per the total emg amb transport time AND
2. that is accepting STROKE emg amb pts
3. if the transport time is greater than 30mins, transport to the closest Primary Stroke Center in accordance with section (F)(2) of this policy

B. pts ID-ed as meeting Primary Stroke Alert Criteria shall be transported to
1. closest stroke center to the incident location per the total emg amb transport time AND
2. that is accepting STROKE emg amb pts

A. pts meeting STEMI alert criteria shall be transported to:
1. closest STEMI receiving center to the incident location per total emg amb transport time AND
2. that is accepting STEMI pts

A. adult pts acheiving ROSC shall be transported to:
1. closest STEMI center to the incident location per the total emg amb transport time AND
2. that is accepting emg amb pts that meet ROSC

A. a pediatric pt who meets trauma alert criteria shall be transported to:
1. closest pediatric trauma center to the incident location as determined by total emg amb transport time AND
2. that is accepting emg amb pts

B. A pediatric pt who meets the following:
1. cardia dysrhythmia
2. evidence of poor perfusion (pallor, cyanosis, etc)
3. sever respiratory distress (retractions, strido, etc)
4. persistent AMS
5. stroke-like symptoms
6. status epilecticus
7. brif unresolved unexplained event BRUE)
8. ROSC
9. suspicion of child abuse
10. paramedic discretion
shall be transnported to:
1. the closest ADVANCED pediatric receiving Center ID-ed to the incident location per total emg amb transport time AND
2. that is accepting emg amb pts

C. a pediatric pts who does NOT meet trauma, in-extremis or critically ill criteria shall be transported to:
1. any pediatric receiving center of choice AND
2. that is accepting emg amb pts

A. EMS sys surge/multiple pts events
1. when central pt routing is in effect, all pt destinatin assignments will be directed by the county through county comms
2. pts may be transported to acute care hopstals not listed in this policy only when directed by the county
3. if out of county mutual aid amb are being used in the SCC operational area, all transports will occur in accordance w/ the destination prescribed unless directed by the county
4. when authorized by the county, pts may be transported to Alternate Care sites (ACS)m Field Treatment Sites (FTS), or Mobile Field hospitals (MFH)

B. Base hosp directed destination
1. pts may be transported to any in-county destinatio nauthorized w/in policy whe directed by the Base Hosp

C. Standford Health Care
1.All adult patients should be taken to Entrance 500P.
2.Patients who are more than 20 weeks pregnant and in active labor, irrespective of maternal age, as well as all pediatric patients (those under 15 years old), should be transported to Entrance 300P.

D. EMS aris resource destination
1. pt destination shall be determiend by ground crew & provided by air crew
2. If the pilot believes that flight to the selected destination is unsafe, the flight crew will advise the ground crew and a destination will be determined collaboratively and according to the direction provided in this policy.
3. When a ground crew is not present or if the ground crew is not designated EMS providers, the flight crew shall determine destination based on this policy.

E. transport out of county hosp from SSC
1. pts may be transported out of county hosp only when permitted by 602
2. SCC prehosp care personnel shall determine & honor out of county 911 amb diversion statuses prior to beginning transport
3. SCC prehosp care personnel shall notify the out of couty hosp prior to transport to ensure hosp is open & receiving pts

F. destination changes while transporting
1. A patient can change their requested destination before the ambulance arrives at the hospital property, provided the new destination complies with the policy requirements.
2. Once the ambulance has reached the property of an acute care hospital, the patient's care will be handed over to the hospital staff.
3. If a patient wishes to leave the ambulance while en route to a hospital, EMS personnel will:
a. EMS will try to convince the patient to continue to the chosen destination or the nearest suitable emergency department.
b. If the patient insists on leaving, EMS will stop at a safe location, let the patient exit, and inform their communications center immediately.
c. EMS will prioritize patient safety according to Santa Clara County Prehospital Care Policy #618: EMS Life Safety Procedures.

G. Custodial pts from county jails
1. the preferred destinations for custody pts & are from incidents ocuring in the county jail (SJ), Elmwood (Milipitas), & juvenile hall (SJ), is Santa Clara Valley Med Center (VMC) if the transport is consisten with the directives contained in this policy w/ directives in 602
a. ex: the hosp must be accepting emg amb pts
b. the destination s determined by jai staff, not pts
2. from time to time the EMS agency will issue specific transport policies related to amb transport of hig risk/high profile inmates. These policies will augment the direction provided w/in
602

H. incidents occuring at acute care hospitals: if acute hosp is the incident location, pts shall be transported the emg departments except
1. when acute care hosp is not acepting emg amb pts
2. when multiple pts tranpost & must be distributed to multiplle acute care hosp
3. when acute caare hosp reauests a 911 emg amb response to transport pt in accordance with SCC prehosp care policy #620

I. Veterans - vetran pts may be transported to the Palo Alto Vet Admin Hosp (PAV) if:
1. reauested by the pt AND
2. if transport is consisten with directeves contained w/in this pol 602

J. Ventricular Assist Devices (VAD): VAD centers in SCC are located in Kaiser SC hosp & Stanford Health care:
1. if VAD pt presnts w/ stroke symptoms these 2 stroke/VAD centers would be the preferred destinations
2. a VAD pt visiting from outside of the SCC area should be transported to either one of these 2 VAD centers for device-related problems
3. in traumatic injury of aa VAD pt consider trauma center as a destination since the pt will be anticoagulated

I. Sexual Assault Forensic Examiners (SAFE): SAFE centers in SCC are located at Stanford Health Care (SUH), VMC, and Saint Louise Regional Medical Center (SLH)
1. the preferred destination for pts seeking ;edical care after sexual assault & intimate partner violence are SLH, SUH or VMD
2. pts may be transported to one of these facilities if transport is consistent with the directives contained w/in this policy

El Camino Hospital of Los Gatos in Los Gatos

El Camino Hospital of Mountain View, in Mountain View

Good Samaritan Hospital, in San Jose

Kaiser Foundation San Jose, in San Jose

Kaiser Foundation Santa Clara, in Santa Clara

O'Connor Hospital, in San Jose

Palo Alto Veterans Administration Hospital, in Palo Alto

Regional Medical Center of San Jose, in San Jose

Saint Louise Regional Medical Center, Gilroy

Santa Clara Valley Medical Center, in San Jose

Stanford Health Care, in Palo Alto

1. ECH
2. GSH
3. KSC
4. LGH
5. OCH
6, PAV
7. RSJ
8. SLH
9. STH
10. SUH
11. VMC

VMC

1. ECH
2. GSH
3. KSC
4. LGH
5. OCH
6. RSJ
7. SLH
8. STH
9. SUH
10. VMC

1. ECH
2. GSH
3. KSC
4. RSJ
5. SUH

1. ECH
2. GSH
3. KSC
4. OCH
5. RSJ
6. STH
7. SUH
8. VMC

1. RSJ
2. SUH
3. VMC

1. SUH
2. VMC

1. KSC
2. SUH
3. VMC

1. ECH
2. GSH
3. KSC
4. OCH
5. RSJ
6. SLH
7. STH
8. SUH
9. VMC

1. EPS (Emergency PSychiatric Services)
2. ECH
3. GSH
4. KSC
5. LGH
6. OCH
7. PAV
8. RSJ
9. SLH
10. STH
11. SUH
12. VMC

1. KSC
2. SUH

1. ECH
2. GSH
3. KSC
4. LGH
5. OCH
6.SLH
7. STH
8. SUH
9. VMC

1. SLH
2. SUH
3. VMC

1. GSH
2. KSC
3. RSJ
4. SLH
5. SUH
6. VMC

Dominican Hospital in Santa Cruz, Santa Cruz

Kaiser Foundation Fremont in Fremont, Alameda

Kaiser Foundation Redwood City in Redwood City, San Mateo

Sequoi Hospital in Redwood City, San Mateo

Washington Township Hspital in Fremont, Alameda

Watsonville Community Hospital in Watsonville, Santa Cruz

1. DOM
2. KFF
3. KRC
4. SEQ
5. WTH
6. WCH

1. DOM
2. KFF
3. KRC
4. SEQ
5. WCH
6. WTH

1. DOM
2. WTH

purpose: to clarify the service areas for each trauma center in SCC

1. SUH Catchment Zone: covers areas from the county's northern border on the west side of the Bay to De Anza Boulevard in Cupertino, passing through the center of Sunnyvale with the separation line at Sunnyvale-Saratoga Road to East Remington/Fair Oaks Avenue leading to the Bay.

The Santa Clara Valley Medical Center (VMC) Catchment Zone spans from south of De Anza Boulevard in Cupertino to south of Sunnyvale-Saratoga Road to East Remington/Fair Oaks Avenue in Sunnyvale.
- Its eastern border extends from North First Street/Monterey Highway from Alviso to the intersection of Highways 101 and 85 in San Jose.
- Patients needing transport from areas south of the 101/85 Interchange and west of Highway 101 to the county's southernmost borders should be transported to VMC

RSJ catchment zone: encompasses all areas east of North First Street/Monterey Highway, including Milpitas, to the southern boundary at the intersection of Highways 101 and 85 in San Jose, with the northern border being the San Francisco Bay.
- Patients requiring transport from areas south of the 101/85 Interchange and east of Highway 101 to the county's southernmost borders should be transported to RSJ.
- Incidents occurring on or near dividing lines are subject to paramedics' discretion for transportation.

EMS aircraft providers must transport trauma patients to the nearest designated trauma facility with a Caltrans approved helipad, except for specific cases:
1. Patients meeting major burn criteria but not suffering traumatic injuries should be transported to Santa Clara Valley Medical Center as per relevant county policies.

2. Pediatric patients (under 15 years old) meeting Trauma Triage Criteria should be transported to the closest Pediatric Trauma Center, either Santa Clara Valley Medical Center or Stanford University Hospital.

3. In cases of trauma center diversion, patients should be rerouted to the next nearest trauma center.

purpose: to ensure the safe dispersion of inbound 11 EMS pts away from hosps experiencing unsafe APOD and/or from hosps that will likely experience unsafe APOD b the arrival of additional ambs

1. Preserve 911 ambulances for emergent needs in Santa Clara County.

2. Focus primarily on dispersing lower acuity patients not requiring emergent or specialty care (STEMI, stroke, trauma, burn).

3. Use patient dispersion along with hospital bypass strategies to reduce unsafe APOD incidents.

4. Dispersion of stroke and STEMI specialty care system patients may be needed to mitigate unsafe APOD incidents.

5. Patients requiring trauma specialty care system services are exempt from redirection to another hospital.

1. The EMS Duty Chief decides if a hospital's APOD status is unsafe, and indering 911 ambulance response.

2. Upon determination, SDO 21 "Patient Routing Directed by the County" is implemented.

3. The EMS Duty Chief oversees dispersion or delegates management to an on-duty County Ambulance Accredited Field Supervisor.

4. Dispersion continues until APOD is considered safe again.

purpose: to outline when hospitals can request EMS patient bypass, a temporary measure used when patient load overwhelms hospital resources, potentially compromising patient safety upon arrival at the emergency department or specialty center.

1. Hospital bypass involves diverting 911 EMS patients from affected emergency departments and associated specialty receiving centers.

2. Hospitals can request bypass if they have an EMS Agency-approved patient volume management plan, reviewed annually, showing they can no longer safely care for additional patients.

3. Lack of inpatient beds alone is not sufficient cause for bypass.

4. All Santa Clara County hospitals must use EMResource to maintain availability status, ensuring constant monitoring and awareness of bypass criteria.

5. Hospitals must document reasons for bypass in EMResource's comment section.

6. Hospitals may close entirely if an Internal Disaster occurs, as defined by the California Department of Health Care Services, utilizing EMResource; if unable to change status, prompt notification to County Communications and report to the Department of Health Care Services is required.

A. : All designated hospitals in the County's bypass program must participate except for the Palo Alto Veterans Administration (PAV) Hospital, which is federally exempt but will assist in multi-casualty incidents/disasters

B. All designated hospitals can divert 911 System ambulance traffic except for in-extremis cases.

C. Only one hospital per Bypass Zone can be on bypass at a time; hospitals must use EMResource to request bypass status
1. North Bypas Zone: SUH, ECH, KSC
2. Central Bypass Zone: VMC, OCH, GSH
3. South Bypass Zone: STH, RSJ, SLH
4. Other (No Zone): LGH, PAV

D. Hospitals can remain on bypass for a maximum of 60 minutes per occurrence and must stay open for at least 60 minutes before requesting bypass again.

E. The EMS Agency can require hospitals to open as necessary if hospital bypass negatively affects the EMS System.

F. Hospitals must immediately comply with directions from the EMS Agency or County Communications to open or remain open during bypass, with limited discretion for staff to discuss concerns with the EMS Duty Chief.

G. Each hospital can request up to 36 hours of 911 System bypass within a calendar month.

H. Hospitals must promptly update their status on EMResource, and County Communications will only make status changes based on EMResource data.

I. EMS Agency staff may conduct unannounced site visits to hospitals to ensure compliance.

J. Failure to comply may lead to loss of bypass privileges and revocation of specialty center designation(s) until issues are resolved to the EMS Agency's satisfaction.

A. Trauma Center Bypass operates independently from Stroke and STEMI Open or Bypass status.

B. Only one Trauma Center can be on bypass status at a time; if a second Trauma Center requests bypass, an interim patient management solution must be agreed upon by Trauma Center Medical Directors and the EMS Duty Chief/Agency.

C. The requesting Trauma Center must notify the EMS Agency Duty Chief, who will discuss the rationale for the request and may authorize bypass if necessary after consulting the Trauma Center currently on bypass.

D. If both pediatric trauma centers are on bypass simultaneously, paramedics will contact the Base Hospital for advice on destination selection, which will then consult both trauma centers for a destination.

E. The EMS Agency will consult with Trauma Center Medical Directors to ensure public safety.

F. A Trauma Center can't remain on bypass for more than 60 minutes.

G. A Trauma Center must stay open for at least 60 minutes before executing bypass again.

purpose: to establish criteria for prehosp care personnel to determine when to withold resuscitative measures

A. No Code/No CPR: equivalent to 'Do not resuscitate'

B. DNR form: DNR Form means the "California Emergency Medical Services Authority - California Medical Association, Emergency Medical Services, Prehospital Do Not Resuscitate (DNR) Form," approved by the
EMSA and the CMA, and bearing the insignias of both organizations.

C. CDNR medallion: A DNR medallion is a state-approved metal or imprinted insignia worn by patients, meeting California EMS Authority criteria, imprinted with "Do-Not-Resuscitate, EMS," ensuring recognition by prehospital personnel.

D. Durable Power of Attorney for Health Care (DPAHC)/Advance Health Care Directives:
1. An advance health care directive is a document that lets someone choose another person to make medical decisions for them if they can't do it themselves. It can also outline the kind of medical treatment they want, including end-of-life care.
2. Even if a person is still able to make decisions, they can still appoint someone to act on their behalf. The person appointed can't consent to certain treatments like mental health care or surgery, though. Health care providers, including emergency responders, won't get in trouble for following these directives as long as they act responsibly and according to medical standards.

E. Physician Orders for Life Sustaining Treatment (POLST):
1. The POLST is a form with instructions from a doctor about the treatment a patient should receive. It's signed by the doctor and either the patient or someone acting on their behalf.
2. The original should stay with the patient, but copies are also valid if signed by both the doctor and the patient or their representative. It covers things like CPR, medical treatments, antibiotics, and feeding tubes.

A. if upon prehosp personnel arrival, the pt is determined to be pulseless & apneic
1. establish DNR/adv directives/code status

2. Prehospital care providers can stop resuscitative efforts if they find:
a. A valid DNR form
b. DNR medallion
c. No Code order
d. POLST or DPAHC indicating "Do Not Resuscitate"
e. If immediate DNR paperwork isn't available, providers start resuscitative measures until status is confirmed
f. During transport between medical facilities:
i. With valid DNR order or POLST in patient's medical record
j. Provider has a copy
k. All instances of DNR orders or POLSTs must be documented on the prehospital care report.

1. If a conscious patient requests resuscitative measures despite having a DNR order or POLST, their wishes override the directive.

2. When encountering an unfamiliar DNR form, CPR must continue, and Base Hospital should be contacted immediately for guidance.

3. BLS units ensure ALS response, stay on scene until paramedics arrive, who then contact Base.

4. Instances where resuscitation is withheld due to DNR, DNR Medallion, POLST, or DNR Order require a Prehospital Care Report.

5. If DNR Order validity is uncertain or POLST lacks required signatures, full resuscitative measures should be administered.

A. Resuscitative Measures:
1. DNR patients are not to receive resuscitative interventions such as chest compressions, defibrillation, assited ventilations, intubation (endotracheal or dual lumen), cardiotonic drugs or transcutaneous pacing

B. Supportive Care:
1. DNR patients receive supportive care like oxygen therapy, medication administration, wound care, and pain relief measures. Invasive airway procedures are avoided unless necessary for specific conditions like acute airway, anaphylaxis obstruction or major hemorrhage.

C. Transport Decision:
1. During transportation, DNR documentation (original/copy), DNR medallion, or a copy of the valid DNR order from the patient's medical record must accompany the patient. If available, a copy of the POLST form should also be carried.

Once resuscitation is withheld, the procedure for handling the decedent will vary dependent upon location:
1. in a public place, the local public safety agency retains jurisdiction & resp for disposition of the decedent

2. at home AND the local police or fire agency is present, they retain jurisdiction and resp for dispostion of the decendent

3. at a residential care facility, the staff of the facility will make the appropriate arangements

4. if the pt expires during transport, transport w/o BLS or ALS interventions

when a pt dies en route the following options exist:
1. Transport to a pre-arranged destination while ensuring readiness to maintain the deceased individual, and notify local law enforcement if necessary.

2. Consider returning to the initial departure point if deemed appropriate.

3. Alternatively, transport to the nearest emergency department at an acute care hospital.

purpose: to provide standard criteria for the prehospital triage of trauam & burn pts in SCC

A. Definition: Trauma alert patients are those who meet ACS National Guidelines for Field Triage Criteria.

B. Adult Protocol: Adults meeting trauma alert criteria should be promptly transported to the nearest Trauma Center.

C. Pediatric Protocol: Trauma alert patients under 15 years old should be transported to the closest pediatric trauma center (Stanford Hospital or Santa Clara Valley Medical Center).

D. Pregnant Patients: Pregnant trauma alert patients over 20 weeks gestation should be taken to the nearest trauma center with an approved Level III Neonatal ICU (Stanford Hospital or Santa Clara Valley Medical Center).

E. Identification Criteria: Patients meeting one or more specified criteria are identified as trauma alerts.
1. Red Criteria: high risk injury, mental status & vital signs
2. Yellow Criteria: moderate risk mechanism
3. EMS Judgement

1. Penetrating injuries to critical areas such as the head, neck, torso, and proximal extremities.

2. Suspected skull fracture, spinal injury with new motor or sensory loss.

3. Chest wall instability, suspected flail chest, pelvic fracture, or fractures of multiple proximal long bones

4. Severe extremity injuries like crush injuries, degloving, mangled limbs, or proximal amputations.

5. Active bleeding requiring immediate intervention such as tourniquet application or continuous pressure wound packing.

6. Inability to follow commands with a motor Glasgow Coma Scale (GCS) score below 6.

7. Abnormal respiratory rate: less than 10 or greater than 29 breaths per minute, or signs of respiratory distress necessitating support.

8. Oxygen saturation below 90% on room air.

9. Vital signs falling below specified parameters:
- For ages 0-9: Systolic blood pressure less than 70 mmHg plus twice the age in years.
- For ages 10-64: Systolic blood pressure less than 90 mmHg.
- For ages older than 65: Systolic blood pressure less than 110 mmHg.
- Heart rate exceeding systolic blood pressure in individuals aged 10 and older.

1. Auto crash with partial or complete ejection.

2. Auto crash with intrusion greater than 12 inches at the occupant site, or over 18 inches at any site, or requiring extrication.

3. Death occurring within the passenger compartment of a vehicle.

4. Unrestrained or improperly secured child (aged 0-9) or in an unsecure child safety seat.

5. Vehicle telemetry data indicating severe injury.

6. Rider separated from the transport vehicle with significant impact (e.g., motorcycle, ATV, horse, etc.).

7. Rollover accidents with unrestrained occupants.

8. Pedestrians or bicycle riders thrown, run over, or sustaining significant impact.

9. Falls from a height greater than 10 feet, applicable to all age groups.

Factors beyond standard criteria that may influence the decision to transport a patient to a Trauma Center include:
1. Patients with minor traumatic injuries who are also on anti-coagulants or have bleeding disorders.

2. Time-sensitive extremity injuries.

3. EMS provider's judgment indicating the need for trauma center care.

4. Cases of hanging or mechanical asphyxiation in cardiac arrest with suspected head or neck injury.

5. Unwitnessed drowning cases with suspected head or neck injury.

6. Low-level falls resulting in significant head impact.

7. Pregnant patients beyond 20 weeks gestation (uterine fundus palpated at or above the umbilicus) in cardiac arrest, not meeting obvious death criteria.

A. Patients with burn injuries qualify as major burn cases if they meet any of the following criteria:
- Partial-thickness burns exceeding 10% of total body surface area.
- Burns involving critical areas like the face, hands, feet, genitalia, perineum, or major joints.
- Full-thickness burns.
- Electrical burns (including high voltage and lightning injury).
- Chemical burns.
- Inhalation injury.
- Burn injuries in patients with existing medical conditions complicating management or affecting recovery.

B. Transport Protocol:
1. Designated Burn Center:
- Transport all identified major burn patients to a designated burn center.
2. Non-Major Burn Cases:
- Patients not meeting major burn criteria should be transported to an acute care hospital with emergency services.
3. Combined Major Burn and Trauma Alert Cases:
- Major burn patients meeting trauma alert criteria, with traumatic injuries posing greater risks, should be transported to the closest trauma center meeting specific criteria.

purpose: to define the process of the transfer of care from one prehosp care provider to another and/or to hosp or other medical care facility personnel

A. Scene mgt:
1. The primary public safety agency holds authority at an emergency scene to manage it with a focus on minimizing risks to life and health for patients and others. Collaboration with EMS professionals or healthcare experts on-site is crucial for assessing risks effectively.

B. Pt health care mgt
1. In an emergency, the authority for patient healthcare management lies with the most medically qualified licensed or certified healthcare professional present at the scene. If no such professional is available, the authority shifts to the most suitable medically qualified representative from public safety agencies.

Upon arrival at the receiving hospital:
A. Prehospital providers transfer care to hospital personnel (RN or MD).

B. If offloading delay occurs, providers notify ED MD of critical patient condition changes.

C. Providers give verbal report to RN or MD, including:
1. Demographic data
2. Chief complaint
3. Any treatment/medications given
4. For major trauma victims: Mechanism, Injuries, Vital Signs, Treatment
5. For Stroke patients: Last seen normal, Stroke scale assessment results
6. For STEMI patients: Time of symptom onset, 12 lead ECG results

A. The first paramedic on the scene directs treatment and provides verbal report to arriving paramedics. All paramedics document care per policy.

B. Paramedics collaborate to provide patient care.

C. In urgent situations ("load and go"), first responder paramedic retains control; transporting paramedic cooperates.

D. Transporting paramedic directs treatment after care transfer, consulting other providers.

E. Patient care discussions between providers occur privately, away from patients and family.

F. First responder paramedic can accompany patient to hospital anytime.

G. ALS providers with treatment differences contact Base Hospital for guidance.

A. Ground paramedics give verbal and written reports, including triage tag if needed, to arriving flight crew.

B. Patient care isn't transferred to ALS flight crews until they're ready, allowing prep time for lift-off and interventions.

C. Ground paramedic gives destination to air ambulance and reports to receiving hospital.

D. ALS flight crew reports to hospital staff upon arrival.

A. EMT personnel can assume responsibility for patient care after paramedics conduct a thorough assessment and determine that advanced life support (ALS) interventions are not required.

B. Transfer of care may occur under specific circumstances:
1. During Standard Dispatch Order (SDO) 10 activation, when a Basic Life Support (BLS) ambulance is dispatched, and the patient does not require ALS interventions.
2. In instances where a paramedic ambulance transports a patient to an emergency department experiencing ambulance patient offload delays (APOD), and the patient has not received ALS care before or during transport and does not need paramedic-level care upon arrival. This includes patients with a paramedic-established saline lock but no prior administration of drugs or fluid boluses.

C. Generally, patients who have received ALS-level interventions are not transferred to BLS units, except during declared mass casualty incidents (MCIs) and disaster situations.

D. Each responding and/or transporting provider agency is responsible for completing an electronic patient care record following Policy #500 "Electronic Patient Care Record (ePCR) Documentation" standards.

purpose: to identify criteria for the utilization of non-emg amb in the SCC 9911 EMS sys

A. interfacility transportation
1. County permits interfacility ground ambulance transport at BLS, ALS, and CCT-RN levels, with staffing requirements outlined in Policy 620.
2.. Non-emergency ambulances can transport patients within their scope of practice, authorized by a transferring physician. If patient meets specific criteria, crew must request 911 EMS response.

B. Emergent pts encoutered by non-emg amb crews
1.Emergent patients require immediate care for life or limb-threatening conditions, excluding those with valid DNR orders.
2. Emergent patients are transported to the closest emergency department with RLS if arrival time is under 10 minutes; otherwise, a 911 ALS response is requested.
3. If transported with RLS, the unit notifies County Communications for an EMS Event Number.
4. Non-Emergency Ambulance crew transfers care to arriving 911 paramedic unit; if not available, 911 paramedic and ALS equipment accompany patient.
5. Policy 602 guides patient transport when Non-Emergency unit activates 911 EMS System.

purpose: to guide the use of EMS ambulances and resources for standby at incidents without identified patients but with a potential need for prehospital medical services. Such incidents include fire ground operations, hazardous materials incidents, search and rescue operations, and law enforcement tactical operations, ensuring the safety of public safety personnel and the public.

purpose: identify roles & resp of public & private emg service agencies at the scne of an emergency in SCC

A. The public safety agency with investigative authority for the incident is responsible for managing and mitigating the incident's consequences.

B. the EMS Duty Chief may serve as:
1. agency rep/liaison (supervision, regulation & mgt, allocating county-wide medical resources, authorizing emg policy changes, any & all action deemed necessary & authorize by county health officer to mitigate potential public health emg)
2. EMS Duty Chief may assign system management roles to ALS Field Supervisors as needed.
3. Fill necessary positions within the Incident Command System (ICS) when qualified and assigned by the Incident Commander (IC).
4. Act as a delegate of the County Health Officer for medical mutual aid, public health emergencies, and liaison to emergency operations centers when necessary.

C. private amb service supervisors
1. agency rep: supervision & mgt under direction of IC or EMS duty Chief, suspension of non-emg company fn (ie. IFT, meal times, work hours, etc)

A. Ambulance Supervisors are expected to:
1. Resolve interpersonal and operational incidents.
2. Respond to requested incidents and perform appropriate tasks.
3. Act as the main point of contact for all Contractor-related issues, available 24/7.

B. They must notify the EMS Duty Chief of:
1. Critically low system levels.
2. Incidents of political or press interest.
3. Any ambulance collisions.
4. Significant injuries to private EMTs or paramedics.
5. Major conflicts between Contractor and subcontractors.
6. Activated EMERGENCY status without confirmation.
7. Complaints or unusual occurrences requiring immediate action.
8. Failures of Base Hospital communications.
9. Events posing risks to large groups of people.
10. Instances where 911 units are used for standby response services.

C. The EMS Duty Chief is available 24/7 to assist ambulance supervisors with system operations and management.

purpose: This policy sets standards for emergency medical responders at hazardous materials (HAZMAT) incidents to ensure safety. Responders must remain vigilant as contamination can occur without proper procedures. Government agencies handling hazardous materials must adhere to their internal policies.

This policy defines terms related to hazardous materials (HAZMAT) incidents:
A. HAZMAT Incident: Uncontrolled release or threat of release of hazardous material.

B. Exposure: Contact with hazardous substance/pathogen through inhalation, ingestion, or contact.

C. Contamination: Presence of harmful material.

D. Decontamination (DECON): Physical and/or chemical process of removingeducing contamination from personnel/equipment.

E. Dry Decontamination: Removing contaminants without water.

F. Gross Decontamination: Removing contaminants with water.

G. Wet Decontamination: Removing contaminants with water.

This policy outlines procedures for decontaminating potentially contaminated patients and responders in hazardous materials (HAZMAT) incidents:
A. Only trained HAZMAT responders can decontaminate patients and responders in the "Warm" Zone.

B. Potentially contaminated patients must be decontaminated by trained HAZMAT responders before receiving medical treatment or transport.

C. Decontamination methods include removing clothing and fresh air exposure, gross water rinse with mild soap, neutralization solution rinse, and specific procedures for equipment decontamination.

A. If responders are contaminated during transport, they should stop at the nearest safe location, notify County Communications, and request a fire department response. Safety and patient care are top priorities.

B. If contamination occurs at the incident site, responders should notify the Incident Commander. Those presenting with symptoms should be treated as patients.

C. Responders accidentally contaminated at the scene should not enter transport rigs until thoroughly decontaminated. Those with symptoms should be treated as patients.

D. Patients and responders contaminated in transport rigs should immediately wash with water and contact the Incident Commander for further guidance.

purpose: to establish procedures for appropriate use of EMS air resource in the SCC sys

purpose: to provide standards for the use of amb task forces & amb strike teams in & out of SCC

A. State Type 1 Ambulance Strike Team:
1. Composition: 5 ALS ambulances with 2 personnel each (at least 1 paramedic), 1 strike team unit leader vehicle, and the State Disaster Medical Support Unit (DMSU).
2. Deployment: Typically used for out-of-county deployment.

B. State Type 2 Ambulance Strike Team:
1. Composition: 5 BLS ambulances with 2 personnel each (EMT level minimum), 1 strike team unit leader vehicle, and the State Disaster Medical Support Unit (DMSU).
2. Deployment: Typically used for out-of-county deployment.

C. State Medical Task Force (Out-of-county deployment):
1. Composition: Mixed assembly of ambulances with 2 personnel each (ALS, BLS, or CCT level), 1 task force unit leader vehicle, and the State Disaster Medical Support Unit (DMSU).

D. Ambulance Task Force 1 (In-county deployment only):
1. Composition: 3 ALS ambulances with 2 personnel each (at least 1 paramedic), 1 EMS Field Supervisor.
2. Surge Capability: BLS ambulances may replace ALS ambulances during system surges.

E. Ambulance Task Force 2 (In-county deployment only):
1. Composition: 6 ALS ambulances with 2 personnel each (at least 1 paramedic), 1 EMS Field Supervisor.
2. Surge Capability: BLS ambulances may replace ALS ambulances during system surges.

A. Ambulance resources must be fully loaded before leaving the scene.

B. Ambulance Task Force deployment is suitable when the incident isn't generating additional patients.

C. Any officer from a system provider agency can request Ambulance Task Force 1 or 2.

D. Immediate notification to the EMS Duty Chief is required for Ambulance Task Force requests.

E. In-county Ambulance Task Force 1 or 2 is only for in-county responses, not recognized in the State Medical Mutual Aid System.

F. Common uses include multi-vehicle collisions, rescuer rehabilitation, aircraft incidents, multi-alarm structure fires, events with a fixed number of patients, and responses to MCIP Level 1 or 2 activations.

A. The EMS Duty Chief collaborates with relevant authorities (MHOAC, County Health Director & RDMHS/RDMHC) to coordinate Type 1 or 2 Ambulance Strike Teams and State Medical Task Force deployments via the State Medical Mutual Aid System.

B. The primary goal of the County's contracted ALS ambulance provider is to prioritize Santa Clara County's welfare, and they should avoid assignments in declared states of emergency when feasible.

C. The EMS Duty Chief is responsible for appointing leaders for State Type 1 or 2 Ambulance Strike Teams and State Medical Task Forces.

purpose: this policy sets out the rules for when fire department ambulances can be used in Santa Clara County and the Palo Alto Exclusive Operating Areas (EOA). Following these rules is the responsibility of the County and the fire departments, not the ambulance crews. The policy gives instructions to ambulance crews about how to work with fire department ambulances.

purpose: to identify the processes that are to be used when requesting or receiving medical-health mutual aid in the SCC operational area

A. Requests for medical-health mutual aid must follow SEMS and NIMS guidelines.

B. The County Health Officer and EMS Director serve as the MHOAC for Santa Clara County.

C. The MHOAC or their designee is responsible for coordinating all medical-health mutual aid requests in the county.

D. The MHOAC or their designee reviews and may authorize requested medical-health mutual aid resources, ensuring they don't excessively reduce the county's medical response capabilities.

E. The EMS Director or Health Officer can delegate MHOAC authority to the EMS Duty Chief, who must adhere to this policy within the delegated limits.

F. The EMS Duty Chief acts as the initial contact for all medical-health mutual aid requests when the OA Emergency Operations Center (EOC) and/or Department Operations Center (DOC) are inactive.

purpose: to establish a formal mechanism for requesting trauma surgon assistance form the Ase hops, in the prehosp environment by public safety departments and/or the EMS agency

A. Surgeon assistance may be requested for life-saving procedures or surgical extrications beyond paramedic capabilities, such as in challenging environments.

B. Paramedics must consult the Base Hospital before requesting surgeon response through the Incident Commander.

C. Authorized surgeon response may involve providing additional equipment or supplies not carried by paramedics. Surgeons cannot exceed established scope of practice, and paramedics can assist them according to county EMS policy.

purpose: This policy establishes standards and procedures for issuing EMS system identification badges to various certified and accredited personnel in Santa Clara County. The badges confirm authorization to access EMS data systems, verified medical credentials, background checks, tracking of required training, and affiliation with authorized EMS provider organizations for emergency medical care.

purpose: to identify & implement procedures to ensure the safety and protection of emg medical services responders

A. Acknowledges the inherent risks in emergency response and emphasizes the importance of reducing predictable risks.

B. States that EMS providers may participate in 911 responses within the county and highlights the need for all providers to understand life safety procedures.

C. Highlights the responsibility of all EMS providers to prioritize situational awareness and continuously watch for threats, hazards, and abnormal events.

D. Acknowledges that EMS providers may be mistaken for other personnel such as firefighters or police officers.

E. States that the first provider arriving at an emergency scene assumes the role of Incident Commander and is responsible for ensuring scene safety before aiding the ill or injured.

F. Exempts Santa Clara County fire departments from certain sections of the policy, as they follow internal response policies and operational standards outlined in the Santa Clara County Fire and Rescue Operational Area Mutual Aid Plan during mutual aid responses.

A. if the 1st unit to arrive at the scene of an emergency is an amb, one crewmember shall become IC & be resp for overall incident safety

B. The IC must provide a "CAN" report to County Communications or another suitable public service answering point (PSAP), including:
1. Conditions: Reporting what is observed at the incident scene.
2. Actions: Describing the planned actions or interventions by the IC.
3. Needs: Requesting any additional resources required to manage the incident effectively.

C. the IC shall always prioritize responder safety & scene protection while implementing the procedures contained w/in this policy

D. The Incident Commander (IC) must promptly provide a CAN report, transfer command to the appropriate jurisdictional authority, and request an assignment as soon as possible after the arrival of the fire department or law enforcement agency at the scene.

E. Upon the transfer of command, all communications centers involved must be notified of position changes. This ensures that scene safety notifications and single-point ordering continue to be managed by the appropriate communications center.

A. the first EMS unit arriving on scene shall advise county comms of any safety concerns, provide location of any staging areas & (if appropriate) provide a CAN report

B. the CAN report shall always be provided by the first arriving amb to County comms if multiple non-fire EMS units are responding to the incident. Examples include FAA alert @Lm A:bulance Task Forcem MCIP activation, etc

A, the area containing a process or cdt that would likely cause seirous injury or death to exposed persons. A LHZ shall be isolated by the IC or designee with identifying barriers to alert responders to the presence of the hazard

B. Conditions found which require a LHZ include, but are not limited to:
1. Fallen power lines or any power lines that responders may approach or come into contact with.
2. Energized electrical equipment, especially if it is damaged.
3. Collapse zones, which are areas around damaged structures that could be covered in debris if the structure collapses.
4. Large unprotected holes, ditches, and openings such as trenches, swimming pools, and sewer access points.
5. A damaged vessel containing any pressurized liquid or gas.
6. Ammunition or explosives, such as gun powder, blasting caps, and dynamite.
7. Presence of suspected or actual hazardous materials, including fuel spills from traffic collisions..

C. LHZs should be marked with a minimum of three horizontal strands of red and white barrier tape with "Do Not Enter" or "Do Not Cross" printed conspicuously.

D. Responders encountering barrier tape should exercise caution until the reason for the barrier is identified.

E. Any area barricaded with three horizontal strands of any color/pattern of barrier tape should be assumed to be a LHZ until proven otherwise.

F. Entering an area marked "Do Not Enter" or "Do Not Cross" is strictly prohibited.

G. All responders must observe and ensure others do not enter established LHZ areas.

H. LHZs may also be marked with cones or light sticks/strobes.

I. LHZ barriers should be clearly illuminated.

J. Responders who discover a previously unrecognized LHZ must:
1. Ensure personal safety.
2. Restrict access to the area immediately.
3. Notify County Communications of the hazard and provide a CAN report if they are the only unit at the scene.
4. If a fire/law Incident Commander (IC) is present, notify them immediately.
5. Remain at the border of and restrict access to the LHZ until reassigned by the IC, Safety Officer, or their designee.

A. Using LCES (Lookouts, Communications, Escape Routes, Safety Zones) on every response will help responders adapt to changing scene conditions and recognize marked or unmarked Life Hazard Zones (LHZ).

B. Ambulance crew members should prioritize situational awareness, with non-patient-care crew members continuously scanning the scene for potential dangers.

C. Crew members must promptly communicate any threats or hazards to the Incident Commander (IC) or designee and inform County Communications to relay LHZ conditions to responding units.

D. Safe escape routes must be identified for every emergency scene, allowing rapid retreat from the incident location and considering the positioning of equipment, vehicles, and personnel.

E. The IC or designee should establish a safety zone close to the incident location, serving as a staging area or safe refuge.

F. LCES observations include identifying loose sharps, bodily fluids, fuel leaks, unusual bystander or patient behavior, aggressive animals, self-locking doors, fire spread, emergency vehicle parking, indicators of abnormal events, traffic, and fall/trip hazards.

A. Safety support involves positioning emergency vehicles as a physical barrier between the emergency scene and flowing traffic or other hazards, primarily used for traffic collisions but applicable in any situation.

B. If an ambulance arrives first at an active roadway scene, it should position itself to provide safety support against traffic flow, allowing for safe egress if possible.

C. Minimize traffic flow impacts in adjacent lanes or areas once the emergency scene is protected.

D. Procedures for emergency vehicles providing safety support include angling the driver's side away from traffic, ensuring the vehicle is unoccupied, avoiding patient loading unless safe, and parking far enough from the scene to create a safety zone.

E. Arriving ambulances should position themselves beyond the scene for rapid egress unless directed otherwise by the Incident Commander (IC).

F. Parking beyond the incident offers the most protection for crews and patient loading.

G. The IC or designee may establish a staging area to manage on-scene units and enhance responder mobility and scene safety.

H. Additional ambulances arriving at the scene should park beyond the incident, report to staging, or follow IC instructions.

I. Emergency lights should be used to alert others to the emergency scene and provide visible warning.

J. Scene lights, like flood/takedown lights, should be used where possible and appropriate for the incident.

A. Scene Staging:
1. Dispatch may advise responders to stage if imminent danger is suspected at or near the scene.
2. Responders may decide to stage if they believe imminent danger exists, notifying County Communications of their decision and the reason.
3. If staging for more than ten minutes due to imminent danger, the crew should coordinate with the Incident Commander (IC) to find safe access to the patient, document actions taken, and report them in the patient care report.

B. Scene Security:
1. Force protection involves law enforcement support for overall scene security during routine events without imminent danger. Coordination with the IC is necessary to request force protection when needed. EMS responders should not enter scenes with imminent danger, regardless of law enforcement presence.
2. EMS personnel are prohibited from entering scenes with imminent danger, even with law enforcement or specialized personnel. Examples include tactical law enforcement entries, hazardous materials areas, water rescues, and high/low angle rescues.
3. Personnel must be trained, qualified, and authorized for such operations. EMS responders may assist allied agency personnel while staying in the cold zone or safe-refuge area only.

A. Defines EMS responders as EMTs, paramedics, and those facilitating patient care in accordance with California Health and Safety Code sections.

B. States that if EMS responders encounter imminent danger at a scene, they are permitted to retreat to a safe area, with imminent danger defined as any threat likely to cause immediate death or serious physical harm.

C. If retreat is necessary, EMS responders must make reasonable efforts to evacuate patients and thoroughly document these efforts. If evacuation isn't possible, responders should aim to return to assist the patient when safe to do so.

D. If EMS responders retreat, they must immediately inform County Communications and the Incident Commander (IC), requesting additional resources like law enforcement assistance to mitigate danger to any remaining patients.

E. Once safe, EMS responders should notify the EMS Field Supervisor, complete a System Variance Report, and have the supervisor inform the EMS Duty Chief.

This section discusses the interaction between EMS responders and law enforcement agencies in situations involving potentially uncooperative individuals:

A. Law enforcement policies regarding engagement of individuals could influence EMS responder actions.

B. Peace officers may opt not to engage physically with uncooperative individuals if certain conditions are met, such as no crime in progress and no immediate risk to others.

C. Law enforcement disengagement can occur regardless of whether the individual is placed under Welfare and Institutions Code 5150 or if a licensed clinical social worker is present.

D. Verbal de-escalation or involvement of crisis response teams may continue efforts to resolve the situation.

E. If law enforcement disengages, EMS responders should confirm the disengagement, ensure contact with a crisis intervention team, and document the disengagement and its reasons.

F. After completing the necessary actions, EMS responders can return to service.

A. EMS responders have both the right and obligation to report unsafe working conditions.

B. If an EMS responder believes a work assignment is unsafe, they must try to identify safe alternatives for completing the assignment.

C. A "turn down" occurs when an EMS responder determines, due to safety concerns, they cannot undertake an assignment as given and cannot negotiate a safe alternative.

D. Reasons for turning down an assignment as unsafe include violations of safe work practices, unsafe environmental conditions, lack of qualifications or experience, defective equipment, violation of laws or regulations, and violations of agency policies or procedures.

E. If an assignment is turned down due to safety, the EMS responder must immediately notify the Safety Officer or Incident Commander (IC), inform the EMS Field Supervisor, and complete a Safety Variance Report (SVR) when safe to do so.

F. The EMS Field Supervisor, upon being informed of a turned-down assignment, must notify the EMS Duty Chief and ensure the involved EMS crew completes an SVR.

purpose: to assist providers in honoring valid end of life directives in the prehosp field setting & act in accordance with the pt's wishes when death appears imminent

A. Aid-In Dying Drug: A physician-prescribed medication that a qualified individual may choose to self-administer to bring about their death due to terminal illness. The medication, chosen by the individual, can take effect within minutes to several days after self-administration.

End of Life Option Act: The End of Life Option Act is a California state law (Health & Safety Code section 443 et seq.) that permits adults aged eighteen (18) or older, meeting specific qualifications and diagnosed with a terminal illness by their attending physician, to request an "aid-in-dying drug" prescribed to end their life in a humane and dignified manner.

This document serves as the patient's declaration of their intention to end their life. It should be filled out within forty-eight (48) hours before the patient self-administers the Aid-in-Dying Drug.

Medical interventions aimed at reviving cardiac activity and breathing, including CPR (cardiopulmonary resuscitation), defibrillation, drug therapy, and other life-saving measures.

medical interventions used to provide and promote pt comfor, safety, & dignity including but not limited to airway maneuvers & removal of a foregin body obstruction

A. Prehospital responders should follow specific guidelines.
B. Patients are required to complete a Final Attestation within 48 hours before self-administering the drug.
C. The Final Attestation should contain specific language outlined in the policy.
D. Patients are not mandated to keep the Final Attestation close when administering the drug.
E. Providers should verify that the Final Attestation contains the required language.
F. Verify patient identity through photo ID or family/witness identification.
G. Address patient needs and contact 911 appropriately, with guidance from the Base Physician.

H. Administer supportive or comfort measures as needed, including airway ventilation.
I. Follow the patient's directives if a valid Do Not Resuscitate (DNR) or Physician Orders for Life-Sustaining Treatment (POLST) form is present.
J. If a Final Attestation is present, refrain from resuscitative measures if the patient is in cardiac arrest.
K. Patients can withdraw their request for the Aid-in-Dying Drug at any time; providers should follow standard protocols and consult with the Base Physician.
L. If family members object to the patient's decision under the End of Life Option Act, inform them comfort measures will be provided and consult the Base Physician.
M. Complete the prehospital care report (PCR) documenting all care provided, including communications with the patient and/or family, along with relevant times.

purpose: to establish standards for the ground amb transport of non-911 pts at the BLS, ALS, & CCT levels

A. BLS: any SCC permitted basic life support amb staffed with at least 2 SCC accredited EMTs

B. ALS (paramedic): any SCC permitted advanced life support am staffed with at least 1 SCC accredited paramedic and one SCC accredited EMT or paramedic

C. CCT Amb: any SCC permitted critical care transport amb with one of the following staffinf configs:
1. 1 SCC accredite CCT-RN + 2 SCC accredited EMT and/or paramedic
2. 1 SCC accredited CCT-RN + 1 SCC EMT/paramedic , if the CCT-RN has completed the SCC EMS Agency system orientation & can function at the same operational level as an accredited EMT

D. Interfacility Call: A request for transporting a patient from one health facility to another.

E. Non-emergency Call: Transporting a patient to/from a private residence, health facility, or non-medical facility in a permitted ambulance, not classified as an emergency (BLS or ALS).

F. Wait and Return Call: Transport request where the ambulance crew waits for the patient at the destination, then returns them to the original pick-up location without responding to other calls during that time.

purpose: to identify SCC permitted ground amb providers and service levels

1. AMR: CCT RN (1) / EMT (1)
2. Falcon CCT: CCT RN (1) / EMT (1)
3. Norcal Amb: CCT RN (1) / EMT (1)
4. Pro transport-1: CCT RN (1) / EMT (1)
5. Royal Amb: CCT RN (1) / EMT (1)
6. Westmed Amb: CCT RN (1) / EMT (1)

1. pro-transport 1: Paramedic (1) / EMT (1)
2. Royal amb: Paramedic (1) / EMT (1)
3. westmed amb: Paramedic (1) / EMT (1)

1. AMR: EMT (2)
2. Falcon CCT: EMT (2)
3. Norcal Amb: EMT (2)
4. Pro-Trasport 1: EMT (2)
5. Royal Amb: EMT (2)
6. Westmed: EMT (2)

purpose: identify SCC sys transfer guidelines

DO NOT DELAY: initiate the process immediately, transfer can be cancelled

step 1: contact the receiving "Trauma Center" & confirm that the receivnig physician will accept the pt

step 2: determine the appropriate 'Type of Amb Transport"

step 3: Initiate response by requesting "CODE 3 Trauma Transfer" from the appropriate amb provider.
1. for EMERGENCY TRANSFER pts, use county cooms direct line, when 911 amb is used, the pt must alwasys go to the closest trauma center
2. for URGENT TRANSFER pts, call contracted amb provider directly or other non-911 amb provider. When a non-911 amb is used, the destination is at the discretion of the sending physician

step 4: prepare pt & paperwork for immediate transfer of care when the amb arrives (include a disc with imaging)

A. BP:
1. B of less than 90
2. decrease in BP by 30mmHg after 2 liters of crystalloid solution infusion

B. Head injury with blown pupil

C. penetrating thoracic or abdominal trauma

D. pt requiring immediate evaluationesuscitation per transferring physician

E. Contact trauam hosp emg dptmt before calling for a 911 amb

for pts NOT requiring immediate transfer by 911 amb

A. CNS:
1. penetrating injury or open fracture to head
2. GSC decrease with abnormal CT
3. spinal cord or major vertebral injury

B. Chest:
1. Major chest wall injury with >3 rib fractures and/or pulmonary contusion
2. Wide mediastinum or other signs of great vessel injury -Transfer to Stanford
3. Cardiac injury
4. Penetrating chest injury

C. Major extremities injuries:
1. Fracture / dislocation with loss of distal pulses and/or ischemia
2. Open long bone fractures
3. Two or more long bones fractures
4. Amputations requiring re-implantation; 4a Transfer to Stanford or Regional ifpatient is ≥15 y/o; 4b Transfer to Stanford if patient is <15 y/o

D. Pelvis/abdomen:
1. pelvic ring disruption
2. solid organ injury confirmed by CT or ultrasound demonstrating abdominal fluid

E. Multiple sys injury
1. burns associated injuries - transfer to Valley
2. maor injury to more than 2 body regions
3. signs of hypo-perfusion -- lactate >4 or Base deficit >4

F. Co-morbid factors
1. adult >65 y/o
2. children <6y/o
3. insulin dependent diabetes
4. morid obesity
5. cardiac or respiratory disease
6. immunosuppression
7. pregnancy >20 weeks gestation -- transfer to standford or Valley

A. Ground transport
1. 911 ALS: provide standard ACLS capabilities & medications

2. CCT-RN provide ACLS, administer most medications/drips & provide mechanical ventilation

3. non-911 BLS: provide standard BCLS only. Staffed by 2 EMTS. Last groun amb option. Consider sending facility RN or MD with crew.

B. Air Ambulance Transport
1. provide ACLS, administer most medications/drips & provide mechanical ventilation.
2. policy 621: interfcility transfer-air amb identifies sys requirements & providers

1. Regional San Jose (RSJ), level of care: adults

2. Standford (SUH), level of care: adult/pediatrics

3. Valley Medical Center (VMC), level of care: adult/pediatrics

purpose: to identify SCC sys Transfer guidelines

Step 1: Confirm if the patient requires endovascular or surgical neuro-intervention.

Step 2: Contact the designated "Stroke Center" to ensure they can accept the patient.

Step 3: Determine the appropriate type of ambulance transport based on medication needs and the need for a CCT-RN.

Step 4: Initiate the transfer process with a non-911 contracted ambulance provider, considering the patient's acuity and ETA.

Step 5: If the patient doesn't need medications or a CCT-RN and requires rapid transfer, contact County Communications for a 911 ALS response with a 10-minute ETA. Have all necessary paperwork & films ready prior to amb arrival.

Step 6: Prepare the patient and paperwork for immediate transport when the ambulance arrives.

Ground Transport
A.CCT-RN (Critical Care Transport Nurse):
1. Provides ALS (Advanced Life Support), administers most medications/drips, performs mechanical ventilation, and offers nursing care according to the California Board of Nursing scope of practice.

B. Non-911 ALS:
1. Provides ALS, but many IV medications used for stroke patients, including thrombolytics, are not within the paramedic's scope of practice.
2. Options for medication administration include giving bolus medication prior to arrival, completing the infusion, or sending facility staff (minimum one RN) during transport to finish the infusion. Thrombolytics cannot be running at the time of the call unless a facility staff member (minimum RN) is present with the patient.

C. 911 ALS:
1. Reserved for critically ill patients requiring immediate transfer.
2. Similar medication administration restrictions as Non-911 ALS apply.

D. Non-911 BLS:
1. Provides Basic Life Support only, considered a last resort.
2. Facility staff (minimum one RN) accompanies the patient during transport to complete infusion and care.

Air Transport
E. provide ALS, administer most medications/drips, provide mechanical ventialtion & provide nursing care in accordance with CA board of nursing scope of practice.

1. Good Samaritan (GSH); Level of care: Comprehensive/primary

2. Regional-San Jose (RSJ); Level of care: Comprehensive/primary

3. Standford (SUH); Level of care: comprehensive/primary

4. El Camino-Mountain View (ECH); Level of care: thrombectomy capable/primary

5. Kaiser Santa Clare (KSC); Level of care: thrombectomy capable/primary

6. El Camino-Los Gatos (LGH); Level of care: primary

7. Kaiser-SJ (STH); Level of care: primary

8. O'Connor (OCH); Level of care: primary

9. Saint Louise (SLH); Level of care: primary

10. Valley Medical CEnter (VMC); Level of care: primary

purpose: to identify SCC STEMI sys transfer guidelines

Step 1: Confirm if the patient requires percutaneous coronary intervention or coronary artery bypass graft.

Step 2: Contact the receiving "STEMI Center" to ensure they can accept the patient.

Step 3: Determine the appropriate ambulance transport type based on whether the patient is receiving medications or if a CCT-RN (Critical Care Transport Nurse) is needed.

Step 4: Initiate the transfer process with a non-911 contracted ambulance provider, requesting "Red Lights and Siren" if necessary. Evaluate the expected time of arrival and consider contacting another ambulance provider if needed.

Step 5: If the patient doesn't require medications or a CCT-RN and needs rapid transfer by 911 ALS (Advanced Life Support), contact County Communications for a ten-minute response time. Ensure all necessary paperwork and films are ready.

Step 6: Prepare the patient and paperwork for immediate transport when the ambulance arrives.

Ground Transport
A. CCT-RN:
1. Provide ACLS (Advanced Cardiac Life Support), administer most medications/drips, and provide mechanical ventilation.

B. Non-911 ALS:
1. Provide ACLS. Paramedics cannot administer most IV medications used for STEMI patients, including IV nitroglycerine and thrombolytics. Options include giving bolus medication prior to arrival, completing the infusion, or arranging for facility staff (minimum one RN) to complete the infusion during transport.

C. 911 ALS:
1. Reserved for critically ill patients needing immediate transfer. Provide ACLS. Paramedics cannot administer most IV medications used for STEMI patients. Similar options as non-911 ALS apply.

D. Non-911 BLS:
1. Provide BCLS (Basic Cardiac Life Support) only. As a last resort, facility staff (minimum one RN) will be sent during transport to complete the infusion and care for the patient.

Air Amb Transport
E. Provide ACLS, administer most medications/drips and provide mechanical ventilation. Policy 621: Interfacility Transfer-Air Ambulance identifies system requirements and providers.

1. ECH
2. GSH
3. STH
4. OCH
5. RSJ
6. SUH
7. VMC

purpose: to define the use of Air Amb providers ofr interfacility transports

Air ambulance:
A Santa Clara County permitted air ambulance must adhere to the following criteria:
1. It must provide advanced life support in accordance with Title 22 Regulations.
2. The air ambulance must be staffed with a minimum of two attendants, including one registered nurse.
3. The second attendant must be either another registered nurse or a Santa Clara County accredited paramedic.

A. Provider: CALSTAR 2
1. Minimum attendant staffing: CCT RN (2) or CCT EN (1)/Paramedic (1)

B. Provider: CALSTAR 5
1. min attendant staffing: CCT RN (2) or CCT RN (1)/Paramedic (1)

C. Provider: Stanford Life Flight
1. min attendant staffing: CCT RN (2)

purpose: to provide guidelines for the safe and prompt transfer of patient care duties from Emergency Medical Services (EMS) personnel to Emergency Department (ED) medical staff, as mandated by Health and Safety Code 1797.125. Additionally, it outlines procedures to manage offload delays effectively.

the time the amb arrives at hte location outsied the hosp ED where the pt will be unloaded from the amb

the time interval between the arrival of an amb pt at an ED and the time the pt is transferred to the ED gurney, bed, chair or other acceptable location & the emgcy dptmt assusms the resp for care of the pt

the amb pt offlod time for a pt exceeds a period of time designated by the LEMSA. For purpose of this policy & for SCC EMS sys oversight reveiw, all transfer of care timestamps over 20 mins & up to 60 mins will be considered an offload delay

the occurence of a pt reminaing on the amb gurney and/or the emgcy dptmt has not assuemd resp for the pt care beyond the LEMSA maximum delay-time over 60 mins

ED physician, physician assistant, nurse practicioner or RN

publis safety-1st responders, EMTs, and/or paramedics responsible for out of hospital pt care and transport consisten with the scope of practice as authorized by their level of credentialing

A. EMS personnel must continue providing patient care until transfer to the designated hospital's Emergency Department (ED) medical staff. Care should adhere to county protocols and be documented accordingly.

B. During triage, EMS personnel will provide a verbal patient report to ED staff. Patient care transfer is complete upon receiving the report and offloading the patient. Delays exceeding 20 minutes are documented as Ambulance Patient Offload Delays.

C. Once patient care is transferred to ED staff, EMS personnel are relieved of monitoring or providing care.

D. EMS personnel must promptly return to readiness status after transferring patient care and offloading the patient.

purpose: to establish best practices for the fficient & sustainable use of 911 emgcy ambs in SCC EMS Sys

Amb resources are consistent with daily practice within the EMS sys

Amb resources are nto consistent with daily practices but, maintain or have minimal impact on usual pt care practices within the EMS sys

Amb resources are not consistent with usual standard of care

A. 911 emergency ambulances are deployed when a patient requires transport to an acute care hospital via the 911 system.

B. In the conventional system, ALS ambulances respond to all types of calls, including ECHO, DELTA, CHARLIE, BRAVO, ALPHA, and non-triaged calls.

C. In the contingency system, ALS ambulances respond to ECHO, DELTA, CHARLIE, and non-triaged CODE 3 calls, while BLS ambulances respond to BRAVO, ALPHA, and non-triaged CODE 2 calls.

D. In the crisis system, the closest ambulance, whether ALS or BLS, is dispatched for ECHO and DELTA calls. For CHARLIE, BRAVO, ALPHA, and non-triaged calls, no initial ambulance dispatch occurs.

A. Public safety providers must promptly cancel 911 emergency ambulance requests if transport is deemed unnecessary or if the patient declines transport.
1. The EMT or paramedic assesses the need for ambulance use upon arrival and during patient assessment.
2. Refusal of Service documentation is completed if applicable, and the ambulance is cleared unless it arrives before public safety providers.

B. 911 emergency ambulance crews must inform their dispatch center immediately if a response will not result in patient transport and then make themselves available for further response.

C. 911 emergency ambulance services will establish procedures for completing patient care records, returning to service, and managing other operational aspects not covered in this policy.