Harbor: Base Hospital Resource for Physicians and MICNs

Harbor UCLA Medical Center

• This is intended as a quick reference for Harbor UCLA Base Hospital Physicians and MICNs.

Base Hospital Map in Los Angeles County

Prehospital Care Manual and Treatment Protocols

• Complete Prehospital Care Manual
• Adult and Pediatric Treatment Protocols

Types of Radio Calls

• Base Contact (MICN, Attending, R4, R3)
  • Including Cardiac Arrest, Pronouncement in the field, AMA
• Base Notification (MICN, Attending, R4, R3)
• Base to Base Referral (MICN or experienced Base Hospital Physician)
• 911 Interfacility Transport for Trauma (Attending must take the report and accept patient)
  • Reference No. 506, Policy VI
• 911 Interfacility Transport for STEMI (Attending must take the report and accept patient)
  • Reference No. 513.1
• Multiple Casualty Incident (MICN or experienced Base Hospital Physician)
  • Reference No. 519

Provider Codes

Common Provider Codes for Harbor UCLA Medical Center

• Most Commonly Used Provider Impression Codes
  • ABOP = Abdominal Pain/Problems
  • ETOH = Alcohol Intoxication
  • ALOC = Altered Level of Conciousness-Not Hypoglycemia or Seizure
  • PSYC = Behavioral/Psychiatric Crisis
  • BRUE = BRUE
  • CANT = Cardiac Arrest-Non-Traumatic
  • CPNC = Chest Pain-Not Cardiac
  • CPMI = Chest Pain-STEMI
  • CPSC = Chest Pain-Suspected Cardiac
  • DIZZ = Dizziness/Vertigo
  • HYPR = Hyperglycemia
  • HYTN = Hypertension
  • HYPO = Hypoglycemia
  • HOTN = Hypotension
  • SOBB = Respiratory Distress/Bronchospasm
  • RDOT = Respiratory Distress/Other
  • CHFF = Respiratory Distress/Pulmonary Edema/CHF
  • SEPI = Seizure-Postictal
  • SEPS = Sepsis
  • SHOK = Shock
  • SYNC = Syncope/Near Syncope
  • TRMA = Traumatic Injury
  • WEAK = Weakness-General
• Common Paramedic Provider Agency Codes
  • CF = Los Angeles County Fire
  • CI = Los Angeles City Fire
  • CM = Compton Fire
  • MB = Manhattan Beach Fire
  • RB = Redondo Beach Fire
  • TF = Torrance Fire
• Most Common ECG Codes
  • AFI = Atrial Fibrillation
  • ASY = Asystole
  • PEA = Pulseless Electrical Activity
  • SR = Sinus Rhythm
  • ST = Sinus Tachycardia
  • VF = Ventricular Fibrillation
  • VT = Ventricular Tachycardia
• Most Common Location Codes
  • HO = Home
  • NH = Nursing Home
  • FR = Freeway
  • ST = Street/Highway
• Most Common 9-1-1 Receiving Hospital Codes
  • CNT = Centinela Hospital
  • KFH = Kaiser South Bay
  • LCM = Providence Little Company of Mary Medical Center - Torrance
  • MHG = Gardena Memorial Hospital
  • MLK = Martin Luther King Hospital
  • TOR = Torrance Memorial

Specialized Care and Transport Considerations

STEMI

• Medical management according to TP 1211
• Ensure Harbor UCLA Medical Center is OPEN to STEMI by checking ReddiNet.
• Reminder to document the EKG time, Initial Rhythm, EMS Interpretation, and Software Interpretation.
• Obtain and print transmitted ECG from STEMI outlook email.
• Discuss with Attending with regard to activating Cath Lab prior to patient arrival.
• All patients in cardiac arrest should also be transported to a STEMI Receiving Center if transport time is <30 minutes.
• Destination: STEMI Receiving Center

Stroke

• Medical management according to TP 1232
• On all patients exhibiting local neurologic signs, paramedics perform an mLAPSS assessment. If mLAPSS is positive, it is followed by a calculation of a LAMS score and documentation of LKWT (Last Known Well Time).
  • 1. Modified Los Angeles Prehospital Stroke Screen (mLAPSS)
    • The mLAPSS is positive if ALL of the following criteria are met:
      • No history of seizures or epilepsy
      • Age 40 years or older
      • At baseline, patient is not wheelchair bound or bedridden
      • Blood glucose between 60 and 400 mg/dL
      • Obvious asymmetry-unilateral weakness with any of the following motor exams:
        • Facial Smile/Grimace
        • Arm Strength
        • Grip Strength
  • If mLAPSS positive --> 2. Calculate Los Angeles Motor Score (LAMS)
    • Facial Droop
      • Absent = 0
      • Present = 1
    • Arm Drift
      • Absent = 0
      • Drifts down = 1
      • Falls rapidly = 2
    • Grip Strength
      • Normal = 0
      • Weak grip = 1
      • No grip = 2
  • If mLAPSS positive --> 3. Document LKWT
• Destination:
  • If mLAPSS positive, LAMS 4-5, LKWT < 24 hours --> Transport to Comprehensive Stroke Center if within 30 min
  • If mLAPSS positive, LAMS ≤ 3, LKWT < 24 hours --> Transport to closest Stroke Center (Primary or Comprehensive)
  • mLAPSS negative but acute stroke suspected --> Transport destination is at discretion of Base Hospital

Trauma

• Medical management according to TP 1244 for adults, TP 1244-P for pediatrics.
• Any patient that meets trauma criteria or is deemed by provider judgment to meet trauma criteria should be transported to the nearest adult or pediatric trauma center.
  • Trauma criteria can be found on the Base Contact Form under the TRAUMA and MECHANISM Sections. Patients are classified as a trauma patient if any of the red boxes are checked.
• Pediatric Trauma Center Criteria
  • Children >15 years old cannot go to an adult trauma center
• Destination: Adult or Pediatric Trauma Center

Trauma Traige Decision Scheme

Burns

• Medical management according to TP 1220 for adults and TP 1220-P for pediatrics.
• If a burn patient meets Trauma Center criteria, then transport to Trauma Center.
• If NO SIGNS OF TRAUMA, consider transport to directly to a burn center if they meet these criteria:
  • ≥ 15 years with 2nd and 3rd degree burn ≥ 20% TBSA
  • ≤ 14 years with 2nd and 3rd degree burn ≥ 10% TBSA
• If the patient does not meet burn center criteria and has NO SIGNS OF TRAUMA, transport to Most Accessible Receiving Center (MAR)
• Destination: Burn center, Trauma center, or MAR

Types of Destinations/Receiving Centers

• MAR = Most Accessible Receiving
• TC = Trauma Center
• EDAP = Emergency Department Approved for Pediatrics
  • Think of an EDAP as a MAR for children approved to care for children ≤ 14 years old.
• PMC = Pediatric Medical Center
  • Approved to care for critically ill children ≤ 14 years old.
• PTC = Pediatric Trauma Center
  • Approved to care for children ≤ 14 years old who meet trauma criteria.
• Perinatal Center
  • Basic ED with 24/7 Obestrical services approved to care for pregnant patients >20 weeks gestation.
• SRC = STEMI Receiving Center
• PSC = Primary Stroke Center
  • Able to care for most ischemic strokes.
• CSC = Comprehensive Stroke Center
  • Able to care for all ischemic and hemorrhagic stroke cases with 24/7 neurosurgery and capable of performing minimally invasive catheter-based procedures including thrombectomy for large vessel occlusion strokes.

Termination of Resuscitation in Non-Traumatic Cardiac Arrest

• Goal of OHCA resuscitation: Survival with good neurological outcome.
• Transportation without ROSC is discouraged.
• EMS personnel may terminate resuscitation without base contact per Ref No. 814
• Termination of Resuscitation based on presenting rhythm
  • Non-shockable (Aystole or PEA)
    • EMS personnel may determine death without base contact if:

1. Patient 18 years or greater
2. Arrest not witnessed by EMS personnel
3. No shockable rhythm identified at any time during the resuscitation
4. No ROSC at any time during the resuscitation
5. No hypothermia

• • • If all these criteria are not met, base physician consultation is required for determination of death and termination of resuscitation.
  • Shockable (Vfib or Vtach)

Base Contact for a patient refusing transport

• Ref No. 834
• In Los Angeles County, paramedics should not refuse transport and should honor any request by a patient for transport.
• AMA
  • Adults
    • Paramedics are required to make base contact for any patient leaving AMA.
    • An adult with an ongoing medical emergency may refuse transport if they have decision making capacity. The patient must understand and state the risks of leaving AMA. It is highly recommended that the base hospital provider speak with the patient prior to leaving AMA.
    • For patients without decision-making capacity who are refusing transport, assistance from law enforcement should be requested.
  • Pediatrics
    • Pediatric patients with an ongoing medical emergency should be transported under implied consent. If the parent refuses transport for a child with an ongoing medical emergency that requires transport, assistance from law enforcement should be requested.
• Treat and Refer
  • For patients without an ongoing medical emergency and with decision-making capacity (or guardian present), the patient may be released at the scene. Base contact is not required.

911 Interfacility Transport (IFT) Trauma Re-Triage

911 Trauma Retriage

• A system developed to handle walk-in trauma patients or undertriage of trauma patients by EMS to non-trauma centers.
• The patient MUST meet one of the 8 defined criteria or else may be a candidate for MAC transfer.
  • Criteria #8: Patients, who in the judgment of the evaluating emergency physician, have a high likelihood of requiring emergent life- or limb-saving intervention within two hours.
• Consider that some interventions performed at the sending facility may be out of the scope of paramedics (e.g. paralyzing agents, blood products, vasopressors, sedation medications). In select cases, the sending facility may have to send a physician or nurse with the transport crew.

Medications in Paramedic Scope of Practice

• It is important to remember that not all provider agencies may stock all medications within the paramedic scope and that each medication is only approved in the prehospital setting for specific indications.
• Approved ALS medications in Los Angeles County
  • Adenosine
  • Albuterol
  • Amiodarone
  • Aspirin
  • Atropine
  • Calcium Chloride
  • Dextrose
  • Diphenhydramine
  • Epinephrine
  • Fentanyl
  • Glucagon
  • Ketorolac
  • Lidocaine
  • Midazolam
  • Morphine Sulfate
  • Naloxone
  • Nitroglycerin
  • Ondansetron
  • Oxygen
  • Pralidoxime Chloride (DuoDote™)
  • Sodium Bicarbonate
• Ref No. 1300

ReddiNet

• A designated emergency and disaster communication system established for hospitals within Los Angeles County.
• Allows Los Angeles County hospitals to request diversion status, manage MCIs, and report bed availability.
• It is the responsibility of each hospital to ensure ReddiNet remains up to date and online at all times.
• Diversion requests Categories
  • Hospitals may request ED Sat in 1 hour increments if unable to care for ALS patients. BLS traffic is not diverted.
  • Other diversion categories include: CT Scanner, Trauma, Peds, STEMI, Stroke, Internal disaster (only category in which both ALS and BLS are diverted)
  • See Ref No. 503

Fundamental Concepts of Base Hospital Contact

• Ref No. 1200.2
• Base contact is required for specific provider impressions or if certain treatments or medications are administered.
• Paramedics are licensed providers and able to practice independently based on established treatment protocols (Off-line Medical Direction).
• During base contact, physicians and MICNs may direct paramedics to deliver treatments outside established protocols as long as it is within their scope of practice or bypass MAR if there is a clear indication to do so (On-line Medical Direction).
  • When providing on-line medical direction, be clear and direct, offer a brief explanation with the order, document appropriately on the base hospital form.

Base Contact Form Documentation Reminders

• GEN INFO Section
  • Document Time in Military Time
  • Document Weight in Kgs
    • It is ok to approximate weight by dividing lbs by 2 (ex. If medics state the patient is 100lbs, you can respond: "To confirm the patient is 100lbs or approximately 50kgs").
• ASSESSMENT Section
  • Ask providers to obtain family contact information and/or bring along DNR/AHCD/POLST if relevant.
• PHYSICAL Section
  • Document capnography # for all patients receiving positive pressure.
• VITALS & TXS Section
  • Document a pain level when ordering PRN analgesia (ex. Morphine 4mg IV PRN pain >5/10).
• ECG Section
  • Document the time that ECG was taken.
• ARREST Section
  • Ensure Time of Resus D/C is documented when relevant.

Base Contact Form