Harbor:Screening EMS Patients

Surge Mitigation for EMS offload Time(2022)

• Per EMS Agency Directive #4 (12/23/2020) EMS providers will offload their patients to the waiting room with notification of the triage nurse for patients meeting ALL of the below criteria in an effort to reduce ambulance patient offload times (APOT). EMS Directive #4

1. APOT estimate ≥ 30 mins
2. Age ≥ 18 years; or pediatric patients if accompanied by an adult
3. Normal Mental Status (GCS 15)
4. Normal vital signs per MCG 1380 for adults or MCG 1309 for peds: SBP ≥ 90mmHg, HR 60-100 BPM, RR 12-20, SPO2 > 94% on room air
5. Ambulatory with steady gait without assistance (as appropriate for age)
6. No suicidal or not on psychiatric hold (5150/5585)
7. No chest pain, syncope, or acute neurologic symptoms (focal weakness, dizziness/vertigo)

Ambulance Triage

• Goals: Identify any time-sensitive, critical, or decompensating patients who arrive by ambulance, but not yet assigned a bed. This is especially important during hospital surges and staffing shortages.
• General Principles: The triage should include a brief history, a full set of vital signs, mental status, and pertinent physical/psychiatric exams. You may choose to perform point of care testing (blood sugar, hemocue) or breathalyzer testing. The senior resident or attending physician should discuss the urgency of rooming with the AED charge and place additional orders for the patient as needed.

• Screening Process:
  • All EMS Providers/Law Enforcement who arrive via ambulance triage with patients check in with the AED Charge RN (unless pre-registered and going direct to preassigned room)
  • When AED Charge RN determines patient clearly needs to stay in AED:
    • If there is a room available, AED Charge will Quick Reg the patient and room immediately
      • Assign team (purple/green) based on available room
    • If no room available, AED Charge RN assigns by alternating purple/green and notify Senior Resident via Spectra - "EMS is waiting"
      • Hold EMS until physician arrives (30 min max)

• All ambulance patients should be triaged by their assigned team determined to either need a room or sent to main triage:
  • • If assigned "AED" by screening MD, place in next available room (senior to remove team assignment unless they want to keep the patient on their team; if no team assignment, goes to team based on room placement/geography)
    • If assigned "Triage" by screening MD, to triage for physician/NP in triage to perform MSE

• All ED Trauma and ALS patients who are anticipated to be holding the wall in ambulance triage for whatever reason, should be triaged by the assigned senior resident or attending physician immediately. These patient's have a much higher chance of decompensation. The Acute Charge RN will assigned a team to evaluate the patient in ambulance triage.

• Documentation: All patients who are triaged by a physician and determined to need a bed and/or do not meet the below direct to triage crtieria should have an MSE documented in Orchid. Patients being sent direct to triage after physician evaluation require documentation using a free text note using .edambutriage
  
• Direct to main ED triage criteria:
  • Stable Vital Signs
    • T 36-38C
    • HR 60-100
    • SBP 100-210, DBP 60-120
    • RR 12-20
  • Ambulatory
  • Cleared by Charge RN who must Quick Reg the patient AN Use the Pre-Hospital template to enter: VS, EMS unit, and brief statement about patient being stable and ambulatory to triage
  • If the patient meets all 3 criteria, EMS may take them directly to the physician in triage (or NP if physician is unavailable)

Patients not meeting "Direct to Triage" criteria

AED Charge

• Quick-register patient
  • If clearly needs to stay AED
    • Room Available
      • Place in room
      • Assign purple/green based on room
    • No room available - Assign by alternating purple/green
      • Notify Senior Resident via Spectra - "EMS is waiting"
      • Hold EMS until physician arrives (30 min max)
      • If no room, after MSE by senior resident:
        • If assigned "AED" by screening MD, place in next available room (senior to remove team assignment unless they want to keep the patient on their team; if no team assignment, goes to team based on room placement/geography)
        • If assigned "Triage" by screening MD, to triage for physician/NP in triage to perform MSE

Senior Resident

• If you notice EMS patient has been waiting > 30 min for team assignment - call Charge RN
• Respond to screen ASAP to get EMS report
• Release ALS personnel (BLS may have to stay until patient in room)
• If on wall and appears stable for triage/WR, discuss with attending
  • If attending agrees use .edambutriage note but do NOT click the "MSE"
  • Write "Triage" in the RN Comments column
  • These patients will then go to team triage
• If the patient needs to stay in the ED, do a brief MSE note

MICN

• ALS Arrivals ONLY
  • Download and print 2 copies of ePCR (aka EMS Report Form)
  • Place stickers on them
  • Leave 1st copy with patient’s RN
• Give 2nd copy to clerk

ED ATTENDING

• If you notice EMS patient has been waiting > 30 min for team assignment - call Charge RN

See Also

• Harbor:Main

References

Chappell 1/31/18 rev Peterson 1/2019