Harbor:Screening EMS Patients

Ambulance Patient Offload Time (APOT)

• Per DHS Ref 505, APOT is defined as the time interval between the arrival of an ambulance at the location outside the hospital ED where the patient will be unloaded from the ambulance and the time the patient is transferred to the ED gurney, bed, chair or other acceptable location and the ED assumes responsibility for the care of the patient. The APOT Standard in Los Angeles County is within 30 minutes, 90% of the time. Currently, the data source for APOT is the EMS Providers’ electronic patient care report completed by the transporting unit.

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:

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. Not suicidal or not on psychiatric hold (5150/5585)
7. No chest pain, syncope, or acute neurologic symptoms (focal weakness, dizziness/vertigo)
8. No ongoing ALS intervention required
9. Patients who received medications that may require ongoing reassessment (e.g., naloxone, narcotics, epinephrine) shall be discussed with the appropriate ED staff (e.g., triage nurse) prior to being offloaded in the waiting room.

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: All ED Trauma and ALS patients should be triaged as soon as possible by the assigned senior resident or attending physician. 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 clearly communicate and discuss the urgency of rooming with the AED charge and place additional orders for the patient as needed. We should all be conscious that delays in ambulance patient offload can result in longer 9-1-1 ambulance response times in our community.

General Ambulance Patient Screening Process:

• All EMS Providers/Law Enforcement who arrive via ambulance triage with patients must 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 - "EMS is waiting"
      • Hold EMS until physician arrives (30 min max)

Guidelines for EMS Patients who can be directed to ED Triage:

Direct to ED Triage Criteria

• Normal Mental Status (GCS 15)
• Stable Vital Signs
  • HR 60-100 bpm
  • RR 12-20
  • SBP 100/60 to 210/120
  • SPO2 >94% on Room Air
• Ambulatory without assistance (no fall risk)
• No SI/HI/Psychiatric hold (5150/5585)
• No high-risk presentations (e.g., focal neurological deficits, syncope, chest pain)

Role of Senior Resident/Attending Physician:

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

ED Attending should discuss any ambulance offload delays with the AED Charge RN and OCN

Role of AED Charge RN:

• Quick Reg all patients
• 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, send EMS to main triage for physician/NP in triage to perform MSE

Role of 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

See Also

• Harbor:Main

References

Kelsey Wilhelm 7/29/24 rev Bradley Chappell 7/24

http://file.lacounty.gov/SDSInter/dhs/1132904_APOT505_20221101.pdf