Patient Point of Entry
Effective:
Supersedes: CE 233
Purpose: To provide guidelines for the selection of appropriate destinations for acutely ill or injured patients.
Background and Scope
As a general rule, in the case of an emergency, EMS transports patients to the closest geographic hospital with a licensed emergency department, in accordance with the EMS System regulations, 105 CMR 170.355, and the definition in 170.020 for “appropriate health care facility.” The Department interprets this to be the closest hospital by driving time.
Sometimes, a patient’s medical condition makes it more appropriate to take the patient to a hospital that is not the closest. Under the definition at 105 CMR 170.020, an “appropriate health care facility” can also be one designated in a Department-approved point-of-entry plan. The Department currently has approved condition-specific point-of-entry plans for trauma, stroke and STEMI patients.
This point-of-entry plan addresses other circumstances when, because of the patient’s specific medical needs, the patient would clinically benefit from going to a more distant hospital emergency department. Following the procedures in this point-of-entry plan, an ambulance service and its EMTs may transport an emergency patient not covered by a condition-specific Department-approved point-of-entry plan (i.e., stroke, STEMI or trauma) to a hospital other than the closest, based on the patient’s medical condition and need. However, this point-of-entry plan would not require a service and its EMTs to deviate from taking such a patient to the closest hospital emergency department, when not permitted by service policy.
This point-of-entry plan does not affect transport of patients covered by condition-specific Department-approved point of entry plans (i.e., trauma, stroke and STEMI). Such patients are to continue to be transported in accordance with these special point-of-entry plans.
Procedure:
Unstable patients: Transport to the closest hospital emergency department, or as required under a condition-specific Department-approved point-of-entry plan. An unstable patient is one whose vital signs have significantly changed (either upwards or downwards) from normal ranges, in the absence of interventions. See EMS textbooks for normal ranges of vital signs. If there is any question about the stability of the patient, transport to the closest hospital.
Stable patients:
Based on an appropriate assessment of the patient, including obtaining of the patient’s medical history, EMTs may consider transporting a patient to a hospital other than the closest, if the more distant hospital is more appropriate to the patient’s specific medical condition and needs, based on the following factors:
1. The more distant hospital better meets the medical needs of the patient because:
2. The patient’s current physician and medical records are there; the patient has recently been discharged from that hospital; the patient has had previous hospitalizations there; the patient’s complex medical history is followed at the hospital; or
3. The patient’s specific medical condition needs one of the following specialty services for which the hospital is licensed: Burn Unit, Obstetrics, Pediatrics; or
4. The patient’s specific medical condition would be most appropriately addressed at a hospital designated by the Department as a MA Sexual Assault Nurse Examiner (SANE) site. For patients in this category, generally a Protocol X Alert should be transmitted to the receiving hospital, whether it is a designated SANE hospital.
5. The additional time required to transport the patient to the more distant hospital does not exceed 20 minutes. (Multiple hospitals for which estimated transport time from the patient is less than 10 minutes are considered to be of equal transport distance.)
6. The level of service at which the ambulance is operating and the care capabilities of the EMTs are appropriate to the patient’s needs during transport.
7. The available EMS resources in the system at the time of the call would be capable of handling the additional transport time for this unit.
Medical Control Input:
8. If there is any question about whether, based on the above considerations, the patient should be transported to the more distant hospital, contact medical control.
9. If the additional transport time to the more distant hospital, comparted to the closest hospital, is less than 20 minutes, EMTs may transport the patient to the more distant hospital under this point-of-entry plan.
10. If the additional transport time to the more distant hospital may be more than 20 minutes, contact medical control
Documentation and Quality Assurance
11. EMTs must document on their patient care report the clinically based reason for deviating from transport to the closest hospital emergency department. EMTs must also document on the trip record the name of the authorizing physician, if medical control was contacted.
12. The ambulance service will maintain a system for review of all instances in which patients are transported to a hospital more distant than the closest hospital emergency department.
13. Ambulance calls in which patients are transported to a hospital more distant than the closest hospital are reviewable by the ambulance service’s affiliate hospital medical director.
Algorithm for Paramedic-Level Transported STEMI Patients
PO
Following conditions apply:
(1) Patients in arrest, with compromised airway, or transported at BLS or ALS-Advanced EMT level will
go to the closest appropriate health care facility
(2) Ambiguous cases transported at ALS-Paramedic level will go to closest facility
(3) Contact medical control for any questions regarding point of entry or treatment
(4) PCI facility will be notified
(5) Use patient’s medical history and established medical relations if multiple PCI facilities
Massachusetts Statewide Stroke Point-of-Entry Plan (S-PEP)
EMS operational definition of acute stroke:
Presence of symptoms < 5 hr duration (or since last seen at baseline) according to the FAST-ED or other concerning neurologic signs consistent with stroke. Other neurologic signs include:
· sudden dizziness
· inability to walk
· double vision and eye movement abnormalities
· weakness affecting the leg
1. Following the applicable Massachusetts Statewide Treatment Protocol for Stroke, establish a diagnosis of possible stroke based on FAST-ED Stroke Scale
2. Establish time of onset and last time seen at baseline
3. If stroke symptoms present and time from onset of symptoms to hospital arrival will be < 5 hours, transport patient to nearest appropriate Massachusetts Department of Public Health designated Primary Stroke Service (PSS)*
4. Notify receiving facility as early as possible
* Determining most appropriate transport:
1. The goal is to transport patient to PSS within 2 hours of symptom onset. Choose the most appropriate mode of transport (air, ground, etc.) and destination to achieve this.
2. If patient has depressed level of consciousness, compromised airway control, known hypoglycemia, suspected severe hypoglycemia (diaphoretic and a known diabetic), or is hemodynamically unstable, it may be more appropriate to transfer to nearest receiving hospital for acute stabilization.
3. If CT Scan capability is unavailable at the nearest PSS (e.g., “Cautionary Status”), the patient should be transported to the next nearest appropriate PSS as per above guidelines.
[MA OEMS STP: Original issue: 7/1/2005; Last Revised, 5/9/19]