EMS Policy Manual - Contra Costa Health Services

Contra Costa 

County 

Emergency Medical Services 

Policies and Procedures 

Notice 

Updates may occur throughout the calendar year. 

Visit www.cccems.org for updates.



EMS POLICIES AND PROCEDURES 

Contra Costa Emergency Medical Services reviews and updates policies and procedures 

annually. 

Contra Costa Emergency Medical Services Agency approves the following policies and 

procedures for the 2013 calendar year.

EMS Policies 

# 1 - EMT-1 Certification 

# 2 - Paramedic Accreditation 

# 3 - MICN Authorization And Re-Authorization 

# 4 - Contra Costa County EMS Fee Structure 

# 5 - Prehospital Credential Review Process 

# 6 - Prehospital Continuing Education Provider 

# 7 - Paramedic Evaluator 

# 8 - EMS Quality Improvement Program (EQIP) 

# 9 - Patient Destination Determination 

# 10 - Declining Emergency Medical Care And/Or Transport 

# 11 - Base Hospital Communications/Disrupted Communications 

# 12 - EMS System Medical Direction And Oversight 

# 13 - Triage Of Trauma Patients 

# 14 - Transfers To Trauma Centers 

# 15 - Hospital Guidelines For Acute Care Interfacility Transfers Via Ambulance 

# 16 - Transfer Of Care In The Field 

# 17 - EMT/Paramedic Or Non-Transport ALS Programs 

# 18 - Public Safety//EMT AED Programs 

# 19 - Determination Of Death In The Prehospital Setting 

# 20 - 

Do Not Resuscitate (DNR) Orders and Physician Orders for Life-Sustaining Treatment (POLST) in the 

Prehospital Setting 

# 21 - Physician On Scene 

# 22 - Infectious Disease Precautions And Exposure Management For EMS Personnel 

# 23 - Abuse/Assault Reporting 

# 24 - Hospital CT And Internal Disaster Diversion 

# 25 - STEMI Triage And Destination 

# 26 - EMS STEMI Receiving Center Designation 

# 27 - Prehospital Patient Care Record (PCR) 

# 28 - policy suspended 

# 29 - Base Hospital Designation 

# 30 - Patient Restraints 

# 31 - Prehospital Management of Pre-Existing Patient Medical Devices/Equipment: Intravenous Lines And Other 

# 32 - EMS Event Reporting 

# 33 - EMS Aircraft Policies And Procedures 

A – Classification 

B – Authorization 

C – Request, Transport Criteria, And Field Operations 

# 34 - Search For Donor Card 

# 35 - Safely Surrendered Baby Program 

# 36 - EMS Response to Hazardous Materials Incidents 

# 37 - Stroke Triage and Destination 

# 38 - EMS Primary Stroke Center Designation 

# 39 - 9-1-1 Activation Criteria for Non-Emergency Transport Providers

Date 

Effective 

12/15/2012 

CONTRA COSTA COUNTY HEALTH SERVICES DEPARTMENT 

Emergency Medical Services Agency 

Policy Updates 

Policy Number/Name Change 

1/13 23 – Abuse/Assault Reporting Updated the reporting contacts 

1/13 

1/13 

22 - INFECTIOUS DISEASE 

PRECAUTIONS AND EXPOSURE 

MANAGEMENT FOR EMS PERSONNEL 

14 – Emergency Re-Triage and Transfers 

to Trauma Centers 

1/13 13 – Triage of Trauma Patients 

1/13 

8/12 

7/12 

7/12 

7/12 

4 – Contra Costa County EMS Fee 

Structure 

39 – 9-1-1 Activation Criteria for Non- 

Emergency Transport Providers 

10 – Declining Emergency Medical Care 

and/or Transport 

12 – EMS System Medical Direction and 

Oversight 

33C – EMS Aircraft – Request, Transport 

Criteria, and Field Operations 

Revision to EMS 6 form 

Changed to allow for re-triage of a patients meeting specific 

high-acuity criteria to the trauma center for trauma care in a 

more expeditious way 

Changed destination for patients with penetrating trauma 

who arrest after the arrival of transport personnel to a trauma 

center if transport time is 20 minutes or less to that facility 

Fees were revised 

NEW POLICY 

Minor wording changes to clarify application of policy to all 

prehospital personnel 

Minor wording changes to clarify application of policy to all 

prehospital personnel 

Reviewed. No changes. 

7/12 33B – EMS Aircraft Authorization Reviewed. No changes. 

7/12 33A – EMS Aircraft - Classification Reviewed. No changes. 

7/12 35 – Safely Surrendered Baby Program NEW POLICY 

5/12 

26 – EMS STEMI Receiving Center 

Designation 

Addition of List of STEMI Centers 

5/12 37 – Stroke Triage and Destination Addition of List of Designated Primary Stroke Centers 

5/12 

38 – EMS Primary Stroke Center 

Designation 

Updated list to reflect current Designated Primary Stroke 

Centers 

2/12 23 – Abuse/Assault Reporting Reporting contact information updated 

2/12 

2/12 

4 – Contra Costa County EMS Fee 

Structure 

28 – Paramedic Interfacility Transfer (CCT- 

P) Program Standards 

Revised EMT fee payment criteria to allow for both State and 

local fees to be paid with one money order or cashier check 

Policy suspended



EMT CERTIFICATION 

I. PURPOSE 

POLICY #: 1 

PAGE: 1 of 4 

EFFECTIVE: 07/01/10 

REVIEWED: 07/01/10 

To identify the Emergency Medical Technician (EMT) certification and recertification process in Contra 

Costa County. 

II. CERTIFICATION 

A. The following requirements apply to all applicants who have never been certified as an EMT in 

Contra Costa County. 

1. Be eighteen (18) years of age or older. 

2. Provide a current photo ID (CA drivers license, CA ID card or passport). 

3. Provide a valid EMT course completion record from an approved EMT training program. 

a. Apply for certification within two (2) years of the date of course completion 

4. Complete a Contra Costa County EMT certification application.* 

5. Disclose any certification or licensure actions. 

6. Complete a Department of Justice Criminal Offender Record Information (CORI) 

background check.* 

7. Pay the established Contra Costa certification application fee and the applicable State 

EMT Registry fee. 

Upon completion of #1-7 above, and confirmation that the applicant is not precluded from 

certification for reasons defined in Section 1798.200 of the California Health and Safety Code, 

an individual shall be certified as an Emergency Medical Technician for a period of two (2) years 

from the date of successful completion of the National Registry written exam. This certification is 

valid throughout the State of California. 

B. The following requirements apply to a current and valid National Registry EMT-Basic, or a 

current and valid out-of-state or National Registry EMT-Intermediate or Paramedic certificate, or 

a current and valid California Advanced EMT certification or Paramedic license. 



3. Provide documentation of current and valid certificates as outlined above. 

4. Complete a Contra Costa County EMT certification application.* 








an individual shall be certified as an Emergency Medical Technician. The expiration date shall 

be the soonest of the same date as stated on the out-of-state or National Registry certification or 

two (2) years from the date of completion of the National Registry written exam, but shall not 

exceed two (2) years from the effective date. For applicants with a California Paramedic license,



POLICY #: 1 

PAGE: 2 of 4 

the EMT certification expiration date shall be the same date as the expiration of their Paramedic 

license. This certification is valid throughout the State of California. 

C. The following requirements apply to a current and valid out-of-state EMT certificate: 



3. Provide documentation of current and valid out-of-state EMT certificate. 

4. Complete a Contra Costa County EMT-I certification application.* 








an individual shall be certified as an Emergency Medical Technician for a period of two (2) years 

from the date of successful completion of the National Registry written exam. This certification is 

valid throughout the State of California. 

D. An individual currently licensed in California as a Paramedic or currently certified in California as 

an Advanced EMT or EMT is deemed to be certified as an EMT, except when the paramedic 

license or Advanced EMT certification is under suspension. 

E. Certification cards will be mailed to applicants following verification of documentation submitted 

with application. 

III. MAINTAINING CERTIFICATION 

A. To maintain certification, all candidates shall meet the following requirements and provide 

documentation to the EMS Agency: 

1. Possess a valid and current EMT certificate issued in California. 

2. Successfully complete an approved EMT twenty four (24) hour refresher course within the 

two (2) year certification period or provide documentation verifying completion of a minimum 

of twenty four (24) hours of approved BLS continuing education within the two (2) year 

certification period. 

3. Submit a completed skills competency verification form (EMSA-SCV 07/03).* 

4. Complete a Contra Costa County EMT recertification application.* 



background check, if not already on file with the Contra Costa EMS Agency.* 

7. Pay the established Contra Costa certification application fee and the applicable State EMT 

Registry fee. 



an individual shall be recertified as an Emergency Medical Technician. If the recertification 

requirements are met within six (6) months prior to the current expiration date, the effective date 

of the certification shall be the expiration date of the current certification and the expiration date 

shall be the final day of the final month of the two (2) year period. If the recertification 

requirements are met greater than six (6) months prior to the current expiration date, the



POLICY #: 1 

PAGE: 3 of 4 

effective date shall be the date all certification requirements are completed and the expiration 

date shall be the final day of the final month of the two (2) year period. 

B. Certification cards will be mailed to applicants following verification of documentation submitted 


IV. EXPIRATION WHILE ON ACTIVE DUTY IN MILITARY 

EMT certification expirations while on active duty or within six (6) months from the date released 

from active duty will be processed according to State EMT regulations, Title 22, Division 9, Chapter 

2, Article 5, section 100080(k). 

V. RECERTIFICATION AFTER LAPSE IN CERTIFICATION 

A. All candidates for EMT recertification whose EMT certificate has lapsed shall meet the following 

requirements: 

1. For a lapse of less than six (6) months: 

a) Provide a copy of the expired certificate. 

b) Successfully complete an approved EMT twenty four (24) hour refresher course 

within the prior two (2) year period or provide documentation verifying completion of 

a minimum 24 four (24) hours of approved BLS continuing education within the prior 

two (2) year period. 

c) Submit a completed skills competency verification form (EMSA-SCV 07/03).* 

d) Complete a Contra Costa County EMT certification application.* 

e) Complete a Department of Justice Criminal Offender Record Information (CORI) 


f) Provide a current photo ID (CA drivers license, CA ID card or passport). 

g) Pay the established Contra Costa recertification application fee and the applicable 

State EMT Registry fee. 

2. For a lapse of six (6) months or more, but less than twelve (12) months: 

a) Provide a copy of the expired certificate. 

b) Successfully complete an approved EMT twenty four (24) hour refresher course with 

the prior two (2) year period or provide documentation verifying completion of a 

minimum of twenty four (24) hours of approved BLS continuing education within the 

prior two (2) year period. 

c) Provide documentation of an additional twelve (12) hours of continuing education for a 

total of thirty six (36) hours. 

d) Submit a completed skills competency verification form (EMSA-SCV 07/03). 

e) Complete a Contra Costa County EMT certification application.* 

f) Complete a Department of Justice Criminal Offender Record Information (CORI) 


g) Provide a current photo ID (CA drivers license, CA ID card or passport). 

h) Pay the established Contra Costa recertification application fee and the applicable 


3. For a lapse of twelve (12) months or more, but less than twenty four (24) months: 

a) Provide a copy of the expired certificate or license.



POLICY #: 1 

PAGE: 4 of 4 

b) Successfully complete an approved EMT twenty four (24) hour refresher course with 

the prior two (2) year period or provide documentation verifying completion of a 

minimum of twenty four (24) hours of approved BLS continuing education within the 

prior two (2) year period. 

c) Provide documentation of an additional twelve (24) hours of continuing education for 

a total of forty eight (48) hours. 

d) Provide documentation of successful completion of the National Registry of 

Emergency Medical Technicians (NREMT) written and skills exams within the past 

two (2) years. 

e) Submit a completed skills competency verification form (EMSA-SVC 07/03).* 

f) Complete a Contra Costa County EMT certification application.* 

g) Complete a Department of Justice Criminal Offender Record Information (CORI) 


h) Provide a current photo ID (CA drivers license, CA ID card or passport). 

i) Pay the established Contra Costa recertification application fee and the applicable 


4. For a lapse of twenty four (24) months or more, complete an entire EMT basic course. 

B. Upon completion of #1, 2, 3 or 4 above, and confirmation that the applicant is not precluded 

from certification for reasons defined in Section 1798.200 of the California Health and Safety 

Code, an individual shall be recertified as an Emergency Medical Technician. The effective date 

of certification shall be the date all certification requirements are completed and the expiration 

date shall be the final day of the final month of the two (2) year period, except for those 

individuals that are required to pass the written and skills certifying exam, the expiration date 

shall be the last day of the final month of the two (2) year period following the date of passing 

the written exam. 

C. Certification cards will be mailed to applicants following verification of documentation submitted 


*Available at the Contra Costa County EMS Agency or on the website: www.cccems.org



PARAMEDIC ACCREDITATION 

I. PURPOSE 

To identify the process for paramedic accreditation in Contra Costa County. 

II. ACCREDITATION 

A. All candidates shall meet the following accreditation requirements: 

1) Possess a current California paramedic license. 

POLICY #: 2 

PAGE: 1 of 1 



2) Be employed as a paramedic with a designated ALS service provider or the EMS Agency. 

3) Attend a Contra Costa EMS Orientation provided by the provider agency and approved by 

the EMS Agency or provided by the EMS Agency. 

4) Successfully complete the Contra Costa County EMS Optional Scope Skills Session 

provided by the provider agency. 

5) Complete an application form, available online or at the provider agency or the EMS 

Agency. 

B. Documentation that the accreditation requirements have been met must be submitted to the 

EMS Agency, by the applicant’s employer, with the candidate’s application and accreditation 

fee. 

The EMS Agency shall notify individuals applying for accreditation of the decision to 

accredit within thirty (30) days of application. 

III. MAINTAINING ACCREDITATION 

A. Accreditation to practice shall be continuous as long as: 

1) State licensure is maintained, 

2) Employment as a paramedic with a designated Contra Costa ALS service provider or the 

EMS Agency is maintained, 

3) A current and valid ACLS card, according to the standards of the American Heart 

Association is maintained, 

4) Verification of skills competency is completed every two years, and 

5) Any other local requirements are met. 

B. Documentation that the above requirements to maintain accreditation have been met must be 

submitted by the applicant or the applicant’s employer prior to expiration of the paramedic’s 

license.



MICN AUTHORIZATION AND REAUTHORIZATION 

I. PURPOSE 

POLICY #: 3 

PAGE: 1 of 2 



To identify the process for Mobile Intensive Care Nurse (MICN) authorization in Contra Costa County. 

II. AUTHORIZATION 

All candidates shall meet the following authorization requirements: 

A. Prerequisite Criteria (Documentation that these criteria have been met must be submitted with 

the candidate's application for authorization.) 

1. Provide documentation of valid and current licensure as a Registered Nurse in the State of 

California. 

2. Provide documentation of a valid, current ACLS card according to the standards of the 

American Heart Association. (ACLS certification must be renewed at least every two (2) 

years.) 

3. Provide documentation of a minimum of twelve (12) months critical care experience as a 

Registered Nurse in an acute care hospital acquired within the past three (3) years, 

including six (6) months of emergency department experience acquired within the past 

one (1) year. 

4. Provide evidence of successful completion of a Contra Costa EMS approved Mobile 

Intensive Care Nurse (MICN) course within the previous twelve (12) months. 

A waiver of course completion may be obtained if the applicant provides documentation of 

current or previous (within one year) authorization (or certification) as a Mobile Intensive 

Care Nurse (or "Authorized Registered Nurse") in another California EMS system. Upon 

submission of application to EMS, the applicant’s duration of prior experience and nature 

of base station function will be assessed to determine whether waiver of an approved 

EMS course is appropriate. 

5. The candidate will complete and provide documentation of a ground-based paramedic 

staffed emergency response vehicle observation experience in Contra Costa County, 

consisting of eight (8) hours of observation or direct observation of at least 4 (four) patient 

contacts in which the patient is assessed. 

B. Complete the County MICN application form and submit it to the County EMS Agency. 

C. Provide proof of current employment: 

1. within the emergency department of a Contra Costa County designated base hospital; 

2. as an instructor in an ALS training program approved by the Contra Costa County EMS 

Medical Director, or; 

3. by the Contra Costa County EMS Agency. 

D. Satisfactorily complete at least ten (10) proctored ALS radio calls. 

E. Attend an orientation session held by the Contra Costa County EMS Agency. 

F. Upon successful completion of (A) through (E) above, the County EMS Agency shall authorize 

the candidate as a base hospital MICN for a period of two (2) years from the last day of the 

month in which the candidate successfully completed the authorization requirements. Such 

authorization shall be contingent upon the candidate's continued employment as described in 

section I D. of this policy.



POLICY #: 3 

PAGE: 2 of 2 

Candidates failing to successfully complete the authorization process within twelve (12) months from 

their initial application submission date must repeat the entire authorization process. 

Any of the above requirements for authorization may be modified or waived by the Contra Costa EMS 

Medical Director upon his/her discretion. 

III. REAUTHORIZATION 

All reauthorization candidates shall meet the following requirements and provide documentation to the 

County EMS Agency: 

A. Complete the County MICN application form. 

B. Provide documentation of valid and current licensure as a Registered Nurse in the State of 

California. 

C. Provide documentation of a valid and current ACLS card according to the standards of the 

American Heart Association (ACLS certification must be renewed at least every two (2) years). 

D. Provide documentation of current employment as outlined in section II D. 

E. Provide documentation of required continuing education within the current two (2) year 

authorization period as follows: 

1. Obtain a minimum of twelve (12) hours of continuing education as defined below. 

a. Didactic: Formal education relating specifically to prehospital care. This may be 

utilized for up to six (6) hours of the minimum 12-hour continuing education 

requirement. 

b. Chart review: Participate in formal review of patient care records as part of an 

approved quality improvement program. One (1) hour of credit will be provided for 

review of 12 patient care records (PCRs), as arranged for and verified by the base 

coordinator. 

c. Tape review: Review of eight (8) audio tape contacts that meet "ALS Patient 

Contact" criteria, as defined in Section 100159(b) of the EMT-P Regulations. One 

(1) hour care of credit will be given for this activity, and may be utilized for up to two 

(2) hours of the 12 hour continuing education requirement. This shall be prearranged 

and verified with the MICN’s base hospital coordinator. 

d. Self-learning modules: Completion of self-learning modules, as approved by and 

verified by the base coordinator. This may be utilized for up to four (4) hours of the 

12-hour continuing education requirement. 

e. Base hospital coordinators are exempt from the requirements found in section III.F.1 

of this policy. 

F. Upon fulfillment of (A) through (E) above, the County EMS Agency shall reauthorize the 

candidate as an MICN for a period of two (2) years from the expiration date on the candidate's 

current authorization card. 

Any of the above requirements for reauthorization may be modified or waived by the EMS Medical 

Director upon his/her discretion.



CONTRA COSTA COUNTY EMS FEE STRUCTURE 

POLICY #: 4 

PAGE: 1 of 1 

EFFECTIVE: 01/13 

REVIEWED: 12/12 

I. PURPOSE 

To outline the fee structure for various programs administered by Contra Costa County EMS. 

II. FEES are not refundable. Cashier check or money order only made payable to Contra Costa 

Health Services - cash and personal checks will NOT be accepted. 

EMT-I Initial Certification ($60 1 local fee/$75 State Registry Fee) 

EMT-I Re-certification ($60 1 local fee/$37 State Registry Fee) 

Replacement Card (if lost/stolen/damaged) 

$135 Application Fee 

$97 Application Fee 

$10 Fee 

Paramedic Accreditation $60 Application Fee 

MICN Authorization/Re-authorization $60 Application Fee 

Continuing Education (CE) Provider Authorization/Re-authorization – 

Four-year approval 

EMT Training Program – 4-year approval 

(public safety agencies, community colleges pay 50% of fee) 

Paramedic Training Program – 4-year approval 

(public safety agencies, community colleges pay 50% of fee) 

Non-Emergency Ambulance Service Permit 

Three-year county-wide permit 

Emergency Ambulance Service Permit 

Three-year permit per Emergency Response Area (ERA) 

$2,000 2 Fee 

$3,000 Fee 

$12,000 Fee 

$7,500 Fee 

EMS Aircraft Classification $250 Fee 

Non-Emergency Paramedic Transfer Program 

A. Yearly fee 

B. Fee per transfer 

III. DESIGNATION FEES (as specified by contracts) 

$7,500 Fee per ERA 

$3,000 Fee 

$50 Fee 

STEMI Center Designation $5,000 Annual Fee 

Stroke Center Designation $5,000 Annual Fee 

EMS Aircraft Authorization 

(fee reduced by 50% for compliance with written authorization agreement) 

$15,000 Biennial Fee 

1 Fee waived for volunteer and reserve fire personnel affiliated with a public fire agency located within Contra Costa County 

2 

Fee may be waived for providers offering all courses at no charge to participants or public safety agencies offering courses 

to “in-house” employees only.



PREHOSPITAL CREDENTIAL REVIEW PROCESS 

POLICY #: 5 

PAGE: 1 of 1 



Any proceedings by the EMS Agency to deny, suspend or revoke an EMT-I certification or 

MICN authorization, or place any EMT-I or MICN certificate holder on probation pursuant to 

Section 1798.200 of the Health and Safety Code shall be conducted in accordance with 

California Code of Regulations, Title 22, Division 9, Chapter 6. 

I. EMT-1 

Negative action against any EMT or Advanced EMT certificate may be instituted by the EMS 

Medical Director based upon the finding of an imminent threat to the public health and safety 

as evidenced by the occurrence of any of the items listed in Health and Safety Code, Division 

2.5, Chapter 7, Section 1798.200(c). 

All investigations and disciplinary actions shall be conducted in accordance with Health and 

Safety Code, Title 22, Division 9, Chapter 6 and Chapter 5 (commencing with Section 11500) 

of Part 1 of Division 3 of Title 2 of the Government Code. 

II. EMERGENCY MEDICAL TECHNICIAN – PARAMEDIC (EMT-P) 

Paramedic licensure actions (e.g., immediate suspension) shall be performed according to 

the California Health and Safety Code 1798.202. 

III. MICN 

Negative action against any MICN authorization may be instituted by the EMS Medical 

Director based upon the finding of an imminent threat to the public health and safety as 

evidenced by the occurrence of any of the items listed in Health and Safety Code, Division 

2.5, Chapter 7, Section 1798.200(c). 

If at any time during the review or investigation, the Medical Director determines that the facts 

support placing a certificate holder on probation or denying, suspending or revoking an 

authorization, the Medical Director may convene an investigative review panel (IRP). The IRP 

will assess all information on the matter in order to establish the facts of the case and make a 

written report of its findings and recommendations to the Medical Director. 

III. BASE HOSPITAL OR PROVIDER AGENCY REPORTING OF EMS EVENTS 

In compliance with Policy #32 EMS Event Reporting, EMS events (patient/provider safety 

events) involving EMS personnel, which may constitute a threat under California Health and 

Safety Code section 1798.200 (listed on the back of each EMS Event Report Form), should 

be reported to the County EMS Agency. If this report is made by telephone, a written EMS 

Event Report Form should be submitted within 72 hours. EMS Event reporting forms are 

available at www.cccems.org. 

If, in the judgment of the Base Hospital Liaison Physician, or other physician designee-, 

immediate action must be taken by the EMS Agency after normal business hours to protect 

the public health and safety, the On-Call Health Officer may be contacted through the 

Sheriff's Dispatch Center. Call Sheriff's Dispatch at 646-2441 to contact the On-Call Health 

Officer.



PREHOSPITAL CONTINUING EDUCATION 

PROVIDER 

POLICY #: 6 

PAGE: 1 of 1 



I. PURPOSE 

To outline the process for approval of prehospital continuing education (CE) providers in Contra Costa 

County. The California Code of Regulations authorize local EMS Agencies to approve ALS and BLS 

prehospital continuing education (CE) providers. Approved CE providers shall approve individual 

courses, assign course identification numbers, and specify the category, number of hours, and level of 

training, for each course authorized. 

II. PROCEDURE FOR APPROVAL AS CE PROVIDER 

A. Submit the following to the EMS Agency: 

1. completed Continuing Education Provider Application, 

2. documentation demonstrating Program Director and Clinical Director experience and 

qualifications in prehospital care/education as outlined in Title 22, Division 9, Chapter 11, 

Article 6, section100395(g) and (i), 

3. sample course completion certificate, containing information listed in Title 22, Division 9, 

Chapter 11, Article 6, section 100395 (m) of the California Code of Regulations, 

4. other course information requested by EMS Agency. 

B. Approval shall be good for four (4) years from the last day of the month in which the application 

is approved. It shall be the responsibility of the CE provider to submit an application for renewal 

at least sixty (60) days in advance of the expiration date, in order to maintain continuous 

approval. 

CE providers shall ensure that each continuing education activity or course meets the criteria outlined 

in the California Code of Regulations, Title 22, Division 9, Chapter 11. 

All records shall be available to the EMS Agency upon request, or during scheduled or unscheduled 

sit visits by EMS Agency staff. 

The EMS Agency shall be notified in writing within thirty (30) days, of any change in CE provider 

name, address, telephone number, program director or clinical director.



PARAMEDIC EVALUATOR 

POLICY #: 7 

PAGE: 1 of 1 



I. PURPOSE 

To define the qualifications, selection process and maintenance requirements for a 

paramedic evaluator in Contra Costa County. 

II. DEFINITIONS 

A paramedic evaluator is a paramedic currently employed in Contra Costa County to provide 

supervision and evaluation of California State licensed paramedics in Contra Costa County. 

III. REQUIREMENTS/QUALIFICATIONS 

A. Paramedic Evaluator 

1. Minimum of two (2) years full-time experience as a paramedic for a 9-1-1 ALS 

provider; 

2. Minimum of one (1) year current field experience in Contra Costa County; 

3. Paramedic licensure/accreditation current and in good standing; 

4. Absence of pertinent and/or ongoing QI issues; and 

5. Demonstrated professional attitude, appearance and manner of dealing with people. 

IV. SELECTION PROCESS 

A. Paramedic evaluator candidates will be identified by their agency. 

B. All paramedic evaluators shall complete a Paramedic Evaluator Orientation. 

Paramedic Evaluator Orientation Curriculum should adhere to educational standards 

and preparation established by the Contra Costa Fire EMS Training Consortium. 

C. The EMS Agency shall be notified of paramedic evaluator candidates who have 

successfully completed an appropriate orientation program. 

V. MAINTENANCE 

A. To maintain Paramedic Evaluator status all evaluators shall: 

1. Maintain current state paramedic licensure and Contra Costa County accreditation in 

good standing. 

2. Have no patient care/operational issues requiring remediation. 

3. Attend paramedic evaluator updates. 

B. The Contra Costa County EMS Medical Director may withdraw approval to function as a 

paramedic evaluator at any time.



EMS QUALITY IMPROVEMENT PROGRAM (EQIP) 

I. PURPOSE 

POLICY #: 8 

PAGE: 1 of 1 



To identify primary responsibilities of all participants in the Contra Costa County EMS Quality 

Improvement Program (EQIP) and to ensure optimal quality of care for all patients who access the 

EMS system. 

II. DEFINITION 

EMS Quality Improvement Program: An integrated, multidisciplinary program that focuses on system 

improvement. Methods of evaluation are composed of structure, process and outcome 

measurements. 

III. REQUIREMENTS 

A. EQIP includes all Contra Costa County prehospital care providers participating at the level as 

agreed between the agency and Contra Costa EMS. 

B. EQIP indicators will be compliant with the California Code of Regulations, Title XXII, Division 9, 

Chapter 12 and modeled after the State of California Emergency Medical Services Authority 

(EMSA) Publication: Emergency Medical Services System Quality Improvement Program Model 

Guidelines. 

C. The oversight for the EQIP will be the responsibility of the EMS Medical Director with advice 

from stakeholders participating on the Prehospital Quality Improvement Committee. 

D. Appropriate QI indicators shall be reviewed at the agency level on a monthly basis and a report 

of findings shall be made to the Contra Costa EMS Agency at agreed upon intervals. Aggregate 

data for the EMS System will be maintained by the Contra Costa County EMS Agency. 

E. Each Prehospital provider agency shall submit an annual report of quality improvement activities 

to the Contra Costa County EMS Agency. 

F. The Contra Costa County EMS Agency shall provide an annual report of quality improvement 

activities to the California EMS Authority. This information may be incorporated as part of the 

Contra Costa County Emergency Medical Services Agency Annual Report Report. 

G. All proceedings, documents and discussions of the Prehospital Quality Improvement Committee 

are confidential pursuant to section 1157.7 of the Evidence Code of the State of California. 

1. Each member of the Prehospital Quality Improvement Committee shall sign a 

confidentially agreement. 

2. Each agency shall maintain all records in a confidential manner consistent with current 

patient privacy laws (HIPPAA).



PATIENT DESTINATION DETERMINATION 

POLICY #: 9 

PAGE: 1 of 4 


REVIEWED: 07/05/2011 

I. PURPOSE 

To determine the appropriate receiving facility for patients transported by ground ambulance. 

II. POLICY 

A. A patient, transported as part of an EMS response, shall be taken to the most appropriate acute 

care hospital staffed and equipped to provide care appropriate to the needs of the patient. 

B. County boundaries are not a consideration in determining the appropriate receiving hospital. 

C. Field transport personnel are responsible for making transport code decisions. 

III. PROCEDURE 

Field personnel shall assess a patient to determine if the patient is unstable or stable. Patient stability 

must be considered along with a number of additional factors in making destination and transport 

code decisions. Additional factors to be considered include: 

Patient or family’s choice of receiving hospital and ETA to that facility. 

Recommendations from a physician familiar with the patient’s current condition. 

Patient’s regular source of hospitalization or health care. 

Ability of field personnel to provide field stabilization or emergency intervention. 

ETA to the closest basic emergency department. 

Traffic conditions. 

Hospitals with special resources. 

Hospital diversion status. 

A. Unstable Patients 

1. An unstable patient is usually transported to the closest appropriate acute care hospital 

emergency department. 

2. If the patient or family requests, or if other factors exist which indicate that another facility 

be considered, field personnel are to contact the base hospital and present their findings, 

including ETAs to both facilities. Base personnel will weigh the benefits of each destination 

and may direct field personnel to a facility other than the closest. 

3. Trauma and STEMI patients should be transported in accordance with the appropriate 

County trauma or STEMI protocols. 

4. Unstable patients are usually transported Code 3 unless contraindicated for medical 

reasons. 

B. Stable Patients 

1. Stable patients are transported to appropriate acute care hospitals within reasonable 

transport times based on patient’s/family preference. 

2. If a patient does not express a preference, the hospital where the patient normally 

receives health care or the closest ED is to be considered.



POLICY #: 9 

PAGE: 2 of 4 

C. Patients on 5150 Holds 

1. Police or other designated individuals may place a person who, as a result of a mental 

disorder is a danger to self, to others, or is gravely disabled on a “5150” involuntary hold. 

This involuntary hold is an application for detention for up to 72 hours for the purpose of 

psychiatric evaluation and treatment. 

2. A patient placed on a 5150 hold in the field shall be assessed for the presence of a 

medical emergency. Based upon the history and physical examination of the patient, field 

personnel shall determine whether the patient is stable or unstable. 

3. Medically stable patients on 5150 holds shall be transported to Contra Costa Regional 

Medical Center. 

4. Medically unstable patients on 5150 holds shall be transported to the closest acute care 

hospital. 

a. A patient with a current history of overdose of medications is to be considered 

unstable. 

b. A patient with history of ingestion of alcohol or illicit street drugs is considered 

unstable if there is any of the following: 

1) Significant alteration in mental status (e.g., decreased level of consciousness 

or extremely agitated). 

2) Significantly abnormal vital signs. 

3) Any other history or physical findings that suggest instability (e.g. chest pain, 

shortness of breath, hypotension, diaphoresis). 

D. Obstetrical Patients 

1. A patient is considered “Obstetric” if pregnancy is estimated to be of 20 weeks duration or 

more. 

2. Obstetric patients should be transported to acute care hospitals with in-patient obstetrical 

services in the following circumstances: 

a. Patients in labor. 

b. Patients whose chief complaint appears to be related to the pregnancy, or who 

potentially have complications related to the pregnancy. 

c. Injured patients who do not meet trauma criteria or guidelines. 

3. In-patient obstetrical services are provided by all acute care hospitals in Contra Costa 

County with the exception of Doctor’s Medical Center in San Pablo, Kaiser Medical Center 

in Richmond and John Muir Health – Concord Campus. 

Other nearby Approved Ambulance Receiving Facilities in western Contra Costa include: 

Alta Bates in Berkeley, Kaiser Medical Center in Oakland, Sutter Solano Medical Center in 

Vallejo and Kaiser Medical Center in Vallejo. 

4. Obstetric patients meeting trauma criteria are to be transported to adult trauma centers. 

5. Obstetric patients with impending delivery or unstable conditions where imminent 

treatment appears necessary to preserve the mother’s life should be transported to the 

nearest basic emergency department. 

6. Stable obstetric patients should be transported to the emergency department of choice if 

their complaints are clearly unrelated to pregnancy. 

7. The base hospital is available to provide guidance in situations in which the appropriate 

choice of receiving facility is unclear to transport personnel.



POLICY #: 9 

PAGE: 3 of 4 

E. Patients With Burns 

1. Hospital Selection 

a. Burned patients with unmanageable airways should be transported to the closest 

basic ED. 

b. Patients with minor burns and moderate burns can be cared for at any acute care 

hospital. 

c. Adult and pediatric patients with burns and significant trauma should be transported 

to the closest appropriate trauma centers. 

d. Patients with more extensive or complex burns may be appropriate for transport 

directly to a Burn Center including: 

1) Partial thickness (2 nd degree)>20% TBSA 

2) Full thickness (3 rd degree)> 10% 

3) Significant burns to the face, hands, feet, genitalia, perineum, or 

circumferential burns of the torso or extremities 

4) Chemical or high voltage electrical burns 

5) Smoke inhalation with external burns 

2. Procedure for Burn Center destination 

a. Contact Burn Center prior to transport to confirm bed availability. 

b. Consult base hospital for any questions regarding destination decision. 

c. If air transport to UC David Medical Center or Santa Clara Valley Medical Center is 

not available, base contact is advised. 

d. The closest available Burn Centers are: 

Hospital Services Phone 

Santa Clara Valley Medical Center 

751 S. Bascom Avenue 

San Jose, California 

UC Davis Medical Center – Regional Burn Center 

2315 Stockton Blvd. 

Sacramento, California 

St. Francis Burn Center 

900 Hyde Street 

San Francisco, California 

Adult and Pediatric 408-885-6666 



F. Hospital Diversion 

1. CT Diversion 

a. A hospital goes on CT Diversion when it does not have an operational CT scanner. 

The following patients should not be transported to a facility on “CT Diversion,” but 

should be transported to the next closest appropriate ED with a functioning CT 

scanner. 

1) Suspected stroke – duration of signs and symptoms four hours or less. 

Symptoms might include sudden onset of weakness, paralysis, confusion, 

speech disturbances, visual field deficit and may be associated with a 

headache.



POLICY #: 9 

PAGE: 4 of 4 

2) New onset of altered level of consciousness for traumatic or medical reasons. 

b. Most patients meeting the above criteria should be transported to the next closest 

appropriate ED with a functioning CT scanner. 

c. CT Diversion Exceptions 

1) Patients with unstable airways, uncontrolled bleeding, or in cardiac arrest 

should be transported to the nearest ED regardless of CT diversion status. 

2) Patients requesting transport to a hospital on CT diversion have the right to be 

transported to that hospital. These patients should be told: 

a) That the hospital of choice has an inoperative CT scanner and has 

requested that patients that may need this service be transported to 

another facility to assure availability of the necessary level of care. 

b) That transport to a hospital with an inoperative CT scanner might result 

in a delay of care and/or a transfer to another facility. 

2. Internal Disaster (INT) Diversion 

If notified that a hospital is on Internal disaster diversion, transport units should determine 

the appropriate destination for the patient as identified in this policy while eliminating the 

hospital on diversion from consideration. 

3. STEMI Diversion 

If notified that a hospital is on STEMI/Inoperative Cardiac Cath Lab diversion, transport 

units should determine the appropriate destination for the patient as identified in the 

STEMI triage and destination policy (EMS Policy #25) while eliminating the hospital on 

diversion from consideration.



DECLINING EMERGENCY MEDICAL CARE 

AND/OR TRANSPORT 

POLICY #: 10 

PAGE: 1 of 2 



I. PURPOSE 

To provide guidance to prehospital personnel in situations where the patient, or his/her legal 

representative, declines medical care or transport when care is recommended and felt to be 

necessary by the prehospital personnel attending that patient. All qualified persons are permitted to 

make decisions affecting his/her care, including the ability to decline care. 


A. Patient: Any person encountered by prehospital personnel who demonstrates any known or 

suspected illness or injury OR is involved in an event with significant mechanism that could 

cause illness or injury OR who requests care or evaluation. 

B. Competency: The ability to understand and to demonstrate an understanding of the nature of 

the illness/injury and the consequence of declining medical care. 

C. Qualified Person: A competent person making a decision for him/herself or another who is 

qualified by one of the following: 

1. An adult patient defined as a person who is at least 18 years old; 

2. A minor (under 18 years old) who qualifies based on one of the following conditions: 

A legally married minor; 

A minor on active duty with the armed forces; 

A minor seeking prevention or treatment of pregnancy or treatment related to sexual 

assault; 

A minor, 12 years of age or older, seeking treatment of contact with an infectious, 

contagious or communicable disease or sexually transmitted disease; 

A self-sufficient minor at least 15 years of age, living apart from parents and managing 

his/her own financial affairs; 

An emancipated minor (must show proof); OR, 

3. The parent of a minor child or a legal representative of the patient (of any age). Spouses 

or relatives cannot consent to or decline care for the patient unless they are legally 

designated representatives. 

III. PATIENT EVALUATION 

A. All potential patients encountered in the prehospital setting must be offered medical 

care/transport. 

B. Patients should be evaluated as much as capable and allowed. 

C. Qualified persons as defined above have the legal right to decline care or transportation. 

D. Qualified persons may limit the scope of their consent (e.g. may consent to transportation but 

not treatment, or consent only to certain treatments). 

E. Every reasonable attempt should be made to convince a patient or legal representative of the 

need for further medical evaluation and treatment, and he/she should be informed clearly of the 

risks and consequences of declining care. Resources to aid in the effort include family members 

and friends, law enforcement, and base hospital personnel. 

F. Prehospital personnel should not put themselves in danger by attempting to treat or transport 

patients who do not meet qualifications to decline care (not competent to decline care or not



POLICY #: 10 

PAGE: 2 of 2 

qualified to decline). Assistance from support agencies in appropriate circumstances should be 

utilized. 

IV. BASE CONTACT REQUIREMENTS 

A. Base contact is required: 

1. When, in the prehospital personnel’s opinion, the patient’s decision to decline care poses 

a threat to his/her well being. 

2. If the patient’s competency status is unclear (neither competent nor clearly incompetent) 

and treatment or transport is felt to be appropriate. 

3. Any other situation in which, in the prehospital personnel’s opinion, base contact would be 

beneficial in resolving treatment or transport issues. 

B. Patients in law enforcement custody or under 5150 hold do not require consent for 

transportation and base contact is not required in these circumstances. Patients in custody or 

under a 5150 hold may decline treatment. 

V. DOCUMENTATION 

Documentation requirements are outlined in Policy 27 – “Patient Care Record.”



BASE HOSPITAL COMMUNICATIONS/ 

DISRUPTED COMMUNICATIONS 

POLICY #: 11 

PAGE: 1 of 1 



I. PURPOSE 

A. To define the role of the base hospital. 

B. To define the procedure when base contact is required and communication is disrupted. 

II. BASE HOSPITAL ROLE 

A. Contra Costa EMS Policies and Procedures, including the Prehospital Care Manual, are the 

guidance documents that direct the actions of prehospital personnel. The base hospital is 

available at all times to provide additional medical direction and advice. Base contact may 

be necessary to address any of the following issues: 

1. Base hospital orders for medical care as required by Field Treatment Guidelines; 

2. Base hospital orders for care not outlined in the Field Treatment Guidelines; 

3. Patient destination concerns; 

4. Determination of death or cessation of resuscitative efforts; 

5. Other policy concerns that may need additional input and guidance (e.g. patient refusal 

of care, physician on scene). 

B. Emergency medical care personnel are encouraged to contact the base hospital if they have 

any questions regarding patient treatment or disposition. 

III. DISRUPTED COMMUNICATION 

When a paramedic is directed by a field treatment guideline to contact the base hospital and 

he/she is unable to establish or maintain base contact and determines that a delay in treatment 

may jeopardize the patient, the paramedic may initiate indicated ALS care as specified in the 

Field Treatment Guidelines until base contact can be established or until the patient is delivered 

to the closest appropriate receiving facility. The paramedic shall transport the patient as soon as 

possible while providing necessary treatment en route. 

If ALS procedures normally requiring base contact are performed under disrupted 

communications, the paramedic shall: 

A. Immediately following delivery of the patient to the receiving hospital: 

1. Complete the PCR documenting the ALS skills performed; 

2. Notify, or request that the agency dispatcher notifies Sheriff’s Dispatch of the 

communication problem, if the paramedic suspects that any radio problem was due to a 

situation other than location. 

B. Within 24 hours, send a copy of the completed PCR and a written report explaining the 

reason(s) or suspected reason(s) for communication failure to the paramedic provider 

agency QI coordinator. 

C. The paramedic provider agency QI coordinator shall evaluate paramedic reports and submit 

reports on a quarterly basis to the Emergency Medical Services Agency. The paramedic 

shall be prepared to demonstrate that the treatment delivered was appropriate.



EMS SYSTEM MEDICAL DIRECTION AND 

OVERSIGHT 

POLICY #: 12 

PAGE: 1 of 2 



I. PURPOSE 

Emergency medical services rendered by Contra Costa County EMS system provider agencies, both 

emergency and non-emergency, are accomplished under the medical direction of the EMS Medical 

Director. This policy defines the scope of medical direction and oversight provided in the EMS system. 

II. SCOPE OF OVERSIGHT AND DIRECTION 

Medical direction applies to all events involving emergency medical care for patients from the initial 

request for service to the delivery of patients to receiving facilities. Dispatch, first response, transport 

provider care and base hospital direction fall under the auspices of the EMS Medical Director or 

his/her designee. In addition to emergency and non-emergency scene responses, medical direction 

also applies to paramedic (and in some situations to EMT-I) interfacility transports. 

Medical direction is provided prospectively through written policies and procedures, approved by the 

EMS Medical Director, and immediately through on-line communications with the base hospital. 

Oversight is also provided retrospectively through quality improvement activities and continuing 

education of providers. 

Medical direction also includes oversight of EMS personnel credentialed by the county. These include 

EMTs, paramedics, and base station MICNs. 

III. PROSPECTIVE, IMMEDIATE, AND RETROSPECTIVE MEDICAL DIRECTION AND OVERSIGHT 

Below is a listing of examples that describe individual facets of prospective, immediate, and 

retrospective medical direction and oversight. This list is not all-inclusive. 

Prospective medical direction and oversight: 

Credentialing of EMT, paramedic and MICN personnel; 

Designation of continuing education and prehospital training program providers; 

Designation of base hospitals and trauma center; 

Review and approval of medical dispatch protocols, including pre-arrival and post-dispatch 

instructions; 

Provision of the Prehospital Care Manual, which guides EMTs, paramedics, and MICNs in the 

care provided in the field; 

Continuing education activities; 

Provision of the Multicasualty Incident Plan; 

EMS Agency policies. 

Immediate (concurrent) medical direction and oversight: 

Provision for guidance by MICNs following treatment guidelines from the Prehospital Care 

Manual; 

Provision for guidance by base hospital physicians (including situations defined in the 

Prehospital Care Manual); 

Provision for guidance by base MICNs and physicians concerning interfacility transfers with 

regard to scope issues for EMT and paramedic personnel. 

Retrospective medical direction and oversight: 

Quality assurance and improvement activities, coordinated at the EMS Agency level; 

Specific incident review and action by base station and EMS Agency personnel; 

Continuing education prompted by QI data review.



POLICY #: 12 

PAGE: 2 of 2 

IV. INPUT AND MODIFICATION OF MEDICAL DIRECTION 

System participants, including provider agencies and personnel, participate in regular meetings of the 

Medical Advisory Committee (MAC). This committee is open to the public for input. Requests for 

changes in treatment guidelines or policy and procedure changes that impact medical care are 

discussed and recommendations are made. The recommendations of MAC are advisory to the EMS 

Medical Director and the EMS Director. Formal requests for changes are to be made in writing to the 

EMS Medical Director. 

Proposals for utilization of paramedic personnel in settings other than 9-1-1 ground response (e.g. 

bicycle-based units, aircraft-based paramedics) must be submitted to the EMS Medical Director and 

EMS Director for review and authorization. Any approval must include policies and procedures that 

maintain prospective, immediate, and retrospective medical direction and oversight of paramedic 

personnel. 

V. OPTIONAL SCOPE PROCEDURES AND MEDICATIONS 

Most procedures or medications outside of the basic scope of practice require additional 

authorization from the EMS Medical Director and Emergency Medical Services Authority. 

Proposals for optional procedures, medications or trial studies shall be submitted to the EMS 

Medical Director for consideration as part of the treatment guidelines, policy and procedure 

update process. 

The EMS Medical Director is responsible for submission of requests for optional scope 

procedures and medications and for trial studies to the Emergency Medical Services Authority.



TRIAGE OF TRAUMA PATIENTS 

POLICY #: 13 

PAGE: 1 of 5 



I. PURPOSE 

Trauma triage directs trauma patients to appropriate medical facilities for definitive care. The goal of 

triage is to identify critically injured patients who need rapid surgical intervention or the specialized 

services of the trauma center. 


Base Hospital: John Muir Medical Center – Walnut Creek Campus is the designated base hospital for 

Contra Costa County. 

Adult Patients: Adult trauma patients are 15 years of age and older. 

Pediatric Patients: Pediatric trauma patients are ages 0 up to 14 years and 364 days. 

Adult Trauma Center: The most appropriate trauma center for adults is John Muir Medical Center – 

Walnut Creek Campus. 

Pediatric Trauma Center: The most appropriate trauma center for pediatric patients is Children’s 

Hospital, Oakland if transport can be made in less than 30 minutes. 

High-Risk Criteria: Symptoms and mechanisms that correlate with a high risk of critical trauma injuries 

and merit direct transport to a trauma center. 

Early Notification Call: For patients meeting high-risk criteria (direct transport to the trauma center) a 

brief notification to allow the trauma center to prepare resources pending the patient’s arrival. The call 

should be made as early as possible, preferably before leaving the scene. 

Call-In Criteria: For patients who do meet high-risk criteria, but have trauma mechanisms that could 

potentially cause severe trauma. These patients require a destination determination call to the base 

hospital. 

Destination Determination: For patients meeting call-in criteria, the base hospital physician will 

determine which patients warrant trauma center destination based on the report of the field personnel. 

5-minute Update: Notification from the field to the trauma center that the patient will be arriving in five 

minutes. This call initiates hospital activation of a trauma team. 

Patients with Unmanageable Airway: Patients whose airways are unable to be adequately maintained 

with BLS or ALS maneuvers. Adult patients are candidates for immediate redirection to the trauma 

center following airway stabilization at a receiving facility other than the trauma center.



III. TRAUMA TRIAGE ALGORITHM 

High-Risk 

Criteria 

Unmanageable airway 

Trauma arrest (not meeting field determination) 

NO 

PHYSIOLOGIC CRITERIA 

BP 20 minutes 

- Fatalities in the same vehicle 

- Ejection from vehicle 

Unrestrained MVC with: 

- Head-on mechanism > 40 mph 

- Extrication required 

Fall 15 feet or greater 

Auto vs. pedestrian/bicyclist thrown, 

run over, or with significant (>20 mph) 

impact 

NO 

COMBINED CRITERIA 

Motorcycle crash with: 

- Abdominal or chest tenderness 

- Observed loss of consciousness 

Unrestrained motor vehicle crash with: 

- Abdominal tenderness 

NO 

MEETS CALL-IN CRITERIA? 

YES 

*Exceptions outlined in Policy 13 VI. B. 1. 

YES 

YES 

YES 

POLICY #: 13 

**In the absence of significant symptoms or 

physical findings despite mechanism, call for 

destination decision instead of early notification. 

YES 

YES 

PAGE: 2 of 5 

Closest Facility* 

Early notification, 

Trauma Center 

Transport 


Trauma Center 

Transport 


Trauma Center 

Transport 


Trauma Center 

Transport 

Call for 

Destination 

Decision 

For possible helicopter transports only: Trauma patients who do not meet high-risk criteria but by evaluation of mechanism and 

physical exam findings appear to have potential significant injuries merit early notification call and rapid Trauma Center transport.



POLICY #: 13 

PAGE: 3 of 5 

IV. CALL-IN CRITERIA FOR BASE HOSPITAL DESTINATION DECISION 

A. Most trauma mechanisms are variable in terms of risk for significant injury. In order to maintain the 

highest accuracy in trauma triage, base hospital destination decision is required prior to transport of 

the following patients (who do not meet high-risk criteria otherwise): 

1. Evidence of high-energy dissipation or rapid deceleration, which may include: 

a. vehicle rollover with unrestrained occupant, 

b. intrusion of passenger space by one foot or greater, 

c. impact of 40 mph or greater (restrained), 

d. persons requiring disentanglement from a vehicle. 

2. Persons struck by vehicle with impact 20 mph or less. 

3. Persons ejected from a moving object (motorcycle, horse, etc.). 

4. Significant blunt force to the head. Symptoms may include: 

Loss of consciousness, repetitive questioning, abnormal or combative behavior, vomiting, 

headache, or new onset of confusion. 

5. Significant blunt force to the neck, thorax (chest/back), abdomen or pelvis. 

6. Penetrating injury to extremities (above knee or elbow) without apparent fracture. 

Base contact should be made if a patient meets call-in criteria and it is believed trauma center services 

may be needed, even in the event that the trauma has occurred several hours prior to Emergency 

Medical Services (EMS) response. 

B. Patients 60 years of age and older may sustain significant injuries with less forceful mechanisms, 

and may merit call-in for less significant mechanisms (e.g. ground level fall with new alteration of 

mental status). 

C. If no significant symptoms or physical findings noted despite above mechanism(s), call-in is not 

required and the patient may be transported to the patient’s hospital of choice or to the closest 

appropriate facility. 

D. Those patients who do not meet criteria for trauma center services shall be transported to the 

closest appropriate facility or the patient’s facility of choice. 

V. TRIAGE AND REPORTING PROCEDURES 

A. Determine whether the patient meets high-risk criteria for direct transport or meets call-in criteria. 

B. Contact the Base Hospital as soon as possible for either early notification or destination decision as 

indicated in the Trauma Triage Algorithm. 

1. Early Notification Report: This report should be brief (approximately one minute) 

a. Agency name and unit number 

b. Advise as Early Notification Report 

c. ETA at trauma center 

d. Patient age and sex 

e. Urgent concerns 

f. Brief description of mechanism of injury and scene 

g. Brief description of known significant abnormalities in primary and secondary surveys 

2. Destination Decision Report: This report needs to contain sufficient detail to aid in decision 

making by base physician.



POLICY #: 13 

PAGE: 4 of 5 

a. Agency name and unit number 

b. Advise as Destination Decision Report 

c. Paramedic concerns 

d. ETA to trauma center 

e. Patient age and sex 

f. Mechanism of injury (brief description) 

g. Basic scene information (e.g. protective gear, extrication, estimated MPH) 

h. Primary Survey (can be reported as ABCD normal except…) 

i. Secondary Survey (report abnormal findings only) 

j. Prehospital treatments and response 

C. The five-minute update call should be made when five minutes from the trauma center and 

should include expanded patient information, including significant changes in vital signs, mental 

status, physical findings or symptoms en route. 

D. Receiving hospitals shall be contacted by field personnel prior to arrival. 

E. On Trauma Center arrival, use MIVT format at transfer of patient care. (30-second report) 

1. Report should be made to Trauma physician or ED physician 

2. MIVT format 

a. Mechanism of injury 

b. Injuries Sustained and Level of Consciousness (AVPU format) 

c. Vital signs – include ECG rhythm if abnormal, pulse oximetry if known 

d. Treatment and patient’s response to treatment 

e. More detailed information can be provided when requested 

VI. SPECIAL CIRCUMSTANCES 

A. All patients with unmanageable airway should be transported to the closest Basic ED. Adult 

patients (15 years of age and older) who are transported to receiving facilities because of 

unmanageable airways should be immediately redirected to the trauma center following airway 

stabilization. In this setting, the transport is considered a continuation of the field call, and EMS 

will remain at the Emergency Department (ED) for up to 30 minutes to provide transport following 

airway stabilization (when scope of care required is appropriate). In situations in which 

stabilization cannot be accomplished within 30 minutes, the initial crew should be released and 

alternate arrangements for transport should be made. 

B. Patients who do not qualify for field determination of death but have or develop cardiopulmonary 

arrest should be transported to the closest Basic ED by ground ambulance. 

1. Exceptions: 

a. Patients with penetrating trauma who arrest (pulseless, apneic or pulseless with agonal 

respirations) after the arrival of transport personnel should be immediately transported 

to a trauma center if transport time is 20 minutes or less to that facility. If no trauma 

center is available within 20 minutes, transport to the closest basic emergency 

department. 

b. If a helicopter crew is present at the time of arrest (blunt or penetrating) and the air 

transport can be initiated immediately, use of helicopter to transport to a trauma center 

is appropriate.



POLICY #: 13 

PAGE: 5 of 5 

C. Contra Costa County Trauma Center Bypass: 

1. Transport patients who meet high-risk criteria or patients directed to a trauma center by base 

hospital destination decision via ground or air transport, as indicated, to the closest 

appropriate and available designated out-of-county trauma center. 

2. If an out-of-county trauma center is not available: 

a. Transport via ground to the nearest Basic ED, which may include John Muir Medical 

Center – Walnut Creek Campus. 

b. If helicopter transport is utilized, transport to John Muir Medical Center – Walnut Creek 

Campus. 

D. Out-of-County Destinations: 

1. Aside from trauma center bypass situations, an out-of-county destination may be the 

appropriate destination if there is significant time saving. 

2. The base shall be contacted to assist with destination determination of patients who require 

transport to out-of-county destinations, including pediatric patients with prolonged transport 

times (>30 minutes) and patients redirected because of trauma center bypass. 

3. The base will be responsible for notification of other trauma centers to alert them of the 

patient’s pending arrival. 

E. Disrupted Communications with Base: 

1. Patients who normally require base hospital destination determination should be transported 

to the most appropriate and available receiving facility per the field personnel’s judgment. 

2. Alternate mechanisms of communication (e.g., via dispatch) should be used to determine 

trauma center availability if out-of-county destinations are being considered.



EMERGENCY RE-TRIAGE AND TRANSFERS TO 

TRAUMA CENTERS 

POLICY #: 14 

PAGE: 1 of 4 



I. PURPOSE 

To outline the criteria and process for emergency re-triage and for transfer of patients needing trauma 

care from non-trauma facilities to appropriate trauma centers. 

II. POLICY 

Under field trauma triage protocols, most critical trauma patients will be triaged directly to a Trauma 

Center from the field. Trauma patients who present at other facilities via EMS or other arrival mode, 

when medically appropriate, should be considered for re-triage or transfer to trauma centers for 

definitive care. 

III. DEFINITIONS 

A. Emergency Trauma Re-triage: The movement of patients meeting specific high-acuity criteria 

to trauma center for trauma care. Timeliness of evaluation and intervention at the trauma center 

is critical. 

B. Trauma Transfer: The movement of other patients with traumatic injuries to the trauma center 

(those not meeting Emergency Trauma Re-Triage criteria) whose needs may be addressed in a 

prompt fashion but are less likely to require immediate intervention. 

IV. EMERGENCY TRAUMA RE-TRIAGE PATIENT SELECTION 

A. Adult Patients (Age 15 and Over) appropriate for Emergency Trauma Re-Triage to the trauma 

center** include: 

1. Patients with abnormal blood pressure/perfusion as evidenced by: 

a. Systolic blood pressure under 90 

b. Need for high-volume fluid resuscitation (> 2 L NS) or immediate blood replacement 

2. Patients with significant neurological findings or injuries, including 

a. GCS less than 9 or deteriorating by 2 or more during observation 

b. Blown pupil 

c. Obvious open skull fracture 

3. Patients meeting anatomic criteria: 

a. Penetrating injury to head, neck, chest, or abdomen 

b. Extremity injury with ischemia evident or loss of pulses 

4. Patients, who in the judgment of the evaluating emergency physician, are anticipated to 

have a high likelihood for emergent life- or limb-saving surgery or other intervention within 

two (2) hours. 

** Note: John Muir Health - Walnut Creek, Alameda County Medical Center (Highland), and Eden 

Medical Center all utilize these re-triage criteria. Criteria may vary at other centers.



POLICY #: 14 

PAGE: 2 of 4 

B. Pediatric Patients (below age 15) appropriate for Emergency Trauma Re-Triage to the Pediatric 

Trauma Center (Children’s Hospital and Research Center, Oakland) include: 

1. Hemodynamic Criteria 

a. Patients with abnormal blood pressure or poor perfusion (see age-appropriate vital 

signs chart below). Pediatric clinical signs of poor perfusion include: cool, mottled, 

pale or cyanotic skin or prolonged capillary refill, low urine output, or lethargy 

b. Requirement of more than two crystalloid boluses (20 ml/kg each) or requirement of 

blood transfusion (10 ml/kg) 

2. Neurologic criteria 

a. GCS < 12 (pediatric scale – see verbal for young children below) or decrease in 

GCS by 2 

b. Blown pupil 

c. Obvious open skull fracture 

d. Cervical spine injury with neurologic deficit 

3. Respiratory Criteria 

a. Respiratory failure 

b. Intubation required 

4. Anatomic Criteria 

a. Penetrating wound to the head, neck, chest, or abdomen 

5. Patients, who in the judgment of the evaluating emergency physician, are anticipated to 

have a high likelihood for emergent life- or limb-saving surgery or other intervention within 

two (2) hours. 

6. Exceptions 

a. Pregnant pediatric patients should be transferred to an adult trauma center 

b. Pediatric patients with burns should preferentially be transferred to a burn center 

instead of a trauma center 

c. Contact the trauma center to discuss patients with suspected vascular injuries 

V. RE-TRIAGE PROCEDURE 

A. Once the patient has been identified as qualifying for Emergency Trauma Re-triage, the trauma 

center should be contacted (see contact list and phone numbers below) as soon as possible 

and the patient should be specifically identified as an “Emergency Trauma Re-Triage.” Based 

on that notification (and that the center is not on trauma bypass), the patient will be accepted for 

transfer. 

B. Simultaneous or as soon as possible following notification of the trauma center, the appropriate 

transport provider should be contacted to arrange transport. Depending on the needs of the 

patient, the transport unit may be a 9-1-1 paramedic unit, EMT unit, CCT-RN unit or Air 

Ambulance. 

C. Patient records and diagnostic imaging disks (if available) should be readied for transport 

personnel. Records that are not ready at time of transport departure can be faxed.



POLICY #: 14 

PAGE: 3 of 4 

VI. TRANSFER PROCEDURE (if not Emergency Trauma Re-Triage) 

A. Contact the trauma center to discuss patient status and request transfer. See list of hospitals 

and phone numbers below. 

B. If transfer is accepted, arrange for transport, appropriate to patient condition or potential need. 

C. Patient records and diagnostic imaging disks (if available) should be readied for transport unit. 

Records that are not ready at time of transport departure can be faxed. 

VII. TRAUMA CENTERS 

A. John Muir Health – Walnut Creek (JMH-WC) is the designated trauma center for adults (patients 

15 years of age and older) in Contra Costa County. 

B. Children’s Hospital in Oakland is the closest designated trauma center for pediatric patients 

(patients under 15 years). 

C. When JMH-WC is on trauma bypass status, it is unable to accept patients with emergent need 

for transfer or field triages because critical hospital resources (surgeons, operating rooms) are 

not available. Location and helipad availability are items to consider in choice of other trauma 

center destinations. Other local adult trauma centers include: 

1. * Oakland – Alameda County Medical Center (formerly Highland) (no helipad on site); 

2. * Castro Valley – Sutter Eden Medical Center (helipad on site); 

3. Sacramento – UC Davis Medical Center (helipad on site); 

4. San Jose – Santa Clara Valley Medical Center (helipad on site); 

5. San Francisco General Hospital (no helipad on site). 

* Emergency Re-Triage Criteria are the same at JMH-WC and the two Alameda County 

facilities. 

D. When not on trauma bypass status, trauma centers may also be impacted by bed availability 

issues and may not be able to accept non-emergent transfers. 

E. Alternate pediatric trauma centers include UC Davis Medical Center and Santa Clara Valley 

Medical Center in San Jose. Emergency Re-Triage Criteria as addressed in this policy are not 

utilized at these facilities. 

LOCAL TRAUMA CENTER CONTACT PERSONS / PHONE NUMBERS 

Adult Trauma Centers Contact Person Phone Number 

*Alameda County Medical Center – Oakland 

(Highland) 

Re-Triage Only: ED Physician (510) 535-6000 

Other Transfers: On-Call Trauma Surgeon (510) 437-4800 ext 0 

*San Francisco General Hospital Attending Physician (415) 206-8111 

John Muir Health – Walnut Creek Transfer Center (925) 947-4488 

Santa Clara Valley Medical Center – San Jose ED Physician (408) 885-3228 

Sutter Eden Medical Center – Castro Valley On-Call Trauma Surgeon (510) 898-6805 

UC Davis Medical Center – Sacramento ED Physician (916) 734-5669 

Stanford University ED Physician (650) 723-7337 

* Indicates no helipad on site



POLICY #: 14 

PAGE: 4 of 4 

Pediatric Trauma Centers Contact Person Phone Number 

Children’s Hospital Oakland Transfer Center (877) CHO-KIDS 

UC Davis Medical Center – Sacramento ED Physician (916) 734-5669 

Santa Clara Valley Medical Center – San Jose ED Physician (408) 885-3228 

Note: This list is subject to change



HOSPITAL GUIDELINES FOR ACUTE CARE 

INTERFACILITY TRANSFER VIA AMBULANCE 

POLICY #: 15 

PAGE: 1 of 4 



I. PURPOSE 

This policy describes options for interfacility transfer between acute care hospitals and the procedures 

required to arrange transport. Transport options vary in terms of accompanying personnel, scope of 

practice provided and timeliness of availability. 

Transports from other facilities (e.g. nursing homes, clinics, or other facilities that are not licensed to 

provide acute inpatient care) are not acute care interfacility transfers. 

II. TRANSPORT OPTIONS FOR ACUTE CARE INTERFACILITY TRANSFER 

It is the responsibility of the transferring hospital/facility to select the transport option appropriate for 

the patient’s condition. 

A. Emergency Paramedic Ambulance Transport (Interfacility Emergency Response) 

To be used for patient transfer between two acute care hospitals that requires critical timely 

interventions or evaluation at another hospital when that care is not available at the sending 

hospital. 

1. Interfacility Emergency Response Capabilities 

a. The emergency ambulance provider for the area in which the hospital is located will 

respond for these transports as an emergency response. 

b. Provides paramedic-level service with a single paramedic providing care in the 

ambulance. Refer to scope of practice matrix on page three. 

i. Protocols for any patient treatment administered by paramedics during the transport 

are determined by Contra Costa Emergency Medical Services (EMS) policy and 

procedures. 

ii. When patient needs exceed paramedic scope of practice or when care may require 

more than one person, sending facility must provide additional personnel or 

equipment. 

c. Arrival at the sending facility is generally within ten minutes. Patient should be ready for 

transport when ambulance arrives. 

2. Examples would include: 

a. Critical trauma care 

b. Cardiac or Stroke interventional care 

c. Obstetric care - patients in active labor (excluding those with imminent or possible 

precipitous delivery) 

d. Other clinical situations which require specialty emergent care not available at the sending 

facility (e.g. vascular surgery) 

B. Other Acute Care Transports 

The timeliness and availability of other acute care transfers that do not involve a 9-1-1 paramedic 

ambulance response (Interfacility Emergency Response) are not within Contra Costa EMS 

oversight or control. 

1. EMT-I Ambulance 

Provides EMT-I level service with a single EMT-I providing care in the ambulance. Refer 

to scope of practice matrix on page three. 

Arrival time based on availability. 

Numerous private EMT-I ambulance providers are available to provide this service.



POLICY #: 15 

PAGE: 2 of 4 

Generally used for routine interfacility transport of patients with minimal care needs. 

Level of care may be enhanced by personnel and equipment provided by sending facility 

for needs beyond EMT-I scope of practice. 

2. Critical Care Transport Paramedic Ambulance (CCT-P) 

Provides paramedic level service with an extended paramedic scope of practice 

(CCT-P). Refer to scope of practice matrix on page three. 


Provides one CCT Paramedic as caregiver. 

Private ambulance agencies may provide this care. 

Guidelines for any treatment administered by paramedics are determined by Contra 

Costa EMS policy and procedures. 

Generally used for routine interfacility transport of patients whose needs are not highly 

complex and are within the available scope of practice. 

3. Critical Care Transport Ambulance with RN Staffing 

Provides advanced care for patients with complex medical needs. 

The scope of practice of nursing or physician personnel is determined by the ambulance 

provider agency. 


Numerous private ambulance providers offer this level of service. 

Specialty transports for pediatric and obstetric patients are also available. 

4. Air Ambulance 

Provides RN-level of care for patients with complex medical needs. 


In situations where receiving hospital is distant, may provide most rapid mode of 

transport. 

Specialty transports for pediatric and obstetric patients are also available. 

III. PROCEDURES TO ARRANGE ACUTE CARE INTERFACILITY TRANSFER 

A. Interfacility Emergency Response (Emergency Paramedic Ambulance Transport) – For a 

patient who requires emergency transfer (needing immediate care or intervention at the receiving 

facility – e.g. critical trauma or ST-elevation myocardial infarction): 

1. Assure appropriate indication for use. Emergency ambulance transport utilizes 9-1-1 

resources and is reserved for truly emergent cases. 

2. Arrange for transfer with receiving facility personnel. 

3. Assess patient needs in transport to determine if patient needs exceed paramedic 

scope of care. If beyond paramedic scope, hospital will need to provide personnel and 

equipment to accompany patient (e.g. if IV pump needed, blood transfusion in progress, 

management of paralytic agents for intubated patient). 

4. Have records (and staff and equipment, if necessary) prepared for transport. The 

ambulance will generally arrive within 10 minutes of request and patient should be ready for 

transport. If delays occur, the 9-1-1 ambulance may be reassigned for other emergency 

needs. If additional records are not available, they can be faxed or transported separately. 

5. Call 9-1-1 to request “Interfacility Emergency Response.” Exception: For San Ramon 

Medical Center, contact San Ramon Valley Fire Protection District Communication Center. 

*NOTE: The information in the above section is contained in the INTERFACILITY 

EMERGENCY RESPONSE worksheet



POLICY #: 15 

PAGE: 3 of 4 

B. All other interfacility transfers (e.g. hospital to non-acute care setting): Determine transport 

option and contact private ambulance provider.

CONTRA COSTA EMS PROVIDER SCOPE OF PRACTICE FOR INTERFACILITY TRANSFER MATRIX 

SKILL EMT-I SCOPE OF PRACTICE 

EMERGENCY AMBULANCE PARAMEDIC 

SCOPE OF PRACTICE (Includes EMT-I scope) 

PAGE: 4 of 4 

CRITICAL CARE TRANSPORT - PARAMEDIC 

SCOPE OF PRACTICE (CCT-P) 

LIFE SUPPORT CPR CPR plus ACLS within scope CPR plus ACLS within scope 

AIRWAY 

MANAGEMENT 

IV FLUIDS AND 

MANAGEMENT 

MONITORING 

BASIC 

PROCEDURES 

INVASIVE 

PROCEDURES 

Oropharyngeal airway 

Nasopharyngeal airway 

Suction devices 

Oxygen delivery via nasal cannula or simple mask 

only 

Bag-valve-mask 

May monitor peripheral lines containing plain 

isotonic or glucose solutions with no medications 

added. EMT-Is are restricted to monitoring, 

maintaining present rate, or turning off flow of IV 

fluid 

Cannot provide cardiac monitoring. May monitor 

NG and gastrostomy tubes, saline or heparin locks, 

foley catheters or established tracheostomy tubes. 

Central venous access lines may be present but no 

infusions except if via patient-controlled device. 

Cannot transport patients with arterial lines or 

chest tubes 

First aid 

CPR 

Obtain vital signs, pupillary status, assess level of 

consciousness 

Use stretchers and immobilization devices 

May assist patient in use of patient-operated, 

physician prescribed devices 

Endotracheal intubation 

Esophageal (King) airway 

Pediatric intubation (patients > 40 kg ONLY) 

Airway visualization with laryngoscope and 

foreign body removal with forceps 

Administer and adjust rate of glucose or isotonic 

balanced saline solutions. May monitor and adjust 

IV solutions containing potassium (20 mEq/L or 

less). 

Continuous ECG monitoring 

Chest tube monitoring 

Pulse oximetry 

IV line monitoring, not including arterial lines 

Defibrillation 

Synchronized cardioversion 

Valsalva maneuver 

Cardiac pacing 

Venous blood sample draws 

Blood glucose monitoring 

Same as emergency ambulance paramedic plus 

Ventilators (automatic transport) 

Administer and adjust rate of glucose or isotonic 

balanced saline solutions 

May monitor and adjust IV solutions containing 

potassium, heparin, and/or NTG 

May use an infusion pump to administer the above 

Continuous ECG monitoring 

Chest tube monitoring 

Pulse oximetry 

IV line monitoring, not including arterial lines 

Tubes monitoring including foleys, suprapubic 

catheters, and other indwelling GI tubes 

Same as emergency ambulance paramedic 

None Needle thoracostomy Same as emergency ambulance paramedic 

MEDICATIONS Glucose paste only 

Adenosine 

Albuterol 

Amiodarone 

Atropine 

Calcium Chloride 

Dextrose (10% or 50%) 

Diphenhydramine 

Dopamine 

Epinephrine 

Glucagon 

Glucose paste 

Midazolam 

Morphine sulfate 

Naloxone 

Nitroglycerin (sublingual) 

Sodium Bicarbonate 

Does not include Blood 

or Blood Products 

Same as emergency ambulance paramedic, plus: 

IV Heparin, Nitroglycerin or Potassium Chloride 

Continuous infusions of Lidocaine, Midazolam, 

Morphine Sulfate, Sodium Bicarbonate or 

Amiodarone. 

Total Parenteral Nutrition 

Glycoprotein Inhibitors 

Blood and Blood Products

INTERFACILITY EMERGENCY RESPONSE - REQUEST PROCEDURE 

Contra Costa County Emergency Medical Services 

1 Determine Appropriate Indication* 

*Appropriate indication – patient needs immediate intervention at receiving facility that is not available at sending 

facility. Clinical settings other than critical trauma or STEMI may also occur. 

Critical 

Trauma 

Criteria 

Patients with need for immediate neurosurgical intervention 

Patients with penetrating gunshot wounds to head or torso 

Patients with penetrating wounds by an mechanism who present with or develop shock 

Patients with vascular injuries that cannot be stabilized and are at risk of hemorrhagic shock or loss of 

limb acutely (excluding fingers/toes) 

STEMI ST-elevation MI identified by 12-lead ECG requiring transfer for PCI or Cardiac Surgery 

Stroke Patients with signs and symptoms consistent with hemorrhagic/ischemic stroke 

Obstetric Care Patients in active labor (excluding those with imminent or possible precipitous delivery) 

Other 

Other clinical situations which require specialty emergent care not available at the sending facility 

(e.g. vascular surgery) 

2 Contact Receiving Facility for Transfer Acceptance 

Critical Trauma – Closest Trauma Centers STEMI Centers / Stroke Centers 

John Muir Walnut Creek…...…925·941·5005 Name/ ________________________________ 

Adult Alameda County (Highland)…510·437·4800 Phone #s 

Sutter Eden Medical Center…..510·889·5015 ________________________________ 

Pediatric Children’s Hospital Oakland…510·428·3240 ________________________________ 

3 Assess Patient Care Needs / Determine Scope of Care Required 

Assure secure airway, assess need for additional staff, equipment or medication 

Adenosine 

Paramedic scope of practice 

Epinephrine (no infusion) 

Common items beyond paramedic scope 

IV pump/TPN/continuous medication infusions 

Albuterol Glucagon Any IV pressor/inotropic agents 

Amiodarone Midazolam Intravenous NTG or glycoprotein inhibitor 

Atropine Morphine Paralytic agents 

Calcium chloride Naloxone Blood transfusion / blood products 

Dextrose NTG (sublingual only) Arterial line 

Diphenhydramine Sodium Bicarbonate Pediatric intubation (below 40 kg) 

Monitor chest tube, Pulse oximetry, ECG monitoring, Ventilators 

foley catheter 

external cardiac pacing 

Adult endotracheal intubation (no RSI) If any of these items required, additional RN or 

physician staff needed. 

4 Prepare for Transport 

Have records, additional staff and equipment ready for transport. Additional records not available immediately can be 

faxed or transported separately. Expect arrival of transport unit within 10 minutes once 9-1-1 call made and be ready 

to transfer care to EMS crew at time of arrival. 

5 Contact 9-1-1 (Exception: San Ramon) 

If 9-1-1 called, initial police agency dispatcher will transfer to the fire dispatch agency. 

Request “Interfacility Emergency Response” from fire dispatch. 

For San Ramon Regional Medical Center, contact San Ramon Valley Fire Protection District dispatch at 

925·838·6691.



TRANSFER OF CARE IN THE FIELD 

I. PURPOSE 

POLICY #: 16 

PAGE: 1 of 2 



A. To provide guidelines for the transfer of care from non-transport to transport personnel. 

B. To provide guidelines for the transfer of care from an on-scene paramedic to an EMT-I staffed 

transport ambulance. 

II. SCOPE OF DIRECTION AND OVERSIGHT 

A. Patient Care Authority 

1. The most medically qualified pre-hospital personnel first on-scene at a medical emergency 

shall have patient care management authority. 

2. The individual with patient care authority is responsible for the patient until care is turned 

over to another appropriate prehospital care provider or responsible receiving facility staff. 

B. Turn Over of Patient Care Authority 

1. BLS First Responders 

a. BLS first responders initiating patient care shall transfer care upon the arrival of 

either an EMT-I or paramedic transport crew. BLS first responder personnel shall 

maintain patient care authority and accompany a BLS transport unit when an AED 

has been used and the BLS transport personnel do not have an AED. 

2. First Responder Paramedics 

a. First Responder paramedics, when first on-scene, should transfer patient care 

authority and provide a verbal report to the transport paramedics as soon as 

feasible. In those cases where the first responder paramedic believes continuity of 

his/her care will be in the patient's best interest, he/she should maintain patient care 

authority and accompany the patient during transport. 

3. Paramedic to EMT-I Transport Crew 

a. A paramedic may transfer patient care authority to a BLS ambulance crew for 

transport, when all of the following circumstances exist: 

1) The BLS unit is available within a reasonable time, and 

2) ALS care has not been initiated, and 

3) It does not appear that ALS care is likely to be required during transport. 

b. A paramedic shall maintain patient care authority and shall accompany the patient in 

a BLS transport ambulance to the appropriate receiving facility if either of the 

following circumstances exist: 

1) ALS care has been started, or 

2) A reasonable likelihood exists that the patient may require ALS care enroute. 

C. Responsibility for Patients who Decline Care 

1. First responders who determine that patients are declining care or transport are 

responsible for appropriate documentation of those situations. 

2. If patient care has been transferred and a patient subsequently declines further treatment 

or transport, the transport crew is responsible for appropriate documentation.



D. Documentation 

POLICY #: 16 

PAGE: 2 of 2 

1. Documentation of transfer of care shall be made by both transferring and receiving crews, 

e.g., “Patient care transferred to AMR paramedic 56 at 0900,” and “Patient care accepted 

from CCC Fire paramedic 115 at 0900.” 

E. Turn-over Procedures 

Those emergency medical response agencies providing enhanced levels of care are 

responsible for creating and implementing internal operational procedures regarding transfer of 

patient care. These procedures shall be consistent with the EMS Agency's policies, and shall 

interface with the procedures of other emergency medical response agencies which might be 

represented at the scene of an emergency.



EMT/PARAMEDIC OR NON-TRANSPORT 

ALS PROGRAMS 

POLICY #: 17 

PAGE: 1 of 2 



I. PURPOSE 

To define criteria for units staffed with one EMT and one Paramedic or non-transport paramedic units. 

II. STAFFING 

A. Paramedic Non-Transport Units 

Paramedic non-transport units are fully equipped advanced life support vehicles, staffed with a 

minimum of one (1) paramedic, and dispatched simultaneously with an emergency (ALS) 

transport unit. Paramedics assigned to such units must have the training and experience 

necessary to function safely as the sole care providers until the fire first responder and transport 

units arrive. Paramedics assigned to paramedic non-transport units shall be approved by their 

employers and shall meet the following minimum qualifications for staffing such units: 

1. Current accreditation in Contra Costa County 

2. At least two (2) years full-time field experience as a paramedic in the last three (3) 

years 

3. No actions against State paramedic license within the past two (2) years 

B. Paramedic/EMT-I Units 

Paramedic/EMT-I Units are fully equipped fire engines or ambulances staffed with a minimum of 

one (1) paramedic and one (1) EMT-I. Paramedic personnel assigned to these units must have 

the experience necessary to function safely as the single advanced life support provider. 

Personnel assigned to paramedic/EMT-I units shall be approved by their employer and meet the 

following minimum qualifications for staffing such units: 

1. Current accreditation/certification in Contra Costa County 

2. Experience requirements: 

a. Paramedic: at least one (1) year full-time field experience as a paramedic in the last 

two (2) years, or three (3) years field experience as a paramedic. 

b. EMT: at least one (1) year full-time field experience as an EMT-I in the last two (2) 

years, or three (3) years field experience as an EMT-I. 

If unable to meet this criteria, personnel must participate in and successfully complete a 

provisional assignment approved by the EMS Agency. 

3. No actions against State paramedic licensure/EMT-I certification within the past two (2) 

years. 

Individuals functioning under a current Performance Improvement Plan (PIP) may be precluded from 

working on either of these units. Permission to function as a paramedic or an EMT on either of these 

type of units may be rescinded at any time by the Contra Costa County EMS Medical Director. 

III. FIELD TREATMENT 

Personnel assigned to a paramedic/EMT unit or a non-transporting ALS unit work under the existing 

medical control system and follow Contra Costa County EMS field treatment guidelines, policies and 

procedures, including base hospital contact requirements. 

A. Paramedic/EMT Units 

1. The paramedic assigned to the unit is ultimately responsible for all patient assessment 

and care.



POLICY #: 17 

PAGE: 2 of 2 

2. The EMT may accompany the patient in the patient compartment of the ambulance, if: 

a. in the paramedic’s best judgment, the patient does not currently require ALS care 

and there is no reasonable possibility of the patient requiring ALS care throughout 

the transport. 

B. Non-transport ALS Units 

1. The non-transport paramedic shall provide a verbal report of patient assessment and 

treatment provided, to the transporting ambulance personnel. 

2. A written county patient care report (PCR) shall be completed and sent with the patient if 

time permits. If the PCR cannot be completed prior to patient transport, the non-transport 

paramedic shall complete the PCR and fax it to the Emergency Department of the 

receiving facility as soon as possible. 

IV. QUALITY IMPROVEMENT 

A. Each agency having a paramedic/EMT or non-transport ALS unit program shall have processes 

identified in their quality improvement plan for review of all calls. 

B. Personnel assigned to a paramedic/EMT or non-transport ALS unit shall be required to 

complete orientation and training programs which have been developed by the provider agency 

and approved by the EMS Agency. These requirements may be waived at the discretion of the 

EMS Medical Director.



PUBLIC SAFETY/EMT AED PROGRAMS 

POLICY #: 18 

PAGE: 1 of 2 



I. PURPOSE 

Defibrillation, utilizing an automated external defibrillator (AED) according to policies and 

procedures established by the EMS Agency, is included in the EMT-I scope of practice and 

has been approved as an optional skill for use by personnel trained to Public Safety 

Standards. 

II. AED SERVICE PROVIDER 

An AED service provider is an agency or organization that employs individuals as Public Safety or 

EMT personnel and who obtains AEDs for the purpose of providing AED services to the general 

public. 

A. An AED service provider shall be approved by the EMS Agency. In order to receive and 

maintain AED service provider approval, an AED service provider shall comply with the 

requirements of this policy and/or applicable state regulations. 

B. AED service provider approval may be revoked or suspended for failure to maintain the 

requirements of this policy and/or applicable state regulations. 

C. An AED service provider shall be approved if it meets and provides the following: 

1. Completes an application available from the EMS Agency. 

2. Provides orientation of AED authorized personnel to the AED. 

3. Ensures maintenance of the AED equipment. 

4. Ensures initial training and continued competency of AED authorized personnel. 

5. Notices to the EMS Agency when an AED has been utilized on a patient using the 

attached form. 

6. Collects and reports to the EMS Agency quarterly, data that includes: 

a. Number of patients with sudden cardiac arrest receiving CPR prior to arrival of AED 

service provider personnel. 

b. Total number of patients the AED was applied to. 

c. Total number of patients on whom defibrillatory shocks were administered. 

d. Total number of patients on whom defibrillatory shocks were administered, who 

suffered a witnessed cardiac arrest. 

7. Authorizes personnel to use an AED and maintains a list of all authorized personnel and 

provides the list to the EMS Agency annually or upon request. 

D. An approved AED service provider and its authorized personnel shall be recognized statewide. 

III. PUBLIC SAFETY AED SERVICE PROVIDER TRAINING PROGRAM REQUIREMENTS 

A. A public safety agency wishing to implement an AED program must submit a training program 

for approval by the EMS Agency. This program shall include: 

1. A minimum of four (4) hours of initial instruction and testing. 

2. A course outline which includes the topics and skills listed in the current Public Safety 

regulations, for the optional skill of AED. 

3. A final written and practical evaluation.



POLICY #: 18 

PAGE: 2 of 2 

B. The public safety agency shall implement a quality improvement program as outlined in the 

quality improvement plan established by the EMS Agency. 

C. The public safety agency shall follow the policies and procedures issued by the EMS Agency 

Medical Director. 

D. Defibrillators and defibrillator trainers shall be maintained in accordance with manufacturer’s 

recommendations. 

IV. PUBLIC SAFETY AED INSTRUCTOR REQUIREMENTS 

To be authorized to instruct public safety personnel in the use of an AED, an AED instructor shall 

either: 

A. Complete an American Red Cross or American Heart Association recognized instructor course 

(or equivalent) including instruction and training in the use of an AED, or; 

B. Be approved by the EMS Agency Medical Director and meet the following requirements: 

1. Be authorized to use an AED, 

2. Be competent in the proper use of an AED, and 

3. Be able to demonstrate competency in adult teaching methodologies.



DETERMINATION OF DEATH 

IN THE PREHOSPIAL SETTING 

POLICY #: 19 

PAGE: 1 of 4 



I. PURPOSE 

To provide criteria to aid prehospital personnel in determining death in the field. 


Agent: An individual, eighteen years of age or older, designated in a power of attorney for health 

care to make health care decisions for the patient, also known as “attorney-in-fact.” 

Immediate Family: The spouse, domestic partner, adult child(ren) or adult sibling(s) of the patient. 

Conservator: Court-appointed authority to make health care decisions for a patient. 

Advanced Health Care Directive (AHCD): A written document that allows an individual to provide 

health care instructions or designate an agent to make health care decisions for that person. AHCD is 

the current legal format for a living will or Durable Power of Attorney for Health Care (DPAHC). 

Standardized Patient-Designated Directives: 

• Statewide Emergency Medical Services Authority/California Medical Association Prehospital DNR 

(Do Not Resuscitate) Form 

• Physician Orders for Life Sustaining Treatment (POLST): A standardized, signed, designated 

physician order that addresses a patient’s wishes about a specific set of medical issues related to 

end-of-life care 

• A standard DNR medallion/bracelet (e.g. Medi-Alert). 

III. POLICY 

A. Prehospital personnel do not pronounce death but may determine death in certain situations. 

B. Prehospital personnel need not initiate CPR or may direct the discontinuation of CPR when 

death has been determined using the criteria outlined in this policy, or when presented with an 

approved Do Not Resuscitate order. 

C. If any doubt exists as to the presence of vital signs, or if hypothermia, drug overdose, or 

poisoning is suspected, begin CPR and follow the appropriate field treatment guidelines. 

D. The body of a patient who has been determined to be dead from any of the reasons identified in 

the Coroner section of this policy shall not be disturbed or moved from the position or place of 

death without permission of the Coroner or the Coroner's appointed deputy. 

E. If any questions exist about application of this policy base hospital direction may be utilized. 

IV. OBVIOUS DEATH 

A. Pulseless, non-breathing patients with any of the following: 

1. Decapitation 

2. Total incineration 

3. Decomposition 

4. Total destruction of the heart, lungs, or brain, or separation of these organs from the body 

5. Rigor mortis or post-mortem lividity without evidence of hypothermia, drug ingestion, or 

poisoning 

6. Mass casualty situations. 

B. Procedure: 

1. Do not initiate CPR 

2. In patients with rigor mortis or post-mortem lividity:



a. Attempt to open airway 

POLICY #: 19 

PAGE: 2 of 4 

b. Assess for breathing for at least 30 seconds; assess pulse for 15 seconds 

c. Rigor, if present, should be noted in jaw and/or upper extremities 

d. If any doubt exists, place cardiac monitor to document asystole in two leads for one 

minute. 

3. Notify County Coroner and any other appropriate investigative agencies (if not already 

done). 

4. Complete Prehospital Care Report. 

V. PROBABLE DEATH 

Does not apply if hypothermia, drug ingestion, or poisoning is suspected. 

A. Medical Arrest: 

1. Definition: Cardiac arrest with total absence of observers or witness information; or 

cardiac arrest in which witness information states arrest occurred greater than 15 minutes 

prior to arrival of prehospital personnel and no resuscitative measures have been done. 

2. Procedure: 

a. BLS personnel – Follow Public Safety defibrillation treatment guideline. 

b. ALS personnel: 

1) Do not initiate CPR 

2) Assess for presence of apnea, pulselessness (no heart tones/no carotid or 

femoral pulses) 

3) Document asystole in two leads for one minute. 

B. Traumatic Arrest: 

1. Definition: Blunt or penetrating traumatic arrest. 

2. Procedure: 

a. BLS personnel – Follow Public Safety defibrillation treatment guideline. 

b. ALS personnel: 

1) Do not initiate CPR 

2) Assess for presence of apnea, pulselessness (no heart tones/no carotid or 

femoral pulses) 

3) Document asystole or pulseless electrical activity (PEA) with wide QRS and rate 

of 40 or less in two leads for one minute 

Following determination of death, notify coroner and any other appropriate investigative agency (if not 

already done). 

Complete Prehospital Care Report including approximate time death was determined. 

VI. DISCONTINUING ADULT CPR 

Does not apply if hypothermia, drug ingestion, or poisoning is suspected. 

A. Prehospital personnel may discontinue adult CPR without base hospital contact in the following 

situations: 

1. If an approved Do Not Resuscitate (DNR) order is produced for the patient after initiation 

of resuscitative efforts.



POLICY #: 19 

PAGE: 3 of 4 

2. If an Advanced Health Care Directive (AHCD), Living Will or Durable Power of Attorney for 

Health Care (DPAHC) is produced and the responsible party is present and makes the 

request; 

3. If an immediate family member is present and make the request to discontinue resuscitation 

efforts, in the absence of a DNR, AHCD, Living Will, or DPAHC document. Full agreement 

of prehospital personnel and family present to discontinue efforts is required. 

4. If a patient presents with advanced or terminal disease and an incomplete approved DNR 

order (e.g. no signature) is presented or no form is presented and an immediate family 

member, agent or conservator, at the scene, requests no resuscitation. Full agreement of 

prehospital personnel and family present to discontinue efforts is required. 

5. A patient where resuscitative efforts are unsuccessful (asystole or agonal rhythm despite 

interventions). 

B. Procedure: 

1. Document rhythm in two leads for one minute. 

2. Notify Coroner and any other appropriate investigative agency (if not already done). 

3. Complete Prehospital Care Report including approximate time death was determined. 

C. Prehospital personnel should attempt resuscitation and should transport patients with multiple 

rhythms, intermittent perfusing rhythms such as bradycardia or ventricular tachycardia, or in 

whom scene conditions warrant transport (safety issues, some public settings). 

D. CPR may not be discontinued during patient transport. 

VII. EMERGENCY MEDICAL DISPATCH 

A. Obvious Death: 

Emergency Medical Dispatchers (EMDs) provide prearrival instructions for administering CPR 

unless they have been provided information indicating that the patient meets one of the 

following obvious death criteria: 

1. Decapitation 

2. Total incineration 

3. Decomposition that prevents resuscitation 

4. Total destruction of the heart, lungs, or brain, or separation of these organs from the body 

5. Rigor mortis that prevents resuscitation. 

B. “Do Not Resuscitate” (DNR): 

The EMD shall provide pre-arrival instructions for administering CPR even if he/she is advised 

that the patient has DNR paperwork. If the caller refuses, the EMD shall advise them to have the 

DNR paperwork available for the responding personnel and shall notify the enroute unit(s) of the 

existence of DNR paperwork. 

VIII. MULTICASUALTY/MULTIVICTIM INCIDENTS 

Field personnel should initiate CPR when there are sufficient numbers of rescuers to adequately 

manage the total number of, and types of, casualties on the scene. 

IX. CORONER INVESTIGATION 

The Coroner is responsible for investigating all deaths listed in California Government Code Section 

27491 including, but not limited to the following: 

Violent, sudden, or unusual deaths; 

Unattended deaths; 

Deaths where a physician has not attended to the deceased in the 20 days before death;



Known or suspected homicide, suicide, or accidental poisoning; 

POLICY #: 19 

PAGE: 4 of 4 

Deaths known or suspected as resulting in whole or in part from or related to accident or 

injury either old or recent; 

Deaths due to drowning, fire, hanging, gunshot, stabbing, cutting, exposure, starvation, acute 

alcoholism, drug addiction, strangulation, aspiration, or where the suspected cause of death 

is sudden infant death syndrome; 

Death in whole or in part occasioned by criminal means; 

Deaths known or suspected as due to contagious diseases and constituting a public hazard; 

Deaths from occupational diseases or occupational hazards. 

The deceased should not be disturbed or moved from the position or place of death without 

permission of the coroner or the coroner’s appointed deputy.



DO NOT RESUSCITATE (DNR) ORDERS AND 

PHYSICIAN ORDERS FOR LIFE-SUSTAINING 

TREATMENT (POLST) IN THE PREHOSPITAL 

SETTING 

POLICY #: 20 

PAGE: 1 of 2 



I. PURPOSE 

This policy identifies situations approved for withholding resuscitative measures or the treatment of 

patients with an advanced airway. 


Agent: An individual, eighteen years of age or older, designated in a power of attorney for health 

care to make health care decisions for the patient, also known as “attorney-in-fact.” 

Immediate Family: The spouse, domestic partner, adult child(ren) or adult sibling(s) of the patient. 

Conservator: Court-appointed authority to make health care decisions for a patient. 

Advanced Health Care Directive (AHCD): A written document that allows an individual to provide 

health care instructions or designate an agent to make health care decisions for that person. AHCD is 

the current legal format for a living will or Durable Power of Attorney for Health Care (DPAHC). 

Standardized Patient-Designated Directives: 

• Statewide Emergency Medical Services Authority (EMSA)/California Medical Association (CMA) 

Prehospital DNR Form 

• Physician Orders for Life Sustaining Treatment (POLST): A standardized, signed, designatedphysician 

order that addresses a patient’s wishes about a specific set of medical issues related 

to end-of-life care 

• A standard DNR medallion/bracelet (e.g. Medi-Alert). 

III. POLICY 

DNR ORDERS HONORED BY PREHOSPITAL PERSONNEL 

Prehospital personnel may honor the following types of DNR orders: 

A. A California EMSA/CMA Prehospital DNR form. 

B. A California EMSA POLST form where Section A – Do Not Attempt Resuscitation/DNR has 

been chosen. 

C. An Advanced Health Care Directive (living will or Durable Power of Attorney for Health Care) 

presented by an agent of the patient empowered to make health care decisions for the patient. 

D. A standard DNR medallion/bracelet (e.g. Medi-Alert) 

E. A DNR order in the medical record of a licensed healthcare facility (e.g., acute care hospital, 

skilled nursing facilities, hospices, intermediate care facilities) signed by a physician. (electronic 

physician’s orders are considered signed and will be honored) 

F. A verbal DNR order given by the patient’s physician who is present at the scene. 

A patient (or patient’s surrogate) may verbally rescind the DNR order at any time. 

IV. PROCEDURE 

A. COMPLYING WITH AN HONORED DNR ORDER 

If an approved DNR order is available: 

1. Verify the identity of the patient 

2. Perform no life saving measures 

3. Cancel the responding ambulance



POLICY #: 20 

PAGE: 2 of 2 

B. COMPLYING WITH A POLST FORM WHEN PATIENT IS NOT IN CARDIAC ARREST 

DNR orders only apply to patients in cardiac arrest. A patient with a DNR order that is not in 

cardiac arrest should be provided treatment as appropriate for their complaint unless a POLST 

is in place that directs care differently. 

1. Verify the identity of the patient 

2. Review the POLST form - Section B 

a. If “Full Treatment” is marked – patient receives full care. 

b. If “Limited Additional Interventions” or “Comfort Measures Only” is marked – No 

Advanced Airway should be done. 

Section C – does not apply to Prehospital Setting 

V. SPECIAL CONSIDERATIONS 

A. An approved DNR order is presented, but on-scene relatives object to the order or the validity of 

the order is in question: 

1. Provide all appropriate care/resuscitation measures for the patient. Although a patient’s 

instructions should remain paramount, resuscitation is to be done until the situation is 

clarified. 

B. A patient presents with advanced or terminal disease and an incomplete approved DNR order 

(e.g. no signature) is presented or no order is presented and an immediate family member, 

agent or conservator at the scene requests no resuscitation: 

1. With complete agreement of family and providers on scene, resuscitative efforts may be 

withheld. 

2. Base contact is not necessary. 

3. This option is present because some patients with advanced or terminal diseases do not 

have DNR or POLST forms. Resuscitation should be initiated if there is any question of 

the circumstances or any disagreement of family or providers on scene. 

C. If CPR is initiated prior to the presentation of an approved DNR order, CPR may be discontinued 

without base hospital contact. 

D. If multiple forms are presented follow the order with the most current date. 

NOTE: EMS personnel shall document all relevant information on a PCR for all patients. Approved 

DNR orders/POLST forms (copies acceptable) shall be attached to PCRs if a patient is not 

transported.



PHYSICIAN ON SCENE 

I. PURPOSE 

POLICY #: 21 

PAGE: 1 of 1 



To provide direction for field personnel and physicians on prehospital emergency medical responses. 

II. POLICY 

Paramedics function by law under physician contact, however, most physicians are unfamiliar with the 

paramedic scope of practice, skills, drugs, equipment, and EMS protocols. Most physicians do not 

have the time to accompany paramedics and their patients to a Receiving Hospital. For this reason, 

Base Hospital physicians assume medical control through input into EMS protocols and through voice 

contact. 

If a physician at the scene wishes to direct paramedic care, s/he should be shown the card issued by 

the State of California entitled Note to Physician on Involvement with EMT-IIs & EMT-Ps 

(paramedic). 

The Endorsed Alternatives for Physician Involvement printed on the back of the card are: 

"After identifying yourself by name as a physician licensed in the State of California, and, if requested, 

showing proof of identity, you may choose to do one of the following: 

A. Offer your assistance with another pair of eyes, hands, or suggestions, but let the life support 

team remain under base hospital control; or, 

B. Request to talk to the base station physician and directly offer your medical advice and 

assistance; or, 

C. Take responsibility for the care given by the life support team and physically accompany the 

patient until the patient arrives at a hospital and responsibility is assumed by the receiving 

physician. In addition, you must sign for all instructions given in accordance with local policy and 

procedure. (Whenever possible, remain in contact with the base station physician.)” 

Even if a physician chooses option #3 listed on the card, in Contra Costa County, the paramedic must 

still maintain Base Hospital control through the voice contact.



INFECTIOUS DISEASE PRECAUTIONS AND EXPOSURE 

MANAGEMENT FOR EMS PERSONNEL 

POLICY #: 22 

PAGE: 1 of 4 



I. AUTHORITY 

Division 2.5, California Health and Safety Code, Sections 1797.186, 1797.188. 1797.189. 

www.leginfo.ca.gov Bloodborne pathogens - 1910.1030, U.S. Department of Labor. 

www.osha.gov/SLTC/bloodbornepathogens/ 

II. PURPOSE 

To provide guidelines and procedures for EMS prehospital personnel, to reduce risk of infectious 

disease exposure to themselves and patients, and to evaluate and report suspected exposures to 

communicable diseases. 

A. Although the presence of disease-causing agents may or may not be known, these agents may 

be present in body fluids and substances. Even apparently healthy persons may carry and be 

capable of transmitting disease. 

B. Precautions identified in this policy are intended to provide prehospital personnel with 

information to safely care for all patients, regardless of disease status. 

III. EXPOSURE RISK REDUCTION 

A. Prehospital Personnel. Prehospital personnel shall: 

1. Follow employer’s policies/procedures for infection control to protect both patients and 

themselves. 

2. Use universal precautions in all patient contacts. Additional barrier precautions are to 

be used based on the potential for exposure to body fluids and substances. 

3. Wash hands, prior to and following patient contact at a minimum, regardless of the use of 

gloves or other barrier precautions. Thorough hand washing with soap and water is the 

most effective infection control activity for prehospital personnel. Waterless hand 

sanitizers are an option if soap and water are not available. 

B. Provider Agency. Each provider agency shall: 

1. Comply with all federal, state, and local regulations regarding infectious disease 

precautions. 

2. Establish and maintain a written exposure control plan designed to eliminate or minimize 

employee exposure. This plan shall include a procedure to be used if an employee is 

possibly exposed to a communicable disease and this plan shall be made easily 

accessible. 

3. Designate an infection control officer to evaluate and respond to possible infectious 

disease exposure of provider agency’s prehospital personnel. 

4. Make available equipment, supplies and training necessary for prehospital personnel to 

reasonably protect themselves and their patients against infectious disease exposure. 

C. Receiving Facility. Receiving hospitals should have staff procedures for: 

1. Assisting possibly exposed prehospital personnel in assessing the significance of the 

exposure, and the need for and provision of prophylaxis. 

2. Obtaining the appropriate testing to determine whether or not the source patient is infected 

with a communicable disease. 

IV. EXPOSURE DEFINITION 

A significant communicable disease exposure is defined by criteria set by the Centers for Disease 

Control (CDC) and the Local Public Health Department and may include:



POLICY #: 22 

PAGE: 2 of 4 

A. Contact with patient's blood, bodily tissue, or other body fluids containing visible blood on nonintact 

skin (e.g. open wound; exposed skin that is chapped, abraded, affected with a rash) 

and/or mucous membranes (e.g., eye, mouth). 

B. Contaminated (used) needle stick injury. 

C. Unprotected mouth-to-mouth resuscitation. 

D. Face-to-face contact in areas with restricted ventilation with patients who have airborne 

communicable diseases (e.g. H1N1, Avian flu, tuberculosis or meningitis). 

E. If extent of exposure is in question contact Contra Costa Health Service’s Public Health 

Department for additional guidance. 

V. CENTER FOR DISEASE CONTROL RECOMMENDATIONS 

CDC recommendations should be used for HIV prophylaxis following significant exposures. Provider 

agencies, designated officers, occupational injury treatment centers, and emergency department staffs are 

expected to coordinate efforts to ensure prompt treatment for affected prehospital personnel. 

VI. RESPONSIBILITIES IN A CASE OF SUSPECTED EXPOSURE 

A. Individual that may have been exposed shall: 

1. Contact his or her employer’s Infection Control Officer/Designated Officer as soon as 

possible to determine the extent of the exposure and if follow-up recommendations including 

prophylaxis are required. 

2. Refer to employer’s internal notification requirements and internal policy for direction and 

advice on reporting, evaluation and treatment. 

3. Complete a Contra Costa Health Services “Notification of Possible Communicable Disease 

Exposure” Form (EMS6), which is available at www.cccems.org . 

a. Submit form to appropriate parties according to instructions on the form. 

b. This form will provide the hospital and Public Health with source patient information as 

well as contact information for the possibly exposed individual. 

c. If the possibly exposed individual does not respond to the hospital that received the 

patient, the individual should follow his/her provider agency procedures for form 

distribution. 

B. Employer of the individual who may have been exposed should: 

1. Assess the potential exposure to determine if the exposure meets the definition as defined 

above. 

2. Assure the individual with a suspected exposure is instructed to report immediately to 

emergency department, or other health treatment facilities for risk assessment and 

determination of need for prophylactic treatment. 

3. Assure that exposed individual has completed and submitted EMS-6 according to the 

instructions on the form available at www.cccems.org: 

a. In situations where the exposed individual does not report to the hospital that received 

the source patient, the form should be faxed to that receiving Hospital’s Emergency 

Department Charge Nurse. 

b. The exposed individual or his/her provider agency is responsible for confirming that 

the faxed form was received. 

NOTE: On significant exposures, the Public Health Division’s Communicable Disease Program should 

be notified by phone, in addition to completing and submitting the EMS-6 form. Use contact 

information, phone and fax numbers provided on the EMS-6 form.



POLICY #: 22 

PAGE: 3 of 4 

VII. RECEIVING HOSPITAL RESPONSIBILITIES – SOURCE PATIENT 

A. Evaluate source patient for any history, signs or symptoms of a communicable disease. 

B. Obtain consent to, and collect appropriate specimens (e.g. blood, sputum) from the source 

patient necessary to determine potential risk to the exposed person. 

C. Expedite the testing process (select the tests with rapid turn around in mind), to the extent 

possible, in consideration of the exposed individual’s concerns and the need for continued 

prophylactic care. 

D. Complete an EMS-6 form and promptly report any reportable communicable diseases 

found in the source patient to the Public Health Division's Communicable Disease 

Program in accordance with the EMS-6 form instructions, as well as on the CMR form as 

required by law. 

VIII. RECEIVING HOSPITAL RESPONSIBILITIES – EXPOSED INDIVIDUAL 

A. Receiving hospitals must assist prehospital personnel who have had significant exposures. 

B. Receiving hospital emergency department staff shall: 

1. Actively assist exposed prehospital personnel in evaluating risk and recommending and/or 

providing appropriate prophylactic care when indicated. 

2. Obtain blood and necessary tests from the exposed prehospital person necessary to 

determine base-line status. 

C. Emergency departments are expected to follow CDC guidelines when managing prehospital 

exposure to potentially infectious substances. Go to http://www.cdc.gov/ for the latest 

information. 

IX. HEALTH SERVICES PUBLIC HEALTH DIVISION RESPONSIBILITIES 

Upon notification, the Health Services Public Health Division will: 

A. Verify the exposure is significant and contact the receiving hospital(s) and the prehospital 

employer’s designated officer for infection control. 

B. Notify the exposed person of any recommended disease prevention/prophylaxis needed and 

provide a written opinion and evaluation of the exposure, as well as identify any medical 

condition(s) resulting from the exposure that may require further evaluation or treatment. 

C. If exposed individuals have immediate concerns about possible exposures, or if the 

exposures are significant, they should contact the Public Health Division’s Communicable 

Disease Program using the contact phone numbers on the EMS-6 form.

Name: 

Employer: 

Employer address: 

CONTRA COSTA HEALTH SERVICES-PUBLIC HEALTH 

NOTIFICATION OF POSSIBLE COMMUNICABLE DISEASE EXPOSURE 

(Complete all information below – PLEASE PRINT) 

PERSON POTENTIALLY EXPOSED 

Work Phone ( ) 

Home Phone ( ) 

□ Completed hepatitis B vaccination series: □ Partial hepatitis B series: □ No hepatitis B vaccinations 

SOURCE PERSON FOR POTENTIAL EXPOSURE: 

Name: 

Address: 

Location of Incident: 

Person transported to: 

Home phone: ( ) 

INCIDENT REPORT: 

Date of Incident: 

Time of Incident: 

Ambulance # 

Incident # 

TYPE OF EXPOSURE: 

□ Mouth to Mouth resuscitation – without protective device 

□ Needle stick injury - with a used/non sterile needle 

□ Blood or secretions splashed into → □ Eyes □ Mouth □ Wound 

□ Meningitis 

□ Close exposure to a person with TB → □ Known TB □ Suspected TB 

□ Other risk exposure → Please describe ________________________________________________________________________ 

______________________________________________________________________________________________________________ 

Notify Public Health (925) 313-6740 during work hours M-F 8a-5p and Fax a copy of this form to (925) 313-6465. 

After hours and holidays leave a voice mail message at this same number. Public Heath will follow-up with the designated officer 

and/or employee during normal work hours. For urgent consults phone (925) 313-6740 to connect with the on-call Health Officer. 

Precautions/equipment used during this exposure: □ Gloves □ Gown □ Face shield 

□ Eye protection □ N95 mask 

□ Other: _____________________________________________________ 

How soon after the potential exposure were you able to cleanse the exposure site? ________________________________________ 

Other information regarding exposure: ____________________________________________________________________________ 

Occupational Health Provider: Address: 

Name of person completing this form: PRINT Phone 

PUBLIC HEALTH FOLLOW UP: 

□ No reportable communicable disease identified in source person 

□ Recommendations given to: □ Employee Date: □ Employer Date: 

Actions taken by Public Health: 

□ EMS-7 mailed to: _______________________________________ By: __________________________ Date:__________________ 

□ Other actions: ______________________________________________________________________________________________ 

Public Health follow up by: Name: Phone: ( ) 

▲ □ Original to Public Health ▲ □ Copy to health facility receiving patient ▲ □ Copy to employee ▲ □ Copy to Infection Control Officer 

EMS – 6 (11/12)



ABUSE/ASSAULT REPORTING 

POLICY #: 23 

PAGE: 1 of 2 



PURPOSE 

To describe reporting requirements for prehospital personnel when child or elder abuse, sexual 

assault, or domestic violence is observed or is reasonably suspected. 

II. CHILD ABUSE, ELDER/DEPENDENT ADULT ABUSE, AND DOMESTIC VIOLENCE 

EMS personnel faced with a situation where s/he has reason to suspect child abuse, elder/dependent 

adult abuse (physical/sexual/financial) or neglect, or domestic violence shall: 

A. Notify the appropriate law enforcement agency immediately if the scene is unsafe or it is 

suspected that a crime has been committed. 

B. Make reasonable efforts to transport the patient to a receiving hospital for evaluation, and 

provide the receiving hospital staff of abuse/neglect suspicions. 

C. Document observations and findings on the patient care report. 

D. Contact the appropriate reporting agency by telephoning immediately or as soon as reasonably 

possible to provide a verbal report. 

E. File a written report with the appropriate reporting agency within two (2) working days. 

III. REPORTING 

A. To Report Child Abuse: 

Complete a Suspected Child Abuse Report Form (SS8572) 

(available online at 

http://oag.ca.gov/sites/all/files/pdfs/childabuse/ss_8572.pdf?) 

Call Children & Family Services Screening Unit: 

Within 2 working days and submit to: 

(all numbers are 24-hours/day) 

Employment & Human Services Department 

1-877-881-1116 

Children & Family Services Screening Unit 

400 Ellinwood Way 

Pleasant Hill CA 94523 

B. To Report Elder Abuse: 

If the alleged abuse has occurred in a long-term care facility 

Complete a Suspected Dependent Adult/Elder Abuse Form (SOC 341) 

Call Ombudsman Services of Contra 


Costa (925) 685-2070 to make a 

http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/SOC341.pdf) 

verbal report 

within 2 working days and submit to: 

Ombudsman Services of Contra Costa 

24-Hour Crisis Line: 

1601 Sutter Street, Suite A 

1-800-231-4024 

Concord CA 94520 

If the alleged abuse has occurred anywhere else 

Complete a Suspected Dependent Adult/Elder Abuse Form (SOC 341) 


Call Adult Protective Services http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/SOC341.pdf) 

(925) 602-4179 

within 2 working days and submit to: 

1-877-839-4347 

Employment & Human Services Department 

to make a verbal report 

Adult Protective Services 

500 Ellinwood Way, 3 rd Floor 

Pleasant Hill CA 94523



C. To Report Domestic Violence: 

POLICY #: 23 

PAGE: 2 of 2 

Reporting responsibilities are fulfilled by notifying the local law enforcement agency, and by 

reporting suspicions and patient finding to receiving hospital staff (if transported). 

IV. SEXUAL ASSAULT 

A. Sexual assault shall be reported as above in situations involving elder, dependent adult, child, 

or domestic violence. 

B. It is recommended to transport patients who have been sexually assaulted to Contra Costa 

Regional Medical Center for evaluation and evidentiary exam; however, the patient may be 

transported to the receiving hospital of choice. 

C. Discourage any activity that would compromise evidence collection prior to transport such as 

bathing, brushing teeth, brushing hair, urinating, defecating or changing clothes.



HOSPITAL CT / STEMI - CARDIAC CATH LAB AND 

INTERNAL DISASTER 1 DIVERSION 

POLICY #: 24 

PAGE: 1 of 1 



I. PURPOSE 

To assure prompt notification of diversion status throughout the EMS system so that emergency 

patients are transported to the most accessible medical facility that is staffed, equipped, and prepared 

to administer emergency care appropriate to the needs of the patient. 

II. TYPES OF DIVERSION 

Inoperable CT scanner (CT Divert) 

Internal Disaster (INT Divert) 

Inoperative Cardiac Cath Lab (STEMI Divert) 

III. REDDINET NOTIFICATION OF DIVERSION STATUS 

ReddiNet is the only accepted notification method for reporting CT, INT and STEMI diversion. 

Once the appropriate ReddiNet status field has been changed, ambulance dispatch centers 

automatically receive the notification and then relay hospital diversion status to their ambulances. 

Emergency Department personnel should note that using the ReddiNet “message” feature alone does 

not reliably result in ambulance diversion. Messaging about diversion status should only to be used 

after the appropriate change has been made in the ReddiNet status field. 

IV. HOSPITAL ELIGIBILITY FOR DIVERSION 

A. CT scanner inoperative (CT divert). If a hospital’s CT scanner is inoperative, diversion of 

specific ambulance patients as specified in the EMS patient destination policy (EMS policy #9) 

may be considered. These patients may include those with: 

1. Suspected stroke – duration of signs and symptoms four hours or less. 

2. New onset of altered consciousness for traumatic or medical reasons. 

B. Internal Disaster (INT Divert): A hospital is eligible for internal disaster divert whenever a 

“physical plant” internal disaster has occurred that has rendered emergency department 

services unavailable to the public, e.g., bomb threat, fire, power outage or explosion. 

C. Cardiac Cath Lab Inoperative (STEMI Divert). If a STEMI Receiving Center’s cardiac 

catheterization lab becomes inoperative due to maintenance or equipment failure, diversion of 

STEMI alert patients may be considered in accordance with the EMS STEMI Triage and 

Destination policy (EMS policy #25). 

V. PROCEDURE FOR REQUESTING, IMPLEMENTING AND CANCELLING DIVERT STATUS 

A. Obtain authorization from hospital administration according to hospital’s internal procedures. 

B. Update appropriate diversion status on ReddiNet the Hospital Status section. 

C. If diversion is anticipated to be prolonged, notify the EMS Agency (during normal working hours) 

or contact the EMS Duty officer (after-hours). 

C. Internal Disaster only: In the circumstance of hospital internal disaster the facility is to notify 

Sheriff’s dispatch (925-646-2441) of the nature of the emergency and request dispatch to notify 

all ambulance providers and the EMS Duty Officer. 

D. To re-establish normal ambulance traffic, the hospital will update appropriate diversion status 

field on ReddiNet. If ReddiNet is unavailable, the hospital is to contact Sheriff’s dispatch and 

request that they notify all ambulance providers and the EMS Duty Officer. 

1 Formerly known as Physical Plant Casualty



STEMI TRIAGE AND DESTINATION 

POLICY #: 25 

PAGE: 1 of 3 


REVIEWED: 07/05/2011 

I. PURPOSE 

Utilizing prehospital 12-lead electrocardiograms (P12ECG), patients presenting with ST-segment 

elevation myocardial infarction (STEMI) shall be triaged and transported, with patient consent, directly 

to STEMI centers for rapid intervention. This policy outlines the process of triage and transport of 

STEMI patients. 


Prehospital 12-lead ECG (P12ECG): A 12-lead electrocardiogram obtained by EMS crews or in rare 

circumstances by a medical facility or office other than a hospital. 

ST-Segment Elevation Myocardial Infarction (STEMI): A specific finding on P12ECG showing STsegment 

elevation of 1 mm or greater in anatomically contiguous leads, indicating this specific type of 

myocardial infarction. 

Computer Interpretation of STEMI: With printout of P12ECG done, a patient with a STEMI is identified 

distinctly with ***Acute MI*** (ZOLL); ***Acute MI Suspected*** (LP12) or ***MEETS ST ELEVATION 

MI CRITERIA *** (LP15) by a computerized algorithm present in the monitor-defibrillator unit (wording 

varies by manufacturer). Other abnormalities of P12ECG do not signify STEMI. 

STEMI Receiving Center (SRC): Hospitals designated by Contra Costa EMS as those to which 

patients with identified STEMI on P12ECG will be transported based on the center’s prompt 

availability of invasive cardiac care. 

STEMI Alert: Report from prehospital personnel that notifies a STEMI Receiving Center as early as 

possible that a patient has a computer-interpreted P12ECG indicating a STEMI. The alert allows the 

SRC to prepare equipment and personnel for arrival of the patient in order to provide intervention in 

the most rapid fashion possible. 

III. TRIAGE 

A. Patients with chest pain or other symptoms suggestive of Acute Coronary Syndrome (ACS) and 

those patients who have Return of Spontaneous Circulation (ROSC) following Sudden Cardiac 

Arrest (SCA) should have a P12ECG performed. 

1. Exceptions include patients who are not cooperative with the procedure, or patients in 

whom the need for critical resuscitative measures, preclude performance of the P12ECG. 

2. Paramedic personnel should review the P12ECG tracing in all instances to assure that 

little or no artifact exists (steady baseline, lack of other electrical interference, complete 

complexes present in all 12 leads). Repeat P12ECG may be necessary to obtain an 

accurate tracing. 

3. Paramedic personnel should, when available, transmit the P12ECG to the destination 

SRC. Exception would be if SRC does not have the capability to receive transmitted 

P12ECG. 

B. If computerized interpretation of accurately performed P12ECG indicates either ***Acute MI*** 

(Zoll) or ***Acute MI Suspected*** (LP-12) or ***Meets ST Elevation Criteria*** (LP-15), the 

patient qualifies as a candidate for transport to an SRC. Patients without these findings should 

be transported per the EMS “Patient Destination Determination” policy (Policy #9).



POLICY #: 25 

PAGE: 2 of 3 

IV. DESTINATION 

A. Patients with an identified STEMI shall be transported to a STEMI Receiving Center (SRC). 

1. Patients shall be transported to the closest SRC unless they request another facility. 

2. Patient request and condition must be considered when determining destination. 

3. An SRC that is not the closest SRC facility is an acceptable destination if estimated 

additional transport time does not exceed 15 minutes. 

4. If the nearest SRC is on STEMI diversion the patient should be transported to the next 

closest accepting SRC. 

B. Patients with cardiac arrest who have a STEMI identified by 12-lead ECG before or after arrest 

shall be transported to the closest SRC. 

C. Patients with unmanageable airway en route shall be transported to the closest basic 

emergency department. 

D. If a SRC is on STEMI Diversion, the patient should be transported to the next closest accepting 

SRC. 

V. STEMI ALERT/PATIENT REPORT 

A. In patients with identified STEMI, desired destination shall be promptly determined after the P12 

ECG is completed and read, and that hospital shall be contracted as soon as possible after 

destination determined. 

B. The STEMI Alert should contain the following essential information: 

1. Situation: 

a. Identify the call as a “STEMI Alert” 

b. Give estimated time of arrival (ETA) in minutes 

c. Patient age and gender 

d. State ECG findings and any urgent concerns 

1) P12ECG shows ***Acute MI*** (ZOLL) or 

2) P12ECG shows ***Acute MI Suspected*** (LP12) 

3) P12ECG shows ***MEETS ST ELEVATION MI CRITERIA*** (LP15) 

e. When 12 lead transmitted, verify that transmission was received. 

f. If patient elects to go to a facility that is not STEMI designated inform receiving 

facility 

2. Background: 

a. Presenting/chief complaint and symptoms 

b. Pertinent past cardiac history 

c. Pacemaker placement 

3. Assessment: 

a. General impression 

b. Pertinent vital signs and physical exam 

c. Pain level 

4. Rx-Recap: 

a. Prehospital treatments given 

b. Patient response to prehospital treatments



POLICY #: 25 

PAGE: 3 of 3 

C. Emergency Room Patient handoff report should repeat STEMI Alert information and include: 

1. Patient identification 

2. Presenting complaint 

3. Additional background information: 

a. Past medical history 

b. Advanced directives if known 

4. Allergy and medication history including high-risk medications 

a. Anticoagulants 

b. Insulin 

c. Digoxin 

d. Erectile Dysfunction Drugs (ERDs) 

5. Previous history of Coronary Artery Surgery or thrombolytic (clot busting) therapy 

6. Cardiologist if known 

VI. DOCUMENTATION 

A. A copy of the P12ECG (multiple if performed) shall be delivered to the nurse caring for the 

patient at arrival in the Emergency Department. 

B. A copy of the P12ECG (multiple if performed) shall be generated for inclusion in the prehospital 

Patient Care Record or incorporated via electronic means into the record. The finding of STEMI 

on P12ECG and confirmation of the STEMI Alert shall also be recorded in the Patient Care 

Record. 

VII. LIST OF STEMI CENTERS 

IN-COUNTY STEMI CENTERS OUT-OF-COUNTY STEMI CENTERS 

Doctors Medical Center San Pablo ValleyCare - Pleasanton 

John Muir Medical Center – Concord Campus Oakland Summit Medical Center 

John Muir Medical Center – Walnut Creek Campus 

Kaiser Permanente Medical Center– Walnut Creek 

San Ramon Regional Medical Center – San Ramon 

Sutter Delta Medical Center - Antioch



EMS STEMI RECEIVING CENTER DESIGNATION 

POLICY #: 26 

PAGE: 1 of 3 



I. PURPOSE 

To define requirements for designation as a Contra costa County STEMI Receiving Center (SRC) for 

patients transported via the 9-1-1- system with ST-elevation myocardial infarction (STEMI) who may 

benefit by rapid assessment and percutaneous coronary intervention (PCI). 

II. APPLICATION PROCESS 

To apply for designation as an EMS STEMI Receiving Center (SRC) for Contra Costa County, an 

interested hospital shall: 

A. Submit a Contra Costa EMS designation application to the Contra Costa EMS Agency. 

B. Pay applicable initial application fee and annual designation fee to cover initial and ongoing 

County costs to support the STEMI program. 

III. DESIGNATION CRITERIA 

A. Current California licensure as an acute care facility providing Basic Emergency Medical 

Services. 

B. Ability to enter into a written agreement with Contra Costa County identifying SRC and County 

roles and responsibilities. 

C. Meets STEMI Receiving Center Designation Criteria as defined in the STEMI Designation 

Application. The criteria include: 

1. Hospital Services 

a. Special permit for cardiac catheterization laboratory. 

b. Intra-aortic balloon pump capability. 

c. Special permit for cardiovascular surgery service. 

1) The Contra Costa EMS Medical Director may waive this requirement for 

patient or system needs. 

2) Conformance with the American College of Cardiology/American Heart 

Association/Society for Cardiovascular Angiography and Intervention 

(ACC/AHA/SCAI) guidelines for centers without backup cardiovascular surgery 

will be evaluated in consideration of the waiver. 

d. Continuous availability of PCI resources (24-hours/7-days a week). 

2. Hospital Personnel 

a. STEMI Receiving Center Medical Director 

b. STEMI Receiving Center Program Manager 

c. Cardiac Catheterization Lab Manager/Coordinator 

d. Intra-aortic balloon pump technician(s) 

e. Appropriate Cardiac catheterization nursing and support personnel 

f. Physician Consultants 

1) Cardiology interventionalist 

2) CV Surgeon



POLICY #: 26 

PAGE: 2 of 3 

3. Clinical Capabilities 

a. ACC/AHA/SCAI guidelines for activity levels of facilities and practitioners for both 

primary PCI and total PCI events are optimal benchmarks. 

b. Performance (timeliness) and outcome measures will be assessed initially in the 

survey process, and will be monitored closely on an ongoing basis. 

D. Appropriate internal (hospital) policies including: 

1. Cardiac interventionalist activation 

2. Cardiac catheterization lab team activation 

3. STEMI contingency plans for personnel and equipment 

4. Coronary angiography 

5. PCI and use of fibrinolytic 

6. Interfacility transfer STEMI policies/protocols 

E. Performance Improvement Program 

1. Participation in Contra Costa EMS SRC QI Committee Core Membership 

a. EMS Medical Director 

b. EMS Quality Improvement Coordinator 

c. Designated cardiologist from each SRC 

d. Designated quality improvement representative from each SRC 

2. Meetings to be held on a quarterly basis initially. Meeting frequency to be reviewed 

following the first year. 

3. Written internal quality improvement plan/program description for STEMI patients shall 

include appropriate evidence of an internal review process that includes: 

a. Death rate (within 30 days, related to procedure regardless of mechanism) 

b. Emergency CABG rate (result of procedure failure or complication) 

c. Vascular complications (access site, transfusion, or operative intervention required) 

d. Cerebrovascular accident rate (peri-procedure) 

e. Post-procedure nephrotoxicity (increase in serum creatinine of >0.5) 

f. Sentinel event, system and organization issue review and resolution processes 

4. Participation in Prehospital STEMI-related educational activities. 

F. Data Collection, Submission and Analysis 

1. Participation in National Cardiac Data Registry (NCDR) 

2. Participation in Contra Costa County EMS data collection as defined by Data 

Requirements for STEMI Centers document available at the Contra Costa EMS Agency. 

IV. DESIGNATION 

A. SRC designation will be awarded to a hospital following satisfactory review of written 

documentation and an initial site survey by Contra Costa EMS staff. 

B. SRC designation period will coincide with the period covered in the written agreement between 

the SRC and the County. 

V. BASIS FOR LOSS OF DESIGNATION 

A. Inability to meet and maintain STEMI Receiving Center Designation Criteria 

B. Failure to provide required data



C. Failure to participate in STEMI system QI activities 

D. Other criteria as defined and reviewed by the SRC QI Committee 

VI. LIST OF STEMI CENTERS 

POLICY #: 26 

PAGE: 3 of 3 

IN-COUNTY STEMI CENTERS OUT-OF-COUNTY STEMI CENTERS 

Doctors Medical Center San Pablo ValleyCare - Pleasanton 

John Muir Medical Center – Concord Campus Oakland Summit Medical Center 

John Muir Medical Center – Walnut Creek Campus 


San Ramon Regional Medical Center – San Ramon 

Sutter Delta Medical Center - Antioch



PREHOSPITAL PATIENT CARE RECORD (PCR) 

POLICY #: 27 

PAGE: 1 of 3 



I. PURPOSE 

The purpose of this policy is to define requirements for patient care documentation and the procedure 

for completion, distribution and retention of the patient care record (PCR) applicable to EMS transport 

providers, ALS first responders, and Enhanced EMT first responders. 

II. AUTHORITY 

The use of EMS approved paper or electronic PCRs and their associated data collection and 

reporting capabilities is established by the Contra Costa County EMS Agency, in accordance 

with the California Health and Safety Code and the California Code of Regulations. 

III. DEFINITION 

Completed PCR: a patient care record which documents required information as defined in Section 

VI.D of this policy. 

IV. POLICY 

A. EMS personnel shall complete patient care records (PCR) on all EMS patient responses 

regardless of patient outcome. This includes calls where a unit responded and there was no 

patient contact, as well as calls where the response is cancelled before arrival on scene. 

B. Emergency department staff shall have early access to information describing all patient care 

provided by EMS personnel so that a continuity of care can be maintained. 

C. All available and relevant information shall be accurately documented on the PCR. 

D. Intentional failure to complete a PCR when required or fraudulent or false documentation on a 

PCR may result in formal investigative action under the California Health and Safety Code, 

1798.200, and Contra Costa County EMS Policy. 

E. Patient care documentation management is to be compliant with HIPAA and medical record 

retention requirements. 

V. PCR AVAILABILITY 

A completed PCR delivered to the receiving facility is a high priority and must be left for each patient 

prior to clearing the receiving hospital, or within 2 hours of providing patient care. 

A. A partially completed or preliminary PCR, marked as such, shall be left with the patient if a PCR 

cannot be completed prior to clearing the receiving facility. 

B. Non-transporting agencies that have turned over care to the transporting personnel may send a 

partially completed or preliminary PCR, marked as such, with the patient. 

C. All PCRs must be fully completed and delivered (fax or hard copy) to the receiving facility within 

24 hours of patient contact. 

VI. PCR PROCEDURES 

A. Personnel providing patient care are responsible for accurately documenting all available and 

relevant patient information on the PCR. 

B. Care given prior to arrival, by bystanders or first responder personnel, shall be documented on a 

PCR. 

C. Use of usual and customary abbreviations is permitted in the narrative section of the record or 

as defined in automated PCR pre-designated pick lists.



D. The PCR shall contain the following Basic Data Elements, when available: 

1. Initial Response Information 

a. EMS unit number 

b. Date and estimated time of incident 

c. Time of receipt of call 

d. Time of dispatch to the scene 

e. Time of arrival at the scene 

f. Incident location 

2. Patient Information 

a. Name 

b. Age and date of birth 

c. Gender 

d. Weight, if necessary for treatment 

e. Address 

f. Chief complaint 

g. Patient history 

h. Vital signs 

i. Appropriate physical assessment 

j. Emergency care rendered, and patient’s response to such treatment 

k. Patient disposition 

l. Time of departure from scene (if transported) 

m. Time of arrival at receiving facility (if transported) 

n. Name of receiving facility (if transported) 

o. Name and unique identifier number(s) of EMS personnel on the call 

p. Signature of EMS personnel on the call 

E. The PCR shall be completed and distributed in accordance with this policy. 

POLICY #: 27 

PAGE: 2 of 3 

F. A completed PCR shall not be altered or changed except by the individual who completed the 

PCR. Exceptions are permitted to add or change billing information, or add a name or other 

pertinent demographics unknown at the time of the call. 

G. If a paper PCR is used, or a change is made on a hard copy of an automated PCR, 

documentation errors shall be lined through (e.g. Like this), and the correction shall have the 

patient attendant’s initials beside it. 

H. Any changes made to an electronic PCR shall have documentation of those changes retained in 

the computer database. 

VII. DOCUMENTATION WHEN MEDICAL CARE OR TRANSPORT IS DECLINED 

A. In situations where the patient, or their legal representative, declines medical care or transport 

when care is recommended and felt to be necessary by the prehospital personnel attending that 

patient, documentation should include all available basic data elements, plus: 

1. Mental status and patient competency to decline care without impairment due to drugs, 

alcohol or organic causes (medical or mental illness). 

2. Patient informed of nature of condition and planned treatment/transportation offered.



POLICY #: 27 

PAGE: 3 of 3 

3. Specific risks and consequences discussed – patient acknowledged understanding. 

4. Specific comments made by patient (with quote marks) in declining care/transport. 

5. Base contact/physician name, if done. 

6. Advisory for patient to contact 911 or seek further care if s/he should change mind. 

7. Disposition – released to self, custody of parent/guardian, law enforcement or other 

person. 

8. Signature of patient/responsible party or documentation of refusal to sign. 

9. Name/signature of witness, if available, plus permanent identifier. 

10. Name of interpreter if used. 

11. Any other information appropriate to document situation or event. 

B. If a first responder agency has patient contact, the call results in no transport, and the transport 

agency has no patient contact, first responder agency personnel are responsible for completion 

of appropriate documentation. 

C. If patient care has been transferred from first responders and a patient subsequently declines 

further treatment or transport, the transport crew is responsible for appropriate documentation. 

VIII. HOSPITAL RESPONSIBILITIES 

Hospitals should implement mechanisms to assure that prehospital documentation arriving with the 

patient is readily available to ED staffs and is incorporated into the hospital medical record system. 

IX. ELECTRONIC SYSTEM FAILURE 

A. Back-up systems to provide for paper PCR documentation must be in place for use should an 

electronic documentation system fail. Electronic documentation system failure is NOT an 

exception for providing the required PCR documentation. 

B. The EMS Agency shall be notified of downtime or transmission difficulties lasting more than 24 

hours. 

X. MULTI-CASUALTY INCIDENTS 

A. Electronic or paper PCRs shall be completed for all patients in multi-casualty incidents unless 

requirements have been shifted to documentation on triage tags per MCI plan directives. 

B. In incidents with large numbers of persons refusing treatment or transport, efforts should be 

made to document as much information as possible.



BASE HOSPITAL DESIGNATION 

I. PURPOSE 

POLICY #: 29 

PAGE: 1 of 3 



To define the criteria, which shall be met by acute care hospitals in Contra Costa County for Base 

Hospital designation. 

II. AUTHORITY 

Health and Safety Code, Division 2.5, Sections 1798, 1798.101, 1798.105, 1798.2 and California 

Code of Regulations, Title 22, Section 100175. 

III. DEFINITION AND FUNCTION 

A Base Hospital is a hospital designated by the Local EMS Agency as responsible for directing the 

advanced life support system and prehospital care system assigned to it by the local EMS agency. 

The Base Hospital functions within the Local EMS system to facilitate and expedite safe, high-quality, 

patient-centered care providing destination and prehospital on-line decision making support without 

interruption, 24 hours per day, 7 days a week. The base hospital works in partnership with local EMS 

stakeholders in accordance with California EMSA and Local EMS Agency requirements. 

IV. DESIGNATION PROCESS 

A. Contra Costa Emergency Medical Services designates Base Hospitals. 

B. Application and agreement process is defined by the Contra Costa Emergency Medical Services 

Agency in compliance with California Emergency Medical Services Authority (EMSA) 

requirements. 

C. The designation period will coincide with the period covered in a written agreement between the 

Base Hospital and the Contra Costa Emergency Medical Services (EMS) Agency. 

V. DESIGNATION CRITERIA 

A. Current California Licensure as an acute care facility providing Basic Emergency Medical 

Services and Joint Commission Accreditation. 

B. Ability to enter into a written agreement as Base Hospital with the Contra Costa EMS Agency. 

C. Continuous availability of Base Hospital service without interruption (24-hours/7-days a week). 

D. Ability to provide immediate response to each and every request by prehospital personnel for 

medical consultation or trauma destination. 

E. Commitment to collaborate with Contra Costa EMS Agency to provide and maintain function of 

communication equipment for the purposes of communicating with prehospital personnel 

without interruption. 

F. Ability to promptly notify receiving hospital of every patient for whom there is Base Hospital 

direction. 

G. Ability to provide audio and written documentation of radio and telephone consultations with 

Prehospital personnel including trauma destination determinations. 

H. Commitment to assist the county in implementing new policies and procedures issued by the 

county. 

I. Designate appropriate personnel to support and oversee Base Hospital functions including: 

1. Base Hospital Liaison Physician Physician responsible for providing oversight and 

leadership to the Base Hospital EMS QI program.



POLICY #: 29 

PAGE: 2 of 3 

a) Licensed physician on the hospital staff experienced in emergency medicine and 

regularly assigned to the Emergency Department. 

b) Experienced in base hospital radio operations and Contra Costa EMS Agency 

policies and procedures. 

c) Maintains Base Hospital Physician requirements. 

d) Participates on Medical Advisory Committee, Pre-Trauma Audit Committee (Pre- 

TAC) and other appropriate prehospital committees or advisory groups. 

2. Base Hospital Nurse Coordinator responsible for providing overall support for base station 

operations and assists the Base Hospital Liaison Physician in the medical supervision of 

prehospital and hospital personnel within the Base Hospital’s area of responsibility. 

a) MICN authorized California Licensed Registered Nurse experienced in emergency 

nursing. 

b) Experienced in base hospital radio operations and Contra Costa EMS Agency 

policies and procedures. 

c) Participates on Medical Advisory Committee and other appropriate prehospital 

committees or advisory groups. 

d) Acts as liaison between receiving facilities and Contra Costa EMS Agency 

supporting identification and resolution of Base Hospital issues. 

e) Coordinates the Base Hospital data collection and quality improvement program. 

3. Base Hospital Physicians knowledgeable and capable of issuing advice and instructions to 

MICNs and prehospital personnel consistent with the standards established by State of 

California EMSA and Contra Costa EMS Agency. 

a) Maintain current certification in ACLS. This requirement may be waived if the 

physician is Board certified in Emergency Medicine. 

b) Board certified or eligible in Emergency Medicine. 

c) Completes radio communications preparation and base hospital orientation to EMS 

prior to acting as EMS Base Hospital Physician including: 

(1) State legislation and regulations governing EMS and prehospital providers. 

(2) Base physician role and responsibilities. 

(3) County Field Treatment guidelines and patient care report forms. 

(4) Policies and procedures pertinent to Base Hospital function and medical 

control, e.g., interfacility transfers, disrupted communications. 

d) Acts as a resource in quality improvement activities to Base Hospital Coordinator 

and Base Hospital Liaison Physician. 

4. MICNs knowledgeable and capable of issuing advice and instructions in consultation with 

Base Physician to prehospital personnel consistent with the standards established by the 

State of California and Contra Costa EMS. 

a) Maintain current certification in ACLS. 

b) Maintain MICN Authorization in compliance with Contra Costa EMS Policies and 

Procedures. 

c) Completes radio communications preparation and base hospital orientation to EMS 

prior to acting as a MICN including: 

(1) State legislation and regulations governing EMS and Prehospital providers. 

(2) MICN role and responsibilities.



POLICY #: 29 

PAGE: 3 of 3 

(3) County Field Treatment guidelines and patient care report forms. 

(4) Policies and procedures pertinent to Base Hospital function and medical 

control, e.g., interfacility transfers, disrupted communications. 

d) Acts as a resource in quality improvement activities to Base Hospital Coordinator 

and Base Hospital Liaison Physician. 

VI. PERFORMANCE IMPROVEMENT 

A. Base Hospital Staff maintains a written Base Hospital Quality Improvement Policy or Plan. 

B. Assures quality improvement plan shall interface with the Contra Costa EMS Agency Quality 

Improvement Program. 

C. Participates in Contra Costa EMS Agency Quality Improvement Program. 

D. Participates in Contra Costa EMS Agency event reporting. 

E. Provides in a timely manner data and statistical reports as may reasonably be required by the 

Contra Costa County EMS Agency and as allowed under HIPPAA. 

F. Maintains and oversees Base Physician and MICN authorization and continuing education 

tracking system. 

VII. BASIS FOR LOSS OF DESIGNATION 

Base hospital designation may be denied, suspended or revoked by the Contra Costa EMS Agency 

Medical Director for failure to comply with state and Contra Costa EMS Agency policies, procedures 

or regulations.



PATIENT RESTRAINTS 

POLICY #: 30 

PAGE: 1 of 2 



I. PURPOSE 

To outline appropriate use of patient restraints. 

II. POLICY 

A. Safety of responding personnel, community, and the patient is of paramount concern. 

B. Restraints should only be utilized in situations where the patient is exhibiting behavior that 

presents a danger to themselves or others. 

C. Law enforcement considerations 

1. Law enforcement personnel are responsible for the capture and/or restraint of assaultive or 

potentially assaultive patients. Law enforcement personnel should assist in preparing these 

patients for safe ambulance transport. 

2. Law enforcement agencies retain primary responsibility for safe transport of patients under 

arrest or on a 5150 hold. 

3. Patients under arrest must always be accompanied by law enforcement personnel. Law 

enforcement personnel should be prepared to accompany a patient on a 5150 hold if 

assistance is needed for safe transport. 

4. Patients under arrest or on 5150 hold shall be searched thoroughly by law enforcement for 

weapons prior to being placed in the ambulance. 


A. General approach 

1. Behavioral emergencies may be a manifestation of a medical condition such as head injury, 

drug or alcohol intoxication, metabolic disorders, hypoxia, or post-ictal state. Field 

personnel should consider these conditions along with psychiatric disorders in the approach 

to behavioral emergencies. 

2. Field personnel should keep scene safety in mind and maintain situational awareness for 

changing circumstances. 

3. Field personnel should attempt to de-escalate verbally aggressive behavior with a calm and 

reassuring approach and manner. 

B. Restraint types 

1. Leather or cloth restraints may be utilized for patient restraint during transport. 

2. Handcuffs may only be applied by law enforcement personnel and should be replaced with 

another method of restraint prior to transport. 

a. If handcuffs must be used for restraint during transport law enforcement personnel 

must accompany the patient in the ambulance. 

b. A patient in handcuffs may not be handcuffed to the gurney. 

3. Chemical restraint may be necessary and shall be used only with a base order. 

C. Patient Restraint Safety Measures 

1. Physically restrained patients shall be placed in a lateral position or supine in Fowler's or 

Semi-Fowler's position (gurney angled 30-90 degrees).



POLICY #: 30 

PAGE: 2 of 2 

2. Patients shall not be transported in a prone or "hog-tied" position. 

3. The method of restraint must allow for adequate monitoring of pulse and respiration, and 

should not restrict the patient or rescuer’s ability to protect the airway should vomiting occur. 

4. Restrained extremities should be monitored for circulation, motor function, and sensory 

function every 15 minutes along with vital signs and mental status. 

5. Patients who are chemically restrained will be placed, whenever possible, on continuous 

cardiopulmonary monitoring and pulse oximetry during transport. 

6. Prehospital documentation should include behavior reason for restraint, other pertinent 

clinical information, and documentation of monitoring of restrained extremities. 

D. Other considerations 

1. If an unrestrained patient becomes aggressive or assaultive during transport, ambulance 

personnel shall make reasonable efforts to calm and reassure the patient and request law 

enforcement assistance. 

2. If the crew believes their personal safety is at risk, they should not inhibit a patient's attempt 

to leave the ambulance. Every effort should be made to release the patient into a safe 

environment. Ambulance personnel are to remain on scene until law enforcement arrives to 

take control of the situation.



PREHOSPITAL MANAGEMENT OF PRE-EXISTING 

PATIENT MEDICAL DEVICES/EQUIPMENT: 

INTRAVENOUS LINES AND OTHER 

POLICY #: 31 

PAGE: 1 of 2 



I. PURPOSE 

To provide guidance for pre-hospital management of patients with pre-existing medical 

devices & equipment during routine, emergency or inter-facility transport; including 

intravenous lines and devices, home ventilators, and other patient care equipment. 

II. PROCEDURE 

A. Peripheral IV Lines 

1. EMT-Is may: 

a. Monitor IV lines delivering glucose solutions or isotonic balanced salt 

solutions including Ringer’s Lactate for volume replacement. 

b. Monitor, maintain and adjust if necessary in order to maintain a preset rate of 

flow and turn off the flow of IV fluid. 

c. They may not monitor an IV if any medication has been added to the solution. 

2. Paramedics may: 

a. Administer intravenous glucose solutions or isotonic balanced salt solutions 

including Ringer’s lactate solution. 

b. Monitor and adjust IV flow rates of existing IV(s) with solutions containing 

potassium chloride (KCl) equal to or less than 20 mEq/L. 

c. Monitor, maintain and adjust approved IV solutions with medications that are 

allowed as part of the local paramedic scope of practice. 

B. Special Populations 

For dialysis patients whose peripheral access site (shunt or fistula) has already 

been accessed, the existing IV line may be used by a paramedic for 

administration of fluids or medications. 

C. Central Lines/Central Venous Access Device/Infusion Devices 

1. EMT-Is may transport patients with existing central lines or central venous access 

devices, e.g. Heparin or saline locked central lines, but may not transport patients 

if any fluid or medications are being administered through these devices. 

Exception: In the case where a patient has a physician-prescribed infusion 

device that is being controlled/monitored by either the patient or a family 

member, e.g. patient controlled analgesia (PCA) pump. 

If any question exists, base contact should be made for further clarification. 

2. Paramedics may transport a patient that has fluid or medication running through a 

central line or other central venous access device as long as the medications are 

within the paramedic scope of practice. 

Exceptions:



POLICY #: 31 

PAGE: 2 of 2 

o In the case where a patient has a physician-prescribed infusion device 

that is being controlled/monitored by either the patient or a family 

member. 

o In the event of cardiopulmonary arrest or extremis due to circulatory 

shock, and a peripheral IV or IO cannot be obtained, an indwelling 

central line(s) can be used by the paramedic to deliver fluids and 

medications within their scope. 


3. Central venous access devices that would require the penetration of skin by the 

paramedic, such as internal subcutaneous infusion ports or fistulas, may not be 

used. 

4. When handling a central line paramedics should: 

a. Use strict aseptic technique, 

b. Not remove injection caps from catheters, 

o Not allow IV fluids to run dry, 

o Always expel air from preloads/syringes prior to medication 

administration, 

o In the event of damage to the central line immediately clamp the external 

catheter between the site of the catheter damage and the patient. 

D. Thorascostomy Tubes 

Paramedics may monitor thorascotomy tubes. 

EMT-Is are not permitted to transport patients with thoracostomy tubes. 

E. Foley Catheters, Nasogastric Tubes, Gastrostomy Tubes, Tracheostomy Tubes 

EMT-I and paramedic personnel may transport these patients, however, these 

devices are not to be manipulated, removed, or discontinued. 


F. Home Ventilators 

EMT-Is may transport patients with home ventilators but these patients should ideally 

be transported via ALS-level ambulance. 

In an emergency situation requiring immediate transport (cardiac arrest, respiratory 

distress or extremis due to shock), patients may be transported to the closest facility 

via EMT-I ambulance and ventilation should be supported via bag-valve-mask device. 

G. Other Devices 

If other equipment is encountered by EMT-I or paramedic personnel, a patient may be 

transported with the equipment provided that the prehospital providers are not 

required to discontinue or alter the functioning of the equipment. 

If the patient cannot be moved without disrupting the function of the equipment, base 

consultation should be obtained.



EMS EVENT REPORTING 

I. PURPOSE 

POLICY #: 32 

PAGE: 1 of 3 



To establish a clear system of patient safety and EMS response-related reporting for the 

purposes of review, data analysis, patient safety and EMS system performance. 

To define reporting requirements for events that have the potential to cause community 

concern or represent a threat to public health and safety. 

To define the reporting and monitoring responsibilities of all EMS system participants. 

To recognize exemplary prehospital care in the EMS system. 

II. AUTHORITY 

California Health and Safety Code; California Code of Regulations, Title 22 and California Health and 

Safety Code section 1798.200. 

III. POLICY 

EMS events shall be appropriately reported, reviewed and tracked to monitor, maintain and improve 

safety. Exemplary care may also be identified, tracked and acknowledged through this process. 

Reporting is encouraged from any individual who encounters or recognizes a situation in which a 

safety related or exemplary event occurred while a patient was being cared for. 

Definitions of EMS Events 

A. Any event that has resulted in or has the potential to lead to an adverse patient outcome. These 

events may be related to systems, operations, devices, equipment, medications or any aspect of 

patient care. 

B. Great Catches: Events that are recognized and prevented before they actually occur. A “great 

catch” includes recognition of provider action that contributes to the prevention of negative or 

adverse patient outcomes. Near miss events are included in this category. 

C. Community events that may cause public concern, (either positive or negative): Examples of 

potential community concerns could include: bomb threats, toxic exposures, multi casualty 

incidents, infectious outbreaks or exposures, and EMS system operational issues. 

D. Exemplary care in the field deserving of recognition or commendation. 

E. Events that represent a threat to public health and safety as defined by 1798.200, as listed on 

the back of the EMS event report form. 

IV. REVIEW PROCESS 

A. The involved agency(ies) will review and take any indicated follow-up actions on all reported 

EMS events. 

1. The on-duty officer or supervisor shall verbally notify EMS Agency promptly of events that 

may cause public concern. 

2. Involved agencies should review, and if appropriate, report EMS events to the EMS 

Agency using the instructions and forms on the Contra Costa County EMS website at 

www.cccems.org. 

a. Contra Costa County EMS Event Report Form 

b. Contra Costa County EMS Event-QI Review Paper or Electronic Form



POLICY #: 32 

PAGE: 2 of 3 

B. Interagency EMS Events 

To allow for prompt review and follow-up, communication of events should occur between the 

involved agencies. Each agency is responsible for its own internal review and follow-up. EMS 

Agency staff is available to assist all participants in seeking solutions to patient safety events 

that affect the EMS system. 

C. EMS events that require review include: 

1. Any threat to public safety as defined by the Health and Safety Code 1798.200 

2. Medication related: incorrect drug choice, dosage, or route 

3. Equipment related: equipment problems, adverse events or failures related to patient care 

or EMS response 

4. Treatment or Procedure related such as: 

a. Difficulties, problems and unexpected events associated with procedures (e.g. 

known esophageal intubation) 

b. Events related to patient assessment or application of treatment guidelines (e.g. 

multiple attempts at interventions outside the number recommended by treatment 

guidelines 

c. Events related to interventions or procedures done that are not consistent with 

paramedic primary impression 

5. Scope related: situations in which an EMT or Paramedic scope of practice was not 

property followed. 

6. Patient Interaction related: Verbal or physical event identified which resulted or had the 

potential for harm, insult, neglect or abuse of the patient. 

V. RESPONSIBILITIES 

A. Prehospital personnel 

1. Assure patient safety by immediately notifying the hospital staff at the receiving facility and 

the base hospital (if involved), when an event impacts or has a potential to impact the 

patient. 

2. Immediately report event of concern to an on-duty officer or supervisor using the 

appropriate chain of command. 

3. Complete the EMS event form. Include verification of verbal reports on the form. 

4. Recommendations for corrective actions from the individuals involved are encouraged. 

B. Provider Agency 

Each agency shall have a process of fact-finding, follow-up and tracking of EMS events. All 

reported events regardless of significance should be reviewed and tracked as part of the 

provider’s quality improvement program. 

1. Assure patient safety first. Assure medical providers involved in the patient’s care at the 

receiving hospital and base station (if involved) have been informed of events that have 

the potential to impact patient care. 

2. Evaluate the event and notify the EMS Agency promptly regarding issues of public 

concern or that require urgent investigation. 

3. Provide the EMS Agency with additional written or verbal reports if requested. 

4. Take action to remediate the situation. Develop remediation programs (e.g., individual 

performance improvement plans) that offer appropriate and timely feedback, skills review 

and competency training.



POLICY #: 32 

PAGE: 3 of 3 

5. Patient safety reporting data may be requested by the EMS Agency at regular intervals 

in order to assist the EMS Agency in evaluating system and operations issues. 

C. Base Hospital 

Base hospital should notify the Base Coordinator or designee of any identified EMS events. The 

Base Coordinator will: 

1. Assure patient safety 

2. Evaluate the event 

3. Complete the EMS event form and forward to involved agency(s) for review 

4. Notify EMS Agency if event meets prompt notification criteria 

5. Take action to remediate the situation 

Patient safety reporting data may be requested by the EMS Agency at regular intervals in 

order to assist the EMS Agency in evaluating system and operations issues. 

D. Receiving Hospitals 

Receiving hospitals should report any identified EMS events to the involved agency 

supervisor(s) if possible. Hospitals may fax EMS events to the EMS Agency to be distributed to 

the appropriate agency. 

E. Other Reporting 

Any other system participants or individuals, including receiving hospital personnel, are 

encouraged to report EMS events to the EMS Agency. 

F. Anonymous Reporting 

EMS events may be reported anonymously to a provider agency representative or to the EMS 

Agency directly. Anonymous reporting should never be discouraged.



EMS AIRCRAFT - CLASSIFICATION 

POLICY #: 33A 

PAGE: 1 of 2 



I. PURPOSE 

To specify the classification requirements for EMS aircraft providers which base their operations 

within Contra Costa County. 

II. AUTHORITY 

Division 2.5 California Health and Safety Code; Title 22 California Code of Regulations. 

III. CLASSIFICATION 

The local EMS Agency is responsible for classifying EMS aircraft based within its jurisdiction, except 

that the California EMS Authority is responsible for classifying aircraft of the California Highway Patrol, 

California Department of Forestry, and California National Guard. 

A. Classification Categories 

An EMS aircraft will be classified as either an air ambulance or a rescue aircraft. Rescue aircraft 

will be further classified as advanced life support (ALS), basic life support (BLS) or auxiliary 

based on level of medical flight crew credentials. 

1. Air Ambulance: Any aircraft that is 

a. constructed, modified, equipped, and used to respond to emergency requests and to 

transport critically ill or injured patients, and 

b. staffed with a minimum of two attendants credentialed in advanced life support. 

2. Rescue Aircraft: An aircraft whose usual function is not prehospital emergency patient 

transport but which may be used, in compliance with EMS policy, for prehospital 

emergency patient transport when use of an air or ground ambulance is unsuitable or 

unavailable. 

a. Advanced Life Support Rescue Aircraft: A rescue aircraft whose medical flight 

crew has a minimum of one attendant credentialed in advanced life support. 

b. Basic Life Support Rescue Aircraft: A rescue aircraft whose medical flight crew 

has at a minimum one attendant certified as an EMT-A. An EMT-NA with the 

additional training and experience specified in Title 22, Section 100283 may be used 

to meet the BLS rescue aircraft medical staffing requirement. 

c. Auxiliary Rescue Aircraft: A rescue aircraft which does not have a medical flight 

crew, or whose medical flight crew does not meet minimum requirements 

established for Basic Life Support Rescue Aircraft. 

B. Medical Helicopter 

IV. 

The term “medical helicopter” shall mean a rotary wing aircraft that has been classified as an 

“air ambulance.” 

CLASSIFICATION PROCEDURE 

A. To become classified in Contra Costa County, and EMS aircraft provider is required to: 

1. Submit a completed Contra Costa County EMS Aircraft Classification form, 

2. Submit all required attachments, and 

3. Pay the current EMS Aircraft Classification Fee. 

B. Prior to classification, EMS Agency staff may visually inspect the aircraft, equipment and radios.



POLICY #: 33A 

PAGE: 2 of 2 

C. An EMS aircraft provider shall apply for re-classification whenever there is a: 

1. Transfer of ownership, or 

2. Change in any factor that applies to or affects its classification category. 

D. No person or organization shall provide or hold itself out as providing prehospital air ambulance 

or air rescue services unless that person or organization has been classified by a local EMS 

agency, or in the case of the California Highway Patrol, California Department of Forestry, and 

California National Guard, by the EMS Authority.



EMS AIRCRAFT - AUTHORIZATION 

POLICY #: 33B 

PAGE: 1 of 3 



I. PURPOSE 

To specify authorization requirements for EMS aircraft providers with operations based in Contra 

Costa County. 

II. AUTHORITY 

Division 2.5, California and Safety Code; Title 22. Division 9 and Chapter 8, California Code of 

Regulations. 

III. AUTHORIZATION 

The local EMS Agency is responsible for authorizing EMS aircraft used for EMS response within its 

jurisdiction. Normally, only EMS aircraft that meet the “air ambulance” classification standard shall be 

authorized by the EMS Agency to respond in Contra Costa County. However, any request by a public 

safety agency dispatch center shall constitute “authorization” to respond to that request only. 

IV. AUTHORIZATION PROCESS 

To become authorized in Contra Costa County, an EMS aircraft provider is required to: 

A. Submit a completed EMS Aircraft authorization form, 

B. Enter into a written agreement with the County, and 

C. Pay the current EMS Aircraft Authorization Fee. 

V. PERFORMANCE STANDARDS 

A. Services 

1. Only an “Air ambulance” may be dispatched in response to an emergency medical aircraft 

request. 

2. Aircraft may respond to emergency requests when and only when requested by a local 

public safety dispatch center. 

3. A seamless “one contact number system,” approved by the EMS Agency, is to be used by 

local public safety dispatch centers when requesting EMS aircraft assistance. 

4. An authorized provider shall assure that its dispatch center provides an accurate 

“estimated time of arrival” (ETA) in minutes and clock hours to the requester of each air 

ambulance request. 

5. An authorized provider shall comply with all applicable Federal, State and local laws and 

regulations, and County EMS policies, procedures and protocols. 

B. Dispatch and Communications 

1. EMS aircraft dispatch centers shall be staffed and equipped to receive and process 

requests for EMS aircraft. 

2. Dispatchers shall be adequately trained and prepared to process emergency medical 

requests. 

3. Aircraft shall be equipped with County’s MEDARS radio system for communications with 

Sheriff’s Dispatch, on-scene ambulances, public safety agencies, and local base and 

receiving hospitals.



POLICY #: 33B 

PAGE: 2 of 3 

C. Staffing 

1. Air ambulance staffing shall include a medical flight crew consisting of a minimum of two 

(2) attendants licensed in advanced life support, at least one (1) of which is a registered 

nurse or physician. 

2. Air medical flight crewmembers and pilots shall maintain all required professional 

licensure. 

D. Training and Orientation 

1. Medical flight crewmembers shall be trained in aeromedical transportation as specified in 

Section 100302, California Code of Regulations, and maintain current professional 

licenses. 

2. Medical flight crews and pilots shall be oriented and familiar with the local EMS system 

prior to responding to local emergency medical requests. Orientation shall include the 

following topics: 

a. Terrain and weather considerations specific to the geographic area of the County. 

b. Local EMS and public safety agencies. 

c. Locations of and special operational information related to local hospitals and 

medical specialty centers, helipads, airports and pre-determined emergency landing 

sites. 

d. Comprehensive communications inventory including frequency numbers, agency 

names and identifiers, PL codes, and any special communications procedures. 

e. (Medical crew) Local medical control policies and procedures. 

E. Medical Control 

1. Local Medical Control Agreements shall be in place for paramedic crewmembers. 

2. Providers shall assure compliance with local policies and procedures for medical control. 

3. Registered Nurse crewmembers function within the Nurse Practice Act and shall be 

trained/qualified to provide advanced life support care within the local paramedic scope of 

practice at a minimum. 

F. Documentation and Reporting 

1. Patients transported from within Contra Costa County: Patient care reports (PCRs) 

shall be completed for all patient transports despite location of receiving facility. PCRs 

include the required patient care data elements, requesting party/agency, and times 

necessary to determine aircraft response time from initial notification, on-scene time, and 

hospital transport time. Copies of PCRs are left with the patient at the receiving hospital. 

a. PCRs for all patients shall be sent to the EMS Agency within ten working days. 

2. Patients transported into Contra Costa County from another county: Patient name, 

age, transport date/time, assessment, CRAMS/GCS, mechanism of injury and destination 

shall be sent to EMS within ten calendar days of the end of that month. 

G. Quality Improvement 

1. Medical treatment guidelines for medical flight crew shall be in place and shall have been 

approved by the County EMS Medical Director. 

2. A comprehensive continuous quality improvement (CQI) program approved by the EMS 

Medical Director shall be in place and shall be overseen by a physician or a registered 

nurse. 

3. Quality improvement information shall be supplied to the County upon request.



POLICY #: 33B 

PAGE: 3 of 3 

4. County shall be notified of any events that could impact the credentials of air medical 

crewmembers. 

5. Provider shall participate in County-related CQI activities. 

H. Equipment and Supplies 

1. EMS aircraft shall meet configuration and restraint standards for “air ambulance” 

according to Section 100306, California Code of Regulations. 

2. Aircraft shall be stocked with full drug and solution inventories, and with basic, advanced 

life support and related specialty medical equipment and supplies at all times. 

VI. MAINTENANCE OF AUTHORIZATION 

1. County may inspect aircraft, facilities, equipment, policies and records relating to aircraft 

maintenance, dispatch, patient care, and personnel qualifications as pertain to local operations. 

2. Provider shall adhere to all applicable FARs including FAR Part 91 and 135 (or their equivalent). 

3. County may deny, suspend, or revoke an air ambulance authorization for failure to comply with 

applicable policies, procedures and regulations.



EMS AIRCRAFT – REQUEST, TRANSPORT 

CRITERIA, AND FIELD OPERATIONS 

POLICY #: 33C 

PAGE: 1 of 3 



I. PURPOSE 

To identify procedures for use by public safety agencies when requesting a medical helicopter or 

rescue aircraft for an EMS system response. 

To specify criteria for patient transport by air ambulance (medical helicopter) and to outline 

coordination of field operations at incidents involving air ambulance response. 

To assure the most appropriate, safest, and most cost effective method of transport based on the 

needs of the patient. 

II. AUTHORITY 

Division 2.5, California Health and Safety Code; Title 22. Division 9 and Chapter 8, California Code of 

Regulations. 

III. REQUEST FOR MEDICAL HELICOPTER OR RESCUE AIRCRAFT 

A. The Incident Commander (IC) or designee is responsible for initiating a medical helicopter or 

rescue aircraft response through his or her fire/medical dispatch center if these resources are 

thought to be necessary and are in the best interest of the patient. Requests may occur prior to 

or after IC arrival at scene. 

B. Requests should include the current weather conditions, and if known: 

1. Number of patients potentially requiring helicopter transport, 

2. Current weather conditions, and 

3. Haz-Mat information if pertinent. 

IV. EMS AIRCRAFT UTILIZATION CRITERIA 

Helicopter transport involves increased costs and more potential risk in transport. The benefits of 

transport should outweigh risks. For these reasons, helicopter transport should only be used when 

both time and clinical criteria are met. 

A. Time Criteria. 

Helicopter transport generally should be used only when it provides an advantage in terms of 

timely delivery of the patient from the scene to the emergency department. 

1. Helicopter field care and transport time (which includes on-scene time, flight time, and 

transport from helipad to the emergency department) is optimally 20-25 minutes in most 

cases. 

2. Time to ground transport a patient to a helicopter rendezvous site, or a time delay in 

helicopter arrival are additional factors to be considered when determining whether or not 

a helicopter is the most rapid method of transport overall. 

3. Trauma patients with potential need for advanced airway intervention (GCS 8 or less, 

trauma to neck or airway, rapidly decreasing mental status) may be appropriate for 

helicopter transport even when time criteria is not met.



B. Clinical Criteria 

POLICY #: 33C 

PAGE: 2 of 3 

1. Patients who meet the following criteria may benefit from helicopter transport. 

a. Trauma patients who meet high-risk criteria according to EMS trauma triage policy 

except for: 

1) Stable patients with isolated extremity trauma (who may meet high-risk criteria 

on that basis). 

2) Patients with mechanism but no significant physical exam findings. 

b. Trauma patients who do not meet high-risk criteria but by evaluation of mechanism 

and physical exam findings, appear to have potential significant injuries that merit 

rapid transport. 

c. Patients with specialized needs available only at a remote facility such as burn 

victims or critical pediatric patients. 

d. Critically ill or injured patients whose conditions may be aggravated or endangered 

by ground transport (e.g. limited access via ground ambulance or unsafe roadway) 

may be appropriate for helicopter transport. 

V. HELICOPTER UTILIZATION AND CANCELLATION DECISION 

A. The decision to use a helicopter rests with the Incident Commander (IC). 

B. The IC is responsible for cancellation of the helicopter response when helicopter transport 

criteria are not met. The following information is important for the IC to consider in making the 

best possible decision regarding mode of transport: 

1. Patient need. The paramedic with primary patient care responsibility will have the best 

information regarding the patient meeting clinical criteria. 

2. Estimated ground transport time versus air response and transport. The ground transport 

crew will be the best resource for determining whether or not there will be a transport time 

savings based on the travel time considering current traffic/weather conditions particularly 

when timesavings by helicopter is minimal. 

3. Proximity of a helispot or need for a helicopter/ambulance rendezvous site. A significant 

amount of time may be added to overall transport time if a helicopter is unable to land in 

proximity to the patient. 

4. ETA of the helicopter. If the patient is packaged and ready for transport, ground transport 

may be the fastest mode of transport overall if a helicopter has not arrived on scene. 

C. The ground ambulance responding to, or at the scene, should not be canceled until: 

1. The helicopter has left the scene with the patient aboard, or 

2. The senior medical personnel with primary patient care responsibility on-scene have 

determined that no patient transport is required. 

VI. COMMUNICATIONS 

A. Under normal circumstances, CALCORD is utilized for air-to-ground communication. The IC or 

designee, in conjunction with the fire/medical dispatch will designate an alternate frequency if 

necessary. 

B. The IC or designee may cancel a helicopter response at any time prior to patient transport 

through the fire/medical dispatch center or by direct communication to the responding 

helicopter.



POLICY #: 33C 

PAGE: 3 of 3 

VII. GROUND AMBULANCE RESPONSIBILITIES 

A. Ground ambulance units shall make trauma base contact as soon as possible to provide early 

notification of patient arrival. 

B. A ground unit paramedic, who accompanies a patient in a rescue aircraft must assure the 

presence of appropriate medical equipment and must obtain orientation to the aircraft and to 

medical air transport procedures prior to transport. 

VIII. HELICOPTER RENDEZVOUS 

A. If a helicopter rendezvous is deemed appropriate even considering added transport time, a 

helispot (rendezvous site) as close as possible to the scene should be established. 

B. A first-responder paramedic may elect to maintain primary patient care responsibility by 

accompanying the patient in transport to the helispot in order to facilitate communication with 

the treating helicopter crew. 

IX. MULTICASUALTY INCIDENT (MCI) RESPONSES 

Detailed roles and responsibilities for EMS helicopter providers during multicasualty incidents are 

specified in the County MCI Plan. Helicopters: 

A. Respond to an incident only when requested. 

B. Prepare to stage at closest airport or location designed by the Incident Commander. 

X. INCIDENT REVIEW AND QUALITY IMPROVEMENT 

A. Helicopter providers shall participate in EMS Agency quality improvement activities. 

B. Contra Costa EMS maintains oversight of helicopter utilization and works with helicopter 

provider agencies in assuring appropriate use of helicopter resources.



SEARCH FOR DONOR CARD 

POLICY #: 34 

PAGE: 1 of 1 



I. PURPOSE 

Section 7150.55 of the Health and Safety Code requires emergency medical personnel to make a 

reasonable search for a document of anatomical gift, or other information identifying the patient as a 

donor or an individual who has refused to make an anatomical gift, “upon providing emergency 

medical services to an individual, when it appears that the death of that individual may be imminent. 

This requirement shall be secondary to the requirement that ambulance or emergency medical 

personnel provide emergency medical services to the patient.” 

No search is to be made by emergency medical personnel after the patient has expired. 


“Imminent Death”: A condition wherein illness or injuries are of such severity that in the professional 

opinion of emergency medical personnel, death will probably occur before the patient arrives at the 

receiving hospital. This definition does not include any conscious patient regardless of the severity of 

illness or injury. 

“Reasonable Search”: A brief attempt by emergency medical personnel to locate documentation that 

may identify a patient as a potential organ donor, or one who has refused to make an anatomical gift. 

This search shall be limited to a wallet or purse that is on or near the individual, to locate a driver’s 

license or other identification card with this information. If a purse or wallet is searched by emergency 

medical personnel, the search must be done in the presence of a witness. 

“Donate Life California” A donor registry (internet-based, accessible by hospital personnel involved 

in transplant or tissue donation decisions) also contains the information on donor status that is present 

on driver’s licenses or identification cards issued since 2006. 


Emergency medical treatment and transport of the patient remains the highest priority for field 

personnel. This search shall not interfere with patient care or transport. 

A. If a document of anatomical gift or evidence of refusal to make an anatomical gift is located by 

emergency medical personnel, and the individual is taken to a hospital, the hospital shall be 

provided with the documentation. In situations where the investigating law enforcement officer 

has requested the card, hospital notification of documentation found will meet this requirement. 

Verification of documentation can be made through the “Donate Life California” registry. 

B. If emergency medical personnel are unable to perform a search due to overriding medical care 

priorities or sensitivity concerns at the scene and/or during the transport, the hospital shall be 

notified that the search has not been performed along with surrounding circumstances. 

C. Details of any search, including witnesses, what was found and who was notified, shall be 

documented on the Prehospital Care Report (PCR) completed for that patient. 

D. Most importantly, a completed PCR that describes the circumstances and timing of events leading 

to the patient’s condition as well as prehospital patient care delivered are critical to hospital 

personnel responsible for anatomical gift decisions.



SAFELY SURRENDERED BABY PROGRAM 

POLICY #: 35 

PAGE: 1 of 1 



I. PURPOSE 

The safe surrender of a child is rare event in the EMS community. This policy identifies the local 

resources and training materials to be used to support Contra Costa County’s Safely Surrendered 

Baby Program. California’s Safely Surrendered Baby Law (SB1368) requires all California Emergency 

Departments and designated sites, such as fire stations, to accept safely surrendered infants. 

The Safely Surrendered Baby Law (SB1368) was created to encourage parents who might otherwise 

abandon their infants in unsafe places to bring their newborns to a safe place without fear of legal 

consequences. The law creates legal immunity from criminal liability for child abandonment so long as 

the child is voluntarily surrendered by a parent or person with legal custody at a designated “Safely 

Surrendered Site.” 


Safely Surrendered Baby Program: The local program that includes county-wide policies and 

procedures for the training of personnel responsible for safe surrender of infants. This program is 

administered jointly by the Employment and Human Services’ Children and Family Services and 

Contra Costa Health Services (CCHS) Family, Maternal and Child Health Programs Division. CCHS 

Emergency Medical Services Division supports this program as part of its EMS for Children efforts. 

Safely Surrender Site: Contra Costa Safely Surrendered Sites include hospitals, fire stations, 

County Health Centers, and Kaiser medical offices. A complete list of sites can be found at 

www.ccchealth.org/topics/baby_safe. 

Newborn Safe Surrender Kits: These kits are used by Safely Surrender Site personnel and contain 

all written procedures and materials necessary to accept a safely surrender baby. These kits are 

available through CCHS Family, Maternal and Child Health Programs. Replacement kits can be 

obtained by calling (925) 313-6254. 

III. POLICY 

A. All EMS personnel will be trained in the roles and responsibilities of the Contra Costa 

County Safely Surrendered Baby Program using the standardized county-wide training. 

1. The standardized curriculum supports Fire-EMS, Emergency Department and Labor 

and Delivery personnel in the proper intake and notification procedures during a 

Safe Surrender. 

2. All training materials are available at www.cchealth.org/topics/baby_safe 

B. Designated Safely Surrender Sites will have appropriate signage and a reliable process to 

store and replace newborn safe surrender kits.



EMS RESPONSE TO HAZARDOUS MATERIALS 

INCIDENTS 

POLICY #: 36 

PAGE: 1 of 2 



I. PURPOSE 

To prevent exposure or contamination of prehospital personnel, other first responders, 

emergency department personnel and the receiving facility to hazardous material incidents. 

II. AUTHORITY 

California Health & Safety Code, Section 1798.6 (b) (c) Hazardous Materials Incidents. 

California Health & Safety Code; Ch 4; Division 2.5; Title 22. 

The responsibility for hazardous materials containment, identification, and decontamination, and 

victim evacuation at the scene of incident shall rest with the designated public safety agencies as 

defined in the Contra Costa County Hazardous Materials Area Plan (HMAP). 

III. DEFINITIONS 

Contamination: When a hazardous material is physically present on a person’s skin, clothing or 

hair (external) or has been inhaled or ingested (internal). 

Decontamination: The act of removing or neutralizing any contaminant from people or equipment. 

DOT Identification Number: Signage system developed by the U.S. Department of Transportation 

which utilizes a series of four (4) digits to identify and provide basic information on specific 

hazardous materials. 

Exposure: Contact by any means with a hazardous material. 

Hazardous Materials: A material that, because of its quantity, concentration, or physical or 

chemical characteristics, poses a significant present or potential hazard to human health and 

safety or to the environment if released into the workplace or the environment. 

Hazardous Materials Incidents: A release or threatened release of hazardous materials. 

Hazardous Material Incident Notification: The process of informing the appropriate regulatory 

authorities and agencies of a hazardous materials incident. 

Hazardous Materials Area Plan (HMAP): The HMAP describes the overall hazardous materials 

emergency response within Contra Costa County and establishes lines of authority for hazardous 

materials incidents. Available at: http://www.cchealth.org/groups/hazmat/pdf/2009_area_plan.pdf 

Exclusion (Hot) Zone: Area that encompasses all known or suspected hazardous materials. 

Material Safety Data Sheet (MSDS): MSDS is a form describing the properties of a particular 

substance. It is intended to provide workers and emergency personnel with procedures for handling 

or working with that substance in a safe manner. 

Prehospital Provider: EMS and Fire First Responders and/or Transport Providers. 

Support (Warm) Zone: Area between the Hot Zone and the location where equipment and rescue 

personnel are staged to receive and treat decontaminated patients. 

IV. PREHOSPITAL PROVIDER AND PROVIDER AGENCY RESPONSIBILITIES 

Prehospital Providers and their Provider Agencies shall comply with state and federal standards 

involving hazardous materials. 

Prehospital Providers shall participate in hazardous materials awareness level training programs. 

All prehospital providers shall be trained in when and how to perform a Hazardous Material Incident 

Notification.



POLICY #: 36 

PAGE: 2 of 2 

Individuals who have not been trained to respond, contain, identify, decontaminate and evacuate 

victims of hazardous materials events, within the contamination area, should not enter the Hot or 

Warm Zone. 

Other rescuers should be trained in accordance with Federal and State OSHA standards to handle 

hazardous materials incidents and include fire, law enforcement, or other local agencies. 

Prehospital providers shall have processes identified for appropriate EMS Event Reporting and 

subsequent review of patient and provider safety issues regarding hazardous materials incidents. 

V. EMS HAZMAT INCIDENT ROLES AND RESPONSIBILITIES 1 

A. Scene Command: First Response agencies arriving on scene shall: 

Implement Incident Command System 

Establish Incident Command Post 

Isolate and Deny Entry 

Assess Incident and request necessary resources 

Notify response agencies 

Provide medical attention 

Rescue victims – If rescue can be done safely 

Contain/Control Release by trained personnel 2 – If actions can be done safely 

Initiate early notification to the hospital(s) receiving victims of a hazardous materials incident 

B. Fire-Medical Dispatch: The fire-medical dispatch agency shall communicate to responding 

units/crews: 

That the call involves suspected or known hazardous substance as an alert. 

Information regarding type of substance, wind direction, staging area (if established), command 

post, designated entry and egress paths or other pertinent patient information should be 

obtained and relayed to responders as soon as possible. 

Responding crews will acknowledge information provided by dispatch. 

Responding crews will alert dispatch to hazardous materials exposures promptly. 

C. Hospital: All hospitals receiving victims from hazardous materials incidents should: 

Prepare a designated staging area for appropriate patient handoff and additional 

decontamination if required. 

Contact CCHS Hazardous Materials through Sheriff’s Dispatch if further information is 

required to determine the need for primary or secondary decontamination. 

Have policies, procedures and trained personnel available to decontaminate exposed 

prehospital personnel and/or patients from the field. 

1 

See EMS personnel recognition of Hazardous Materials Exposure Decision Tree. 

2 

The responsibility for hazardous materials containment, identification, and decontamination, and victim evacuation at the scene of 

incident shall rest with the designated hazardous materials response agencies.

EMS Personnel Recognition of a Hazardous Materials Exposure 

First Responder and Transport Personnel 

While 

Responding 

REPORT TO STAGING AREA IF 

ESTABLISHED 

Prior to arrival request location and 

safe route into staging area/or IC 

from dispatch 

If no staging area determine 

location and safe route to report to 

Incident Commander (IC). 

Do not enter contaminated area 

until cleared by IC. 

DECONTAMINATE PATENT 

Decontamination shall be 

performed by trained personnel in 

designated area 

TRANSPORT 

Obtain clearance from IC 

prior to transport 

Obtain MSDS for chemical 

if available 

Provide early alert to 

receiving Hospital that may 

determine need to repeat 

decontamination. 

Arrive at designated 

hospital staging area as 

needed. 

SO = Sheriff’s Office Dispatch 

Notes 

While 

On-Scene 

CONSIDER YOURSELF EXPOSED 

TO THE CHEMICAL-TREAT 

YOURSELF AS CONTAMINATED 

Evacuate to Safe Location uphill and 

upwind from hazardous scene 

If in cloud travel crosswind until out of 

cloud 

NOTIFY FIRE MEDICAL 

DISPATCH AND IC (thru 

dispatch) THAT YOU HAVE 

BEEN EXPOSED 

Request CCHS HazMat 

response thru SO. 

Request backup Fire/Transport 

as needed for affected EMS 

personnel and patients. 

Stay in safe location until IC 

arrives to provide further 

instructions 

Prepare to be decontaminated 

DECONTAMINATE EMS PERSONNEL 

AND PATIENT 

Decontamination shall be performed by 

trained personnel in designated area 

TRANSPORT 

Obtain clearance from IC 

prior to transport 

Obtain MSDS for 

chemical if available 

Provide early alert to 

receiving Hospital who 

may determine need to 

repeat decontamination. 

Arrive at designated 

hospital staging area as 

needed. 

While 

Transporting 

CONSIDER YOURSELF 

EXPOSED TO THE CHEMICAL- 

TREAT YOURSELF AS 

CONTAMINATED 

DETERMINE IF SAFE TO DRIVE 

Notify Fire-Medical Dispatch 

EMS responders exposed 

Transport will continue or not. 

Request CCHS HazMat response 

to appropriate destination 

SAFE TO DRIVE 

(no symptoms of exposure) 

Early alert of hospital of 

HazMat situation 

REQUEST WHERE TO 

STAGE FOR HOSP SITE 

DECONTAMINATION 

Request Fire/Transport 

backup as needed 

On arrival prepare to be 

decontaminated 

NOT SAFE TO DRIVE 

(symptoms of exposure) 

Immediate 

decontamination needed 

Stop transport 

Notify Fire-Medical 

dispatch and request 

CCHS HazMat thru SO. 

Request Fire/Transport 

backup as needed 

Protect from further 

exposure and prepare to 

be decontaminated 

In all cases, prehospital medical care shall be provided as soon as it is safe. 

Hospitals are encouraged to consult with CCHS HazMat to determine if secondary decontamination is required 

All precautions should be taken to prevent contamination of hospital emergency department and personnel 

Page 1



STROKE TRIAGE AND DESTINATION 

POLICY #: 37 

PAGE: 1 of 2 



I. PURPOSE 

To outline the process of triage and transport of suspected acute stroke patients to the appropriate 

Primary Stroke Center (PSC) for evaluation and treatment. 


Stroke: A rapidly developing loss of brain function due to disturbance in the blood supply to the brain. 

Strokes may be ischemic (due to an occlusion in the blood flow to the brain) or hemorrhagic (due to a 

blood vessel rupture causing bleeding into or around the brain). 

Suspected Acute Stroke Patient: A patient who meets the stroke alert criteria for acute stroke in 

accordance with Contra Costa County’s EMS prehospital care guidelines. 

Cincinnati Stroke Scale (CSS): A validated prehospital screening tool used to identify the presence 

of a stroke in a patient. The scale tests for facial droop, arm drift and speech. If any one of the three 

tests shows abnormal findings, the patient is considered to have an abnormal CSS. 

Primary Stroke Center (PSC): Hospitals that meet Contra Costa Emergency Medical Services’ 

(EMS) Primary Stroke Center designation criteria in accordance with EMS policy and have entered 

into a PSC written agreement. 

Stroke Alert Criteria: A suspected stroke patient that has an abnormal CSS and was last seen 

normal less than four hours prior to contact with field personnel. 

Stroke Alert: A prehospital early “notification” of the closest PSC that a suspected acute stroke 

patient will be arriving. The Stroke Alert acts to activate the PSC response team to ready equipment 

and personnel to respond to the patient’s need for rapid evaluation and intervention prior to patient 

arrival. The prehospital stroke alert includes verbal verification that the PSC CT is operational. 

CT Diversion: CT diversion is defined as an “inoperable” CT and is to be reliably communicated by 

all hospitals via ReddiNet 1 , in accordance with EMS policy on hospital diversion. 

III. STROKE SYSTEM TRIAGE 

Appropriate triage of the suspected acute stroke patient using stroke alert criteria relies on rapid 

prehospital care: 

Recognition of signs and symptoms or stroke using CSS. 

Determination of last time seen without stroke symptoms. 

Optimal scene times of 10 minutes or less followed by direct and rapid PSC transport. 

Early and reliable communication of Stroke Alert. 

Compliance with the Contra Costa Prehospital Treatment Guidelines for Stroke. 

IV. DESTINATION 

Suspected acute stroke patients shall be transported to the appropriate PSC within the following 

parameters: 

Patients shall be transported to the closest PSC unless they request another facility. 

A PSC that is not the closest PSC facility is acceptable but only if the estimated additional 

transport time does not exceed 15 minutes. 

If the closest PSC facility is on CT diversion then the patient shall be taken to the next closest 

PSC. 

1 ReddiNet: Rapid Emergency Digital Data Information Network.



POLICY #: 37 

PAGE: 2 of 2 

Acute stroke patients in cardiac arrest or with an unmanageable airway shall be transported 

to the closest basic emergency department. 

Patients may request an out-of-county PSC if all above conditions are met and EMS 

personnel have verified the out-of-county PSC CT operability prior to leaving the scene. 

V. STROKE ALERT/PATIENT REPORT 

As soon as a suspected stroke patient is identified, the appropriate destination shall be determined 

and a Stroke Alert promptly communicated to the PSC. The Stroke Alert is to contain the following 

brief essential information using the SBAR (Situation, Background, Assessment, Rx/Recap) report 

standard: 

Situation: Identify the call as a Stroke Alert and verify CT operability, report estimated time of arrival 

in minutes, patient age, gender and urgent concerns. 

Background: State time patient last seen without stroke symptoms, CSS, and pertinent history. 

Assessment: Blood glucose and pertinent vital signs (VS) and physical exam findings. 

RX/Recap: Prehospital treatment given and patient response. 

VI. EMERGENCY DEPARTMENT REPORT 

Patient handoff report should repeat stroke alert SBAR report and include the following additional 

information: 

Patient identification 

Presenting complaint 

Additional background information 

Past medical history 

Advanced directives if known 

Allergy and medication history including high-risk medications (e.g. anticoagulants, insulin) 

Previous history of stroke or thrombolytic therapy 

Neurologist, if known 

VII. LIST OF DESIGNATED PRIMARY STROKE CENTERS 

IN-COUNTY STROKE CENTERS OUT-OF-COUNTY STROKE CENTERS 

Doctors Medical Center San Pablo Alta Bates Medical Center – Alameda Co 

John Muir Medical Center – Concord Campus Oakland Summit Medical Center – Alameda Co 

John Muir Medical Center – Walnut Creek Campus Kaiser Oakland Medical Center– Alameda Co 

Kaiser Permanente Medical Center– Antioch 

Kaiser Permanente Medical Center– Richmond 


San Ramon Regional Medical Center



EMS PRIMARY STROKE CENTER DESIGNATION 

POLICY #: 38 

PAGE: 1 of 2 



I. PURPOSE 

To define the designation process and criteria for Primary Stroke Center (PSC) in Contra Costa 

County. PSCs are facilities that have been designated by the Local EMS Agency as appropriate care 

centers for patients with suspected stroke. The PSCs work collaboratively with Emergency Medical 

Services (EMS) system partners to establish and support an optimal system of stroke care in the 

community. 

II. APPLICATION PROCESS 

To apply for designation as an EMS Primary Stroke Center (PSC) in Contra Costa County, the 

hospital shall: 

A. Submit a designation application to the Contra Costa EMS Agency. 

B. Submit applicable designation fees to support Stroke System activities. 

C. Meet PSC designation criteria and contractual requirements. 

III. WRITTEN AGREEMENT 

All PSCs must enter into a written agreement with the Contra Costa EMS Agency prior to designation. 

The written agreement details the specific obligations of all parties responsible for the management of 

stroke patient care within the EMS system. 

IV. PSC DESIGNATION CRITERIA 

Designation criteria for an EMS PSC in Contra Costa County shall require documentation of the 

following: 

A. The facility is a 9-1-1 receiving hospital, licensed in the State of California. 

B. Certified as a Joint Commission or equivalent National Primary Stroke Center as approved by 

the EMS Agency. 

C. Designation of the PSC Medical Director and PSC Nurse Program Manager. 

D. Hospitals may qualify for PSC designation as a Telestroke Center 1 using telemedicine. 

E. A written commitment to fully participate in the Contra Costa County EMS Quality Improvement 

(QI) and data collection program. 

F. Participation in California Stroke Registry (CSR). 

G. Internal policies and procedures to assure reliable use of ReddiNet 2 to communicate CT 

diversion in compliance with EMS Policy 24. 

H. A Community Stroke Reduction Plan including participation in outreach programs to reduce 

cardiovascular disease and stroke. 

V. DESIGNATION PROCESS AND TERM 

A. Initial PSC designation will be awarded to a hospital following satisfactory review of all evidence to 

show compliance with this policy and upon completion of an informational site survey conducted 

by the Contra Costa EMS PSC designation review team. 

1 

As defined by the AHA, Brain Attack Coalition, California Heart Disease and Stroke Prevention Program, and 

CDPH Guidelines 2009. 

2 

ReddiNet: Rapid Emergency Digital Data Information Network.



POLICY #: 38 

PAGE: 2 of 2 

B. The PSC designation term shall be not more than three years, as specified in the written 

agreement between the PSC and the County. 

VI. RENEWAL PROCESS AND TERM 

A. PSCs who maintain compliance with PSC designation criteria will be eligible for automatic renewal 

of designation. 

B. Renewal requires maintaining a written agreement and submission of annual designation fees. 

VII. OUT-OF-COUNTY DESIGNATION 

A. PSCs that are located out of the county qualify for recognition as designated PSCs within 

Contra Costa County under the following conditions: 

1) Certified as a Joint Commission or equivalent Primary Stroke Center as approved by the 

EMS Agency. 

2) Designated by their county’s Local EMS Agency as a PSC. 

3) If the Hospital is located in a county that does not have a stroke system, the Hospital must 

enter into a written agreement to be qualified for PSC designation in the Contra Costa 

Stroke System. 

VIII. LOSS OF DESIGNATION 

The inability to meet and maintain PSC designation as defined in this policy and the written 

agreement is criteria for loss of designation. 

IX. LIST OF DESIGNATED PRIMARY STROKE CENTERS 

IN-COUNTY STROKE CENTERS OUT-OF-COUNTY STROKE CENTERS 

Doctors Medical Center San Pablo Alta Bates Medical Center – Alameda Co 

John Muir Medical Center – Concord Campus Oakland Summit Medical Center – Alameda Co 

John Muir Medical Center – Walnut Creek Campus Kaiser Oakland Medical Center– Alameda Co 

Kaiser Permanente Medical Center– Antioch 

Kaiser Permanente Medical Center– Richmond 


San Ramon Regional Medical Center



9-1-1 ACTIVATION CRITERIA FOR NON- 

EMERGENCY TRANSPORT PROVIDERS 

POLICY #: 39 

PAGE: 1 of 1 



I. PURPOSE 

Define the criteria for upgrade to advanced life support (ALS) for non-emergency transport providers. 


Unstable: A patient who has a life- or limb-threatening condition requiring immediate and definitive 

care. An unstable patient may have respiratory distress, airway compromise, neurological changes 

from baseline, signs of actual or impending shock or may meet criteria for transport directly to a trauma 

center. (Refer to EMS Policy 20 for additional information regarding patients with valid DNR and\or 

POLST orders.) 

Non-emergency ambulance provider: An ambulance provider holding a valid Contra Costa nonemergency 

ambulance permit. 

9-1-1 ambulance provider: An ambulance provider holding a valid Contra Costa emergency 

ambulance permit and/or contracting with the County to provide advanced life support ambulance 

response to 9-1-1 requests. 

Code 3: Responding to a location and/or transporting to a receiving facility, using red lights and sirens. 

III. UNSTABLE PATIENTS 

A. A patient, determined to be unstable and/or needing “Code 3” transportation to a hospital, shall 

be transported by a 9-1-1 ambulance provider, whenever possible. 

B. Non-emergency ambulance providers may transport an unstable patient to the 

closest/appropriate facility, if they can do so safely and the time from arrival on scene to arrival 

at the hospital is less than ten (10) minutes. In all other cases, the non-emergency ambulance 

crew shall activate the 9-1-1 system and request an ALS response. 

C. Any non-emergency ambulance provider transporting a patient that becomes unstable during 

transport should divert to the closest/appropriate ED per the Patient Destination Determination 

Policy (Policy #9). 

Receiving facilities should receive notification as soon as possible of the need for diversion, 

patient status and the ETA to that facility. 

D. All transports by non-emergency ambulance providers of unstable patients, and/or transports 

requiring “Code 3” transportation are considered an unusual occurrence. 

For each such occurrence, an EMS Event Report must be completed and submitted to the 

EMS Agency within twenty four (24) hours of the call. 

IV. “ON-VIEWS” 

In the event that a non-emergency ambulance provider arrives on the scene of a collision, illness or 

injury by coincidence, the crew shall provide appropriate care and immediately activate the 9-1-1 

system.

EMS Policy Manual - Contra Costa Health Services

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