Chapter 3 – Health Care Operations

Policy

• California Department of Corrections and Rehabilitation (CDCR) and California Correctional Health Care Services (CCHCS) shall ensure that medically necessary emergency medical response, treatment, and transportation is available, and provided 24 hours per day to patients, employees, contract staff, volunteers, and visitors.

• It is the responsibility of CCHCS to plan, implement, and evaluate the Emergency Medical Response System (EMRS).  The organized pattern of readiness and response services within CDCR is set forth in this policy.  CDCR shall collaborate in the implementation of this policy by participating in drills and events.

• Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) treatment shall be provided consistent with the American Heart Association (AHA) guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care according to each individual’s training, certification, and authorized scope of practice.

• BLS and ACLS shall be documented on the CDCR 7462, Cardiopulmonary Resuscitation Record.

• Trained CCHCS and CDCR staff or contractors shall perform the functions of First Aid, BLS, and ACLS.

• The standard guidelines for responding to emergencies are:

  • The response time for BLS capable personnel (First Responders) shall not exceed four minutes (the First Responder Response Time).

  • The response time for health care staff shall not exceed eight minutes (Health Care Staff Response Time).

Purpose

• The purpose of this policy is to standardize:

• The structure and organization of the CDCR EMRS facilities, equipment, and personnel training.

• Procedures for emergency medical response.

• Mechanisms for documentation, data management, medical oversight, and quality improvement activities.

Responsibility

• The Chief Executive Officer (CEO) and the Warden at each institution are responsible for implementation of this policy.

General Requirements

• System Organization and Management

  • Patients may request medical attention for urgent/emergent health care needs from any CDCR employee.  The employee shall, in all instances, notify health care staff.

  • Direct contact with the patient by a Registered Nurse (RN) or physician, either in person or by telephone, shall be provided for all patients requesting urgent/emergent medical attention or who are referred by staff.  The RN or physician on duty shall choose one of the following options for evaluating the patient:

    • Arrange to have the patient brought to the clinic.

    • Arrange to have the patient brought to the Triage and Treatment Area (TTA).

    • Evaluate the patient in his/her housing unit or current location.

    • Talk directly to the patient via telephone, complete a telephone triage, and give direction to the patient for subsequent care.

  • At least one RN shall be available onsite at each institution 24 hours a day, 7 days a week for emergency health care. During those hours in which a physician is not onsite, the highest priority for the RN shall be emergency care.  A Provider On-Call (POC) or Medical Officer of the Day (MOD) shall be available 24 hours a day,7 days a week to provide consultation and onsite care as necessary.

  • TTAs, standby licensed emergency departments, and all clinical areas shall be properly staffed and equipped.

  • Local Operating Procedures approved by the designated management team shall be in place for communications, response, evaluation, treatment, and transportation of patients, staff, and visitors.

  • Community Emergency Medical Services responders have ready entry and ready exit into and out of the institution through the vehicle sally port and throughout the facility in order to access the patient.

  • CCHCS shall maintain a system to manage and track physician and mid-level staff ACLS certification requirements.

• Facilities and Equipment

  • Emergency equipment and supplies, emergency medical bags, oxygen and Automated External Defibrillators shall be maintained according to manufacturer’s specifications and readily accessible to Health Care Staff in the TTA, all clinic areas, emergency medical response vehicles, and all other areas deemed appropriate by the CEO and the Warden in the institution.

  • The location of the equipment shall be clearly identified by signage.

  • The equipment shall be maintained, appropriately secured, and inventoried each shift.

• Personnel: Staffing and Training

  • The CEO is responsible for assuring a system is in place to manage and track clinical staff BLS certification requirements.

  • All correctional peace officers (custody) shall, within the previous two years, have successfully completed a course in CPR that is consistent with AHA guidelines. Custody staff shall maintain a system to manage and track correctional peace officers CPR requirements.

  • For allied health care staff who have direct patient contact, BLS certification is recommended but not required.

  • All health care staff with the exception of dental staff and Licensed Clinical Social Workers (LCSWs) shall, within the previous two years, have successfully completed a health care provider-level course in BLS that is consistent with the AHA guidelines. Psychologists who belong to the organized medical staff at their institutions and who have admitting privileges must also complete this course.

  • Certification Requirements:

    • Dentists, dental hygienists, and dental assistants must provide proof of BLS certification which meets the requirements of their respective licensing board or committee.

    • Psychologists who do not have admitting privileges and LCSWs are not required to maintain BLS certification, although certification is recommended.

    • All primary care physicians and mid-level providers are required to obtain and maintain ACLS certification and submit proof of certification/recertification to institutional management and the headquarters credentialing unit.

    • Physicians and mid-level providers who are currently certified in ACLS are not required to have BLS certification.

    • Contract specialty consultants who may perform procedures requiring procedural sedation at CDCR institutions shall, within the last two years, have successfully completed a course in BLS that is consistent with the AHA guidelines.  Proof of certification/recertification must be received by the CEO and the headquarters credentialing unit prior to the contract specialist’s start date and/or prior to the expiration of the contract specialist’s BLS certification.

  • ACLS certification and maintenance of certification is desirable for the Supervising Registered Nurse in charge of the TTA, and TTA RNs.

  • Nursing staff, based on their level of licensure and training, shall provide emergency care only under patient specific individual orders based on clinical indications.  The orders may be given verbally or telephonically when the provider is not present.

  • Nursing staff, based on their level of licensure and training, shall provide ACLS emergency care requiring cardiac rhythm interpretation only under orders of a provider who is at the scene and directly assessing the patient.

• Institutions shall conduct emergency medical response training drills and shall provide access to skills training on an ongoing basis pursuant to the Health Care Department Operations Manual, Section 3.7.2, Emergency Medical Response Training Drill and Nursing Skills Lab.

Procedure Overview

• Implementation of this procedure will ensure that medically necessary medical response, treatment, and transportation is available and provided 24 hours per day to patients, employees, contract staff, volunteers, and visitors.

General Instructions

• All staff has the authority to initiate a 9-1-1 call for Emergency Medical Services (EMS).

• Any individual who encounters a medical emergency is responsible for summoning assistance by the most expeditious means available, e.g., personal alarm device, two-way radio, whistle, shouting, or telephone.

• Any patient may request medical attention for an urgent or emergent health care need from any CDCR or CCHCS employee.  The employee shall in all instances notify health care staff without unreasonable delay.

• To efficiently activate a community EMS response and notify appropriate facility staff of a medical emergency, Local Operating Procedures (LOPs) shall identify a single point of contact for reporting medical emergencies and establish the mechanism to contact appropriate parties. 

• Activation of the institutional Emergency Medical Response System and the community EMS system shall occur as necessary to ensure the most appropriate level of emergency medical care is available in the shortest time interval.

• Preservation of a crime scene shall not preclude or interfere with the delivery of emergency medical care. Preservation of life shall take precedence over the preservation of a crime scene.

• Custody requirements shall not unreasonably delay medical care during a medical emergency unless the safety of staff, patients, or the general public would be compromised.

• If a patient is unable to be resuscitated, the decision to terminate CPR shall be made by a physician or a mid-level provider, community EMS personnel, or by an RN if CPR was initiated for a patient who exhibits clear signs of death as described in Section (g)(2)(D)1.  Pronouncement of death shall only be determined and made by a physician or a mid-level provider per LOP.

Procedure

• Urgent Response, Treatment, and Transportation

  • Upon notification or discovery of an urgent health care need, the staff member shall call the designated clinical area.

  • The requesting staff member shall provide a brief description of the nature of the request to the clinical staff.

  • Direct contact with the patient by licensed clinical staff shall occur in person or by phone and be provided for all patients requesting urgent medical attention.

  • An RN, physician, or mid-level provider shall evaluate the patient’s request by one of the following options:

    • Arrange to have the patient brought to the clinic.

    • Arrange to have the patient brought to the TTA.

    • Evaluate the patient in his/her housing unit or current location.

    • Talk directly to the patient via telephone and thoroughly document the encounter on Interdisciplinary Progress Note.

  • The licensed clinical staff members shall document the evaluation in the health record using an appropriate form.  Documentation of the encounter must clearly state the disposition and the rationale for the disposition decision.

  • The RN, physician, or mid-level provider may direct other licensed staff to obtain vital signs and other clinical data and report the information to them. 

  • All urgent encounters resolved in the yard or yard clinic after hours shall be documented on an Interdisciplinary Progress Note, and discussed by the Primary Care Team the following business day.

  • All dispositions for urgent conditions shall be made at the RN level of licensure or higher.

• Emergency Medical Response

  • A First Responder (FR) shall evaluate the situation and initiate appropriate first aid and/or BLS measures, including establishing airway, breathing, circulation, controlling bleeding, and administering CPR.  The FR shall also:

    • Briefly evaluate the patient and situation, then immediately notify health care staff of a possible medical emergency, and summon the appropriate level of assistance.

    • Inform the health care staff of the general nature of the emergency including the general status of the patient.  This may include whether the patient is conscious, breathing, bleeding, or other observable patient conditions and complaints.

    • Immediately initiate CPR if appropriate.

    • Initiate community EMS activation if necessary.

    • Clearly document the reason(s) if CPR is not initiated due to the condition of the patient.

  • Custody Protocol

    • In medical emergencies, the primary objective is to preserve life.  All peace officers who respond to a medical emergency shall provide immediate life support until medical staff arrives to continue life support measures. All peace officers must carry a personal CPR mouth shield at all times.

    • The peace officer must evaluate and ensure it is reasonably safe to perform life support by effecting the following actions:

      • Sound an alarm (a personal alarm or, if one is not issued, an alarm based on the LOP must be used) to summon necessary personnel and/or additional custody personnel.

      • Determine and respond appropriately to any risk of exposure to blood borne pathogens by adhering to standard precautions.

      • Determine, isolate, contain, and control the emergency and significant security threats to self or others including any circumstances causing harm to the involved patient.

      • Initiate life saving measures consistent with training.

    • The responding peace officer shall document on a CDCR 837, Crime/Incident Report, the decisions made regarding immediate life support and actions taken or not taken (Section (g)(2)(D)1), including cases where life support is not initiated consistent with training and/or situations which pose a significant threat to the officer or others.

  • RN/Licensed Vocational Nurse (LVN)/Licensed Psychiatric Technician (PT) shall:

    • Respond as quickly as conditions permit to the scene of the medical emergency with an emergency medical response bag and Automated External Defibrillator (AED), and initiate and/or assist with CPR if indicated.

    • Make an initial assessment of the situation and determine whether a medical emergency is present.

    • Notify the TTA with relevant clinical information within eight minutes of the initial call for an emergency medical response if an RN is not already at the patient location.

    • The Health Care First Responder (HCFR) shall initiate community EMS activation if needed and not already completed by the FR.

    • In all cases, an RN or higher level of licensure shall be responsible for determining the disposition of the patient and communicating this information to the HCFR either in person or via radio/telephone.

  • The HCFR shall begin appropriate medical treatment and assume responsibility for directing any medical care already in progress.

    • The HCFR shall determine if CPR is appropriate and continue CPR in the absence of:

      • Rigor mortis.

      • Dependent lividity.

      • Tissue decomposition.

      • Decapitation.

      • Incineration.

    • If one or more of the above signs are present, then the HCFR shall determine the patient to be deceased.  The official pronouncement of death is the responsibility of the physician or mid-level provider per LOP.

    • CDCR 7462, Cardiopulmonary Resuscitation Record:

      • The CDCR 7462, Cardiopulmonary Resuscitation Record, shall be maintained on the emergency/crash cart for immediate access, and be completed by an RN or designee during a respiratory and/or cardiac arrest event.

      • All drugs administered during the respiratory and/or cardiac arrest event shall be read back and documented by the recorder in the spaces provided on CDCR 7462, Cardiopulmonary Resuscitation Record, at the time of administration.

      • All other resuscitative measures shall be read back and documented in the spaces provided on the CDCR 7462 as they occur.

      • Names of the team members involved in the code shall be documented in the space provided. Sections of the CDCR 7462 that are not applicable to a specific patient shall be marked “N/A.”

      • All team members involved in the code (e.g., Physician, RN, LVN) must sign the CDCR 7462 next to their name under the “Team Member” column.

    • Once started, CPR shall continue until:

      • Resuscitative efforts are transferred to a rescuer of equal or higher level of training.

      • The patient is determined by a physician or mid-level provider to be deceased.

      • Effective spontaneous circulation and ventilation have been restored.

      • Emergency responders are unable to continue because of exhaustion or safety and security of the rescuer or others is jeopardized.

      • A written, valid Do Not Resuscitate (DNR) order is presented.  If there is any suspicion that a patient’s cardiopulmonary arrest is not part of a natural or expected death (e.g., the patient’s condition is a result of an attempted suicide), resuscitation efforts shall be continued regardless of the existence of a DNR, Physician’s Orders for Life Sustaining Treatment, or Advance Directive to the contrary, and resuscitative efforts shall be commenced and continued until other indications to cease are present.

      • An RN determines that obvious signs of death are present (Section (g)(2)(D)1) and may direct that CPR be discontinued.

• Definitive Care and Patient Transportation

  • Based on the patient’s clinical condition and emergency situation, the RN and the Primary Care Provider shall be responsible for:

    • The continuation of medical treatment until community EMS responders arrive and assume care and transport the patient.

    • Directing the transportation of the patient to the nearest site equipped and staffed for definitive care.

    • Continuing treatment on location and directing EMS personnel to the scene, if clinically appropriate.

  • Transportation Requirements

    • Patients shall only assist with transportation if they are part of the fire crew.

    • CDCR 7252, Request for Authorization of Temporary Removal for Medical Treatment, shall be initiated by health care staff and given to the designated custody representative (e.g., Associate Warden of Health Care, Watch Commander) for final completion and approval.  After the form is completed it is forwarded to the custody transportation team.

    • The transport of a patient via code three ambulance shall not be unnecessarily delayed in order to complete the CDCR 7252 or to obtain other approvals from custody staff.

    • EMS personnel shall transport the patient to a community emergency facility according to local EMS agency policies and procedures.

  • Notification

    • During regular business hours (Monday through Friday) the TTA RN shall notify the Chief Medical Executive (CME), or designee, and TTA Supervising RN, or designee, of the medical emergency transport and the circumstances of the transport as soon as possible.  The Chief of Mental Health shall be notified of all suicides, suicide attempts, and possible overdoses that require medical emergency transport.

    • During non-business hours on evenings, nights, weekends, and holidays the TTA RN shall notify the institution MOD or POC as soon as possible to inform him or her of the patient status and transport decision. The MOD or POC shall notify the CME, or designee, by the next business day.

    • For patients transferred to a community emergency facility, the TTA provider or RN shall contact the receiving facility and provide a report, including available clinical information.

• Documentation

  • General Requirements

    • The RN shall complete a CDCR 7219, Medical Report of Injury or Unusual Occurrence, for all work-related injuries or per custody requirements.

    • The HCFR shall document his/her findings and interventions on the CDCR 7463, First Medical Responder – Data Collection Tool, and sign this form.

    • In the event of a patient death and if CPR is not initiated by non-health care staff, then non-health care staff shall document the reason(s) on a CDCR 837-A-1, Crime/Incident Report Supplement.

    • The use of an AED shall be documented by a health care staff member.  If the AED has download capability, the electronic information record shall be downloaded, printed, and added to the health record.

    • Notice of discharge of an AED shall be reported to the local county EMS utilizing the forms provided by that entity.

    • Documentation of any additional care and treatment provided by other clinical responders at the scene shall be completed on an Interdisciplinary Progress Note.

    • The emergency medical response documentation shall be signed, dated, and timed.  All documentation shall be delivered to the TTA RN immediately at the time the patient arrives in the TTA or as soon as possible if the patient was transferred directly to a community emergency department.

    • The TTA RN shall contact the psychiatrist on duty regarding patients who present with self-inflicted injuries.

  • TTA Documentation Requirements

    • A TTA Log shall be maintained in the TTA at each institution.

    • Care and treatment shall be documented on the CDCR 7464, Triage and Treatment Services Flow Sheet.

    • BLS and ACLS shall be documented on the CDCR 7462.

    • Care delivered pursuant to RN protocols shall be documented on the appropriate RN protocol forms.

    • On arrival at the TTA, the RN shall remain with the patient and continue monitoring the patient’s status until any resuscitative efforts are terminated, or until emergency medical service personnel assume patient care.  During this time, the RN shall record the following:

      • Patient identification data (CDCR number, or, if unavailable, other identifying data).

      • Description of initial events and patient presentation (patient location, position, and witness description of events).

      • Times various treatments and procedures are rendered.

      • Name and title of the RN, name and title of the person to whom the patient is transferred, the date and time of the transfer, and the RN’s signature.

    • TTA staff shall attach all relevant documentation to the CDCR 7464 for inclusion in the health record.

  • Transport Documentation Requirements

    • Copies of the CDCR 7464, Triage and Treatment Services Flow Sheet, CDCR 7462 if applicable, and all attachments shall be provided to the emergency medical service transport staff if the patient is sent out of the institution.

    • CDCR 7252.

    • Sally port officers are to maintain a standardized log of all emergency vehicle traffic entrances and exits, including times.

Policy

• California Department of Corrections and Rehabilitation (CDCR) and California Correctional Health Care Services (CCHCS) shall ensure that an emergency medical response system (EMRS) is maintained at each institution to deliver emergency medical treatment to patients, employees, contractors, volunteers, and visitors 24 hours per day, 7 days per week.

• This system shall ensure rapid identification, early intervention, and Basic Life Support (BLS) treatment of all medical emergencies that may include the 9-1-1 community emergency medical services (EMS) activation and appropriate transportation within the institution and the community. Emergency care includes, but is not limited to, initial survey and assessment, interventions, stabilization for transfers, and transportation.

• CDCR and CCHCS shall maintain a statewide standardized emergency medical response (EMR) training curriculum, including, but not limited to, BLS cardiopulmonary resuscitation (CPR), standardized procedures with competencies, trauma response training exercises, and drills. CDCR and CCHCS shall ensure administrative, correctional, and clinical guidelines are in place to support the EMRS, including, but not limited to, a standardized formulary of EMRS equipment and supplies; accordingly, institutions shall be prepared to provide ongoing necessary treatment and interventions pending EMS arrival, provide an appropriate handoff, and be prepared for immediate transport with necessary documentation upon EMS arrival.

  • Institutions shall implement and maintain a system to ensure care is delivered and maintained according to the community 9-1-1 EMS response times (refer to Community EMS Dispatch County Status and 9-1-1 Response Times located on the Lifeline Nursing Services EMRP tab).

  • Institutions shall establish and maintain a working relationship with community EMS agencies to ascertain appropriate resources, access, and transportation for all 9-1-1 community EMS activations.

• CDCR and CCHCS shall identify key indicators, essential functions, and metrics to benchmark and monitor effectiveness of the program and ensure that the EMRS is organized with an established pattern of response (i.e., access to care, alarm responses, transportation, and quality of clinical intervention). This shall include ongoing evaluation through After Action Reviews and other established forums to identify immediate corrective action and improvement opportunities. Statewide quality and institutional-level committees shall be responsible for monitoring EMR requirements, identifying trends, initiating and directing improvement activities, and responding to changes in technology and evidence-based practice.

Responsibility

• Statewide

  • It is the responsibility of CDCR and CCHCS departmental leadership at all levels of the organization, within the scope of their authority, to plan, implement, and evaluate the EMRS. The designated committee shall monitor EMRS performance metrics statewide to review and provide feedback on identified issues that present an increased level of risk to patients and the organization. These trends shall be referred to the regional executive teams, headquarters, and the institution’s Emergency Medical Response and Review Committee (EMRRC) for quality improvement activities.

• Regional

  • Regional Health Care Executives are responsible for implementation of this policy and shall provide oversight and support at the subset of institutions within an assigned region. Each region shall ensure a regional forum is established to review the institutional trends related to the quality, timeliness, and efficacy of all EMRs, as well as direct process improvements through the institutions’ performance improvement work plans and quality structure. The regional forum shall meet no less than quarterly to review and provide feedback to the institution for continuous quality improvement and sustainability of the EMRS.

• Institutional

  • The Chief Executive Officer (CEO) and the Warden have overall responsibility for implementation and ongoing oversight of the EMRS at the institutional level.

  • The CEO and Warden shall:

    • Ensure that the equipment is maintained with sufficient supplies in approved locations to meet the needs of the institution.

    • Implement the standardized EMR training, including, but not limited to, BLS, CPR, and drills with competencies for all staff and ensure that a tracking system is in place.  

    • Implement an After Action Review process for immediate evaluation and necessary corrective action of emergency events.

    • Ensure that sufficient staff are available to respond to emergencies 24 hours per day, 7 days per week, and that all staff have the means to activate the EMRS including the 9-1-1 community EMS.

    • Ensure that all staff are appropriately trained and maintain current applicable licenses and certifications.

    • Ensure that appropriate transportation is available to transport patients in emergency situations.

    • Establish an EMRRC to:

      • Review EMR incidents.

      • Review the quality, timeliness, and efficacy of all EMRs.

      • Analyze local trends and outliers.

      • Provide systematic assessment, risk stratification, and monitoring of all identified groups of patients to ensure the effectiveness of the EMRS.

      • Develop corrective action measures to ensure continuous process improvement.

      • Report on Section (b)(3)7.a-e. to the Institution Quality Management Committee.

    • Ensure a local operating procedure (LOP) is developed that outlines the institution’s specific activities or requirements as indicated in Section (d).

  • The CEO and Warden have joint, overall responsibility for oversight of the EMRRC at their institution. Identified issues that present an increased level of risk to patients and the organization shall be referred to the institution’s EMRRC.

Procedure Overview

• This procedure describes the EMRS and processes which CDCR and CCHCS staff shall utilize to deliver emergency medical treatment to patients, employees, contractors, volunteers, and visitors 24 hours per day, 7 days per week. EMRS preparedness includes, but is not limited to:

• Competencies.

• Ongoing training programs.

• Standardized equipment inventories.

• Maintenance standards.

• Disaster response.

• Mass casualty response.

• Ongoing multidisciplinary EMRS drills.

• After Action Reviews.

• Access to transportation.

• LOP.

• Fostering professional relationships with community EMS agencies.

Local Operating Procedure Requirements

• Each institution shall develop an LOP to ensure the following minimum EMRS requirements are met:

• A detailed process to ensure staff awareness and ability to activate 9-1-1 community EMS for medical emergencies.

• 9-1-1 community EMS activation shall not be delayed for any reason including due to waiting for the provider-on-call (POC) consultation or custody response.  Activation of 9-1-1 shall occur as soon as a medical emergency is noted by either custody first responder or Health Care First Responder (HCFR).

• Institution transportation team shall be ready upon arrival or within a reasonable amount of time of EMS agency arrival and not delay transport.  The institutions EMRRC committee shall consider the following items in determining any delays:

  • Existing contracted county 911 response times for local EMS agencies.

  • Teams’ readiness for transport upon arrival of EMS agencies or within a reasonable amount of time.

  • Time of notification for 911 activation to watch commander or designee.

• Direct, in-person contact with the patient by licensed health care staff is provided for patients requiring urgent or emergent medical attention.

• In the event that the HCFR contacting the patient is of a lower licensure than a Registered Nurse (RN), a health care provider or RN shall be contacted for final disposition prior to releasing the patient back to their housing unit.

• A system is in place to document EMRS incidents including persons involved, actions taken, and timelines within the institution, and that copies of all documentation are provided to the EMRRC for quality assurance purposes.

• Designation of HCFR’s assigned to respond to medical emergencies to ensure institution-wide coverage, 24 hours per day, 7 days per week.

• A multidisciplinary approach to disaster response via ongoing training based on tools set forth in this procedure, such as mock drills and skills training.

• Availability of a fully stocked EMR bag for each designated HCFR’s use during EMRS events including, but not limited to, Triage and Treatment Areas (TTA), clinics, and medication rooms.

• A disaster response bag is stocked in each location designated in the institution’s LOP. The location of the disaster response bag shall be clearly marked by signage and readily available to responding health care staff during an institution-wide incident response.

• Stock a treatment cart in each location identified as a TTA or licensed inpatient area. The location of the treatment cart shall be readily visible to be accessed by licensed health care staff for individuals and patients in need of urgent or emergent care. Other equipment and supplies shall be located in the locked drawers, boxes or cabinets and identified by appropriate signage. Medications stored in treatment carts used for Advanced Cardiac Life Support (ACLS) shall be independently secured and accessed only by licensed nursing staff or by a Licensed Independent Practitioner (LIP) pursuant to Health Care Department Operations Manual (HCDOM), Section 3.5.22, Emergency Drug Supplies.

• Designate an internal and external transportation plan designed to transport patients, in a medically appropriate manner, to a higher level of care, as needed, to ensure the rapid treatment of the patient’s medical condition.

• Emergency equipment and supplies, EMR bags, disaster bags, emergency medical response vehicles (EMRV) and contents, treatment carts, oxygen delivery systems, Automated External Defibrillators (AED), and other required equipment and supplies are maintained as required in Section (i).

• Required equipment and supplies are readily accessible in the institution at all times to health care staff in the TTA, clinical areas, EMRVs, and other areas as deemed appropriate by the CEO and the Warden.

• A process is in place to document that required inventories and maintenance have been performed. Procedures shall ensure that the required documentation is retained for one year, audited monthly, and reviewed as part of the institution’s EMRS quality improvement process.

• A preventative maintenance plan is in place for training equipment as specified in the manufacturer’s recommendations or guidelines.

• Staff who utilize and access equipment supplies and medications have demonstrated competency in their use, purpose, application, and proper handling and maintenance.

• A joint plan between owners of AEDs (health care, dental, and custody) is in place to ensure:

  • AEDs are strategically placed throughout the institution with a plan for routine checks to ensure functionality and required maintenance.

  • Procedures shall ensure that all AED usage will be downloaded, and AED activity reports are uploaded to the health record.

  • AED utilization incidents shall follow the process defined on CDCR 7188-1, Emergency Medical Response Bag Checklist, and reported for review to the EMRRC as part of the institution’s EMRS quality improvement process.

• Establish an LOP to obtain Patient Care Records (PCR) from community EMS providers involved in treatment or transport for inclusion in the health record.

Emergency Medical Response System Organization and Management

• First Responder

  • Patients may request medical attention for an urgent or emergent health care need from any CDCR or CCHCS employee. In all instances the employee shall notify health care staff without delay.

  • If notified of a possible emergency by any individual, the First Responder shall be at the patient’s side within four minutes of notification.

  • Upon notification or discovery of a health care emergency, the First Responder shall activate local EMRS via radio, personal alarm, whistle, or institutional EMR number; notify the designated clinical area; provide a brief report; request health care staff response; and activate 9-1-1 community EMS if indicated.

  • Custody staff shall isolate, contain, and control the scene of the emergency and significant security threats to self or others including any circumstances causing harm to the involved patient. Custody staff requirements shall not unreasonably delay medical care during a medical emergency unless the safety of staff, patient, or the general public would be compromised.

  • All staff shall utilize Personal Protective Equipment when responding to emergencies.

  • The First Responder shall evaluate the situation and the patient to include the presence of spontaneous respirations, and initiate appropriate First Aid measures including establishing circulation, airway, breathing, controlling bleeding, and administering CPR until health care staff arrives to continue life support measures.

  • The First Responder shall provide a brief description of the nature of the emergency to health care staff.

• HCFRs shall:

  • Respond as quickly as conditions permit to the scene of the medical emergency with an EMR bag and AED.

  • Arrive at the scene within eight minutes of the initial notification of emergency.

  • Initiate, or continue with, necessary BLS measures including CPR as indicated.

  • Take control of the medical response at the scene, continue appropriate treatment as clinically indicated, and determine subsequent action including, but not limited to:

    • Notify the TTA of the need for transportation.

    • Transfer the patient to the TTA.

    • Administration of Naloxone per policy, as clinically indicated.

    • 9-1-1 community EMS activation, if not already activated by the First Responder.

    • Transfer the patient directly to a higher level of care as the patient’s conditions dictate.

    • Continue medical treatment until community EMS responders arrive, assume care, and transport the patient. 

    • Direct the transportation of the patient to the nearest site equipped and staffed for continuation of appropriate care in a setting such as a hospital emergency department under the care of a physician. 

    • Notify the TTA immediately of the patient’s disposition if the patient is sent to a higher level of care.

    • Notify the Medical Officer of the Day or POC of the patient’s disposition if the patient is sent to a higher level of care.

    • Document the encounter including the disposition and the rationale for the disposition decision in the health record.

    • Obtain vital signs, other clinical data, and perform interventions within their scope of practice, as directed by RNs, physicians, or Advanced Practice Providers.

    • Ensure the decision for patient disposition of urgent or emergent conditions occur at the RN level of licensure or higher.

    • Recognize that patients with decision-making capacity are able to refuse emergency and non-emergency ambulance transfers to a higher level of care.  The provider or RN shall review the risks and benefits of the proposed treatment with the patient, complete CDCR 7225, Refusal of Examination or Treatment, and document in the health record.  Refusals may be obtained by CCHCS staff or in combination with community EMS teams.

    • Ensure a patient’s refusal of treatment does not delay activation of 9-1-1 for community EMS activation and transportation of patients to a higher level of care in emergency medical situations threatening the patient’s life, limb(s), or vision.

• Documentation of Emergency Medical Response System Events

  • The HCFR shall document their findings and interventions at the scene when appropriate. Following the EMR, the patient information shall be entered into the health record using the established documentation workflows:

    • 100-170 Ambulatory Emergent Response

    • 100-172 Inpatient Area Emergent Response (Licensed Areas)

  • The use of an AED shall be documented by health care staff.

  • The HCFR shall, if required by the local EMS authority, file a “Notice of Discharge of an AED” with the EMS authority utilizing the forms provided by that entity per the local EMS authority timeframes.

  • The Supervising Registered Nurse (SRN) II shall complete the CDCR 7186-1, Emergency Medical Response and Unscheduled Transport Event Checklist, for unscheduled send-outs, deaths, and known suicide attempts within 48 hours in which the EMR occurred.

  • The Emergency Medical Response Coordinator (EMRC), or SRN II designee, shall complete a review of no less than ten EMR events, not resulting in an unscheduled send-out, death, or known suicide attempt, from the previous month’s TTA log, using a randomized sampling methodology. The review shall be completed using the CDCR 7186-1.

  • The HCFR shall complete the CDCR 7463-1, First Medical Responder – Data Collection Tool – Employees/ Contractors/Volunteers/Visitors.

    • Completed copies of the CDCR 7463-1 shall be provided to responding community EMS units, if available.

    • Applicable workman’s compensation forms shall be generated by the employee’s immediate supervisor.  The custodian of these workman’s compensation records shall reside in and be securely maintained by the Return-to-Work Coordinator.

    • The CDCR 7463-1 completed for employees, contractors, volunteers, and visitors shall be submitted to the institution Warden’s office.

    • Any refusals made by employees, contractors, volunteers, and visitors shall be made directly to the responding community EMS units.

• Transportation Requirements

  • Designated health care staff are responsible for determining the appropriate method of transportation based on the patient’s clinical condition, distance to the nearest treatment facility capable of addressing the patient’s health care need, and other considerations (e.g., weather).

  • Emergency transportation shall be arranged via 9-1-1 community EMS activation and not by contacting the local EMS non-emergency number.

  • Emergent or urgent unscheduled transportation of a patient via 9-1-1 community EMS activation shall not be delayed in order to complete the CDCR 7252, Request for Authorization of Temporary Removal for Medical Treatment, or to obtain other approvals from custody staff.

  • The CDCR 7252, shall be initiated by designated health care staff and given to the designated custody representative for final completion and approval. 

  • Community EMS personnel will transport the patient to a community emergency facility according to local EMS agency policies and procedures.

  • Custody and health care staff shall ensure proper documentation of incident timelines via a designated local process, which shall be provided to EMRRC at the institution. Sally port officers shall maintain a standardized log of emergency vehicle traffic entrances and exits, including times. The log shall be provided to the EMRRC for review.

  • In the case of an unscheduled urgent or emergent transfer to a higher level of care facility, the Primary Care Provider (PCP) or RN shall communicate pertinent health care data to the receiving health care facility.

    • Urgent or emergent unscheduled transfers to higher level of care facilities requires an accepting physician at the receiving facility. This shall be communicated to the responding community EMS transfer provider.

    • Pertinent documentation shall be sent to the receiving facility with the patient pursuant to HCDOM, Section 3.1.9, Health Care Transfer.

    • Communications to outside facilities regarding the patient’s condition shall be documented in the health record.

  • Custody and health care staff shall use clear language and avoid specialized terminology (i.e., jargon, acronyms) when requesting 9-1-1 community EMS activation.

  • Appropriate language within the institution and outside agencies shall include urgent and emergent designations when describing the urgency of the response and transport. Code 1, Code 2, and Code 3 language shall not be used to describe health care emergencies or transportation.

• Cardiopulmonary Resuscitation

  • Once CPR is initiated, it shall be continued until one of the following occurs:

    • Resuscitative efforts are transferred to a rescuer of equal or higher level of training.

    • The patient is determined by a physician or Advanced Practice Provider to be deceased. Pronouncement of death is also possible by community EMS personnel utilizing local agency’s protocol for determination of death in the field.

    • Effective spontaneous circulation and ventilation have been restored.

    • Emergency responders are unable to continue because of exhaustion or safety and security of the rescuer or others is jeopardized.

    • A written, valid Do Not Resuscitate (DNR) order is presented. If there is any suspicion that a patient’s cardiopulmonary arrest is not part of a natural or expected death (e.g., the patient’s condition is a result of an attempted suicide) resuscitation efforts shall be continued regardless of the existence of a DNR, Physician’s Orders for Life Sustaining Treatment, or Advance Directive to the contrary, and resuscitative efforts shall be commenced and continued until other indications to cease are present.

  • Cessation of Cardiopulmonary Resuscitation

    • The decision to terminate CPR shall be made by a physician, an Advanced Practice Provider, or community EMS personnel in the event that they determine that the patient is unable to be resuscitated.

    • The decision to terminate CPR may also be made by an RN if CPR was initiated for a patient who exhibits clear signs of death as described below:

      • Rigor mortis

      • Dependent lividity

      • Tissue decomposition

      • Decapitation

      • Incineration

      • Penetrating or blunt injury with evisceration of the heart, lung, or brain

      • The RN shall still contact a physician or Advanced Practice Provider to declare a time of death.

  • Determination of Death

    • A physician or Advanced Practice Provider shall pronounce the patient deceased after an in-person evaluation.

    • Community EMS personnel may also pronounce a patient deceased utilizing local EMS Agency protocol for determination of death in the field.

    • An RN can pronounce the patient deceased under specified circumstances, as outlined in HCDOM, Section 3.1.18, Registered Nurse Pronouncement of Death.

  • CDCR 7462-1, Cardiopulmonary Resuscitation Record

    • A detailed CDCR 7462-1 that includes all resuscitative measures and drugs administered by the RN or LIP shall be scanned into the health record by an RN, or designee, following a respiratory or cardiac arrest event.

    • Drugs administered by the RN or LIP during the respiratory or cardiac arrest event shall be documented by the recorder on the CDCR 7462-1, at the time of administration.

    • The names of the staff involved in the CPR event shall be documented on the CDCR 7462-1 and in the health record.

Staffing

• Health care staff shall provide emergency care consistent with their licensure or certification, training, competency, and legal scope of practice.

• Licensed Vocational Nurses (LVNs) and Psychiatric Technicians (PTs), based on their level of licensure and training, and when under the guidance of an RN shall provide emergency care as directed by the RN based on clinical indications. The patient-specific orders shall be given verbally or telephonically.

• Naloxone may be administered independently by LVNs and PTs pursuant to the regulatory board, clinical decision support, and the institution’s Naloxone Emergency Medical Response LOP.

• At least one RN shall be available onsite at each institution 24 hours per day, 7 days per week for emergency care. When a physician is not onsite, the highest priority for the RN shall be emergency care.

• A provider shall be onsite during business hours.

• A POC shall be available after hours, weekends, and holidays to provide consultation and onsite care as necessary. The POC shall be readily available to provide telephone consultation and shall respond within 15 minutes of the initial attempt to contact by institutional staff.

• TTAs and clinical areas shall be properly staffed and equipped.

• RN staff, based on their level of licensure, training, and demonstration of competency, shall provide emergency care based upon clinical indications and utilizing patient-specific individual orders or nursing standardized procedures. The patient-specific orders may be given verbally or telephonically when the provider is not present.

Emergency Medical Response System Training

• Basic Life Support Certification Requirement

  • BLS proof of certification or recertification, provided or approved by the American Heart Association, shall be provided to institutional management and maintained pursuant to the HCDOM, Section 1.4.1.2, Licensed Medical Provider Credentialing and Privileging, for the following health care staff:

    • Medical staff.

    • Nursing staff.

    • Psychiatrists.

    • Psychologists who belong to the organized medical staff at their institutions and who have admitting privileges.

    • Dentists, dental hygienists, dental assistants.

  • BLS certification is recommended but not required for the following health care staff:

    • Allied health care staff who have direct patient contact.

    • Licensed Clinical Social Worker.

    • Psychologists who do not have admitting privileges.

• Correctional peace officers shall, within the previous two years, have successfully completed a CPR-First Aid course.

  • The Warden, or designee, shall maintain a system to manage and track correctional peace officers’ CPR requirements.

  • Correctional peace officers shall carry a personal CPR mouth shield at all times.

• Advanced Cardiovascular Life Support Certification Requirement

  • PCPs shall maintain current ACLS certification provided or approved by the American Heart Association. Proof of certification or recertification shall be submitted to institutional management and the headquarters Credentialing and Privileging Support Unit pursuant to HCDOM, Section 1.4.1.2, Licensed Medical Provider Credentialing and Privileging.

  • Contract specialty providers who can perform procedures requiring procedural sedation at CDCR institutions shall, within the previous two years, have successfully completed a course in ACLS that is provided or approved by the American Heart Association. Proof of certification or recertification shall be received by the institutional CEO and the headquarters Credentialing and Privileging Support Unit prior to the contract specialist’s start date or prior to the expiration of the contract specialist’s ACLS certification.

• Emergency Medical Response System Minimum Training and Training Exercise Requirements – Health Care Staff

  • Each institution under the control of CDCR and CCHCS shall ensure minimum training requirements are met and tracked.

  • The Chief Medical Executive (CME), Chief Nurse Executive (CNE), Chief of Mental Health, and Supervising Dentist, or their designees, shall ensure that EMRS skills trainings are scheduled on the education calendar and health care staff have the opportunity to participate in the skills and competency training appropriate to their licensure and classification. Emergency health care skills, in-service training, forms, materials, and documentation shall be maintained and tracked by designated health care staff.  

  • General skills training shall be conducted every two years to ensure competency for health care staff based on their licensure and scope of practice. General skills training shall be conducted more frequently if EMRS deficiencies and remedial training needs are identified by the EMRRC.

  • EMRS skills training and remedial training shall be documented in the employee’s proof of practice (training) file or other approved location (e.g., the CCHCS Learning Management System).

  • Joint EMRS training drills, that include custody, health care, and other institutional staff, shall be conducted in compliance with the requirements as defined in Section (h) below.

Joint Emergency Medical Response System Training and Training Exercises

• Institutional leadership shall:

  • Determine the location, time, and scenario to be used for each drill.

  • Coordinate and conduct drills between disciplines and departments.

  • Ensure that staff participate in scheduled training and drills.

  • Ensure institutional staff respond immediately to EMRS drills within their designated area.

  • Determine responsibility for setting up and maintaining control of the CPR mannequins and/or other necessary EMRS equipment at the designated drill location.

• Institutional fire departments shall respond immediately to EMRS drills within their designated institutions as specified in the institution’s EMRS plan.

• The CEO and the Warden shall conduct periodic EMRS training drills and exercises and shall provide access to skills training on an ongoing basis as outlined below. The mock drill requirements below may be replaced if a real alarm response occurs in any areas below.  Staff shall ensure all documentation is presented to the EMRRC as part of this requirement.

  • One drill shall be conducted in each lock-up unit (e.g., General Population Restricted Housing Unit [RHU], Correctional Clinical Case Management System RHU), Enhanced Outpatient Program RHU building, and Correctional Treatment Center on each watch, each month, on a rotating basis if a yard contains more than one lock up unit.

  • In addition to the above, all other yards shall conduct at least one EMRS training drill each month, on each watch, on a rotating basis (i.e., Month 1 – A Facility 2nd watch, B Facility 3rd watch, and C Facility 1st watch). Monthly drills shall be didactic in nature.

  • Each drill shall address responses to medical emergencies in all areas of the institution and include participation of health care staff, custody staff, and other institutional staff as appropriate for the scenario being utilized.

  • Institutions shall conduct live, hands-on simulation drills at least quarterly. The quarterly drill may suffice as the monthly drill described in Section (h)(3)(A)-(B). (i.e., a separate monthly drill does not have to be conducted for the month in which the quarterly drill was conducted). These drills shall include institution-wide scenario based training and shall be conducted on each shift. Programming shall be paused or modified during quarterly drills.

  • The participants shall respond to the scenario as if they are responding to an actual emergency.

  • Health care and custody staff shall collaborate to conduct a joint institution-wide live, hands-on simulation mass casualty incident training at least annually. Monthly or quarterly drills do not need to be performed during the same month as an annual drill. Every effort should be made to coordinate with, and to include community EMS in the annual incident drill. Programming shall be paused or modified during annual incident drills.

  • Each dental clinic shall conduct at least one EMRS drill annually. The drill shall include participation by dental and all other EMRS program staff (i.e., nursing and custody staff). Programming shall be paused or modified during annual drills.

  • The drills may or may not be pre-announced, shall be conducted under varied conditions, and shall address a variety of potential scenarios to test processes and competencies.

  • Once the drill is initiated and staff is gathered, the Drill Coordinator shall read the drill scenario to the staff participants. The drill scenario shall be read from and documented on the Emergency Medical Response System Mock Code Template (located on the Lifeline Nursing Services EMRP tab).

  • Staff shall complete documentation that would be required in an actual emergency during the drill scenario.

  • Immediately following the drill, the Drill Coordinator shall conduct a debriefing to allow the participants to evaluate their performance, incorporate lessons learned, and discuss additional steps or components necessary to remedy identified deficiencies.

  • The Drill Coordinator shall submit a report to the EMRRC for all drills that includes, but is not limited to, the following:

    • CDCR 7186-1.

    • Emergency Medical Response System Mock Code Template (located on the Lifeline Nursing Services EMRP tab).

    • Areas identified as positive or appropriate interventions.

    • Recommendations on areas needing improvement or training.

    • Development of Performance Improvement Plans.

  • Copies of documentation and After Action Reviews shall be reviewed and signed by the EMRRC, and the results shall be reported to the institution Quality Management Committee (QMC) as described below.

Emergency Medical Response System Preparedness and Equipment

• Emergency Medical Response and Disaster Response Bags

  • EMR and disaster response bags shall be stocked and maintained in accordance with CDCR 7188-1 and CDCR 7185-1, Disaster Response Bag Checklist.

  • Designated health care staff shall inspect the EMR bags at the beginning of each shift to ensure that the bags are complete, seals are intact, and that the bags and the contents do not appear to be damaged.

  • Designated health care staff shall inspect the disaster response bags daily to ensure that the bags are complete, seals are intact, and that the bags and the contents do not appear to be damaged.

  • Zippered compartments of each EMR bag shall be sealed (compartment zippers together) with a numbered plastic seal.

    • The number of the seal shall be indicated on the appropriate checklist.

    • The institution shall coordinate with their local Pharmacy Services to ensure that seals do not duplicate the color of those used to seal emergency drug supplies.

  • If seals are broken, the contents of the bags shall be inventoried, fully restocked, and new seals affixed to the compartments. Each item within the bag shall be inspected prior to the new seals being placed to ensure that it has not reached its expiration date.

    • Items within 30 calendar days of expiration or the next scheduled monthly inspection shall be replaced prior to resealing the bag.

    • Items without a specific expiration date (e.g., mm/dd/yyyy) shall be considered to expire at 23:59 on the last day of the month indicated (e.g., mm/yyyy).

  • An inventory of sealed compartments shall be completed monthly if the seal on a bag has not been broken and an inventory of that compartment has not been completed in the previous 30 calendar days. This inventory is standardized and shall be completed in compliance with the appropriate inventory checklist (refer to CDCR 7188-1 and 7185-1).

  • Designated supervisory staff shall conduct random inspections, no less than once per month, of each EMR bag, disaster response bag, and the associated logs.

  • All inspections (i.e., shift, monthly, supervisory) shall be documented and recorded on the appropriate checklist (refer to CDCR 7188-1 and 7185-1).

  • Completed inventory checklists shall be collected by the SRN II when they are completed, no less than monthly, and retained for a period of no less than one year. Compliance with the requirements of this paragraph shall be reviewed as part of the institution’s EMRRC and Quality Assurance (QA) Program.

• Treatment Carts and Supplies

  • The RN shall secure treatment carts with numbered seals. The number and integrity of the seal shall be checked during each shift and documented on CDCR 7544-1, Treatment Cart Daily Check Sheet. If the seal is not intact, the RN shall:

    • Immediately notify the SRN responsible for the area and document the SRN notified on the CDCR 7544-1.

    • If the medication drawer seal is not intact or needs restocking, immediately notify a Pharmacist and document the Pharmacist notified on the CDCR 7544-1 pursuant to HCDOM, Section 3.5.22, Emergency Drug Supplies. 

    • Complete the CDCR 7547-1, Treatment Cart Inventory Report, and document completion on the CDCR 7544-1.

    • Secure the treatment cart with a yellow seal.

    • Complete sections of the CDCR 7544-1, corresponding to date, time, printed name, and signature of the staff member completing the form.

  • The RN shall replace missing equipment as indicated on the CDCR 7547-1.

  • Treatment carts without complete equipment supplies shall be secured with a yellow seal by the RN until completely restocked (indicated by a red seal).

    • Where quantity levels for replacement equipment are not prescribed, each institution’s EMRRC shall evaluate usage and set local quantity requirements.

    • Missing and non-functional equipment shall be replaced immediately to ensure continued availability for patient care.

    • If equipment cannot be replaced immediately, the SRN II responsible for the area shall be notified. If the equipment is not immediately replaced, the SRN II shall notify the CNE.

  • ACLS medications shall:

    • Be available and accessible.

    • Be controlled by the pharmacy pursuant to HCDOM, Section 3.5.22, Emergency Drug Supplies.

    • Placed in locations in the designated treatment cart, or designated locked cabinet and clearly labeled and sealed with numbered seals provided by the pharmacy.

  • The LIP shall be onsite and shall remain onsite with the patient until the patient has been transferred to a higher level of care.

  • A defibrillator performance check shall be completed by the designated nursing staff at the beginning of every shift in accordance with manufacturer’s instructions with the defibrillator unplugged and documented on the CDCR 7548-1, Defibrillator Performance Test.

  • On the first business day of each month, the RN shall inventory treatment carts and document on the CDCR 7547-1.

    • Equipment shall be restocked as necessary to maintain quantity requirements. 

    • Sterile items shall be checked for package integrity and expiration dates. Equipment, including sterile items, expiring within 60 calendar days shall be ordered for restocking during the next treatment cart inventory.

    • Items within 30 calendar days of expiration or the next scheduled monthly inspection shall be replaced prior to resealing the cart. Items without a specific expiration date (e.g., mm/dd/yyyy) shall be considered to expire at 23:59 on the last day of the month indicated (e.g., mm/yyyy).

  • The RN shall check laryngoscope function prior to placement in the treatment cart on a monthly basis.

  • The RN shall replace oxygen cylinders with less than 1000 psi.

  • Designated nursing supervisory staff shall conduct random inspections, no less than once per month, of each treatment cart and the associated logs.

  • The CDCR 7544-1, 7547-1, and 7548-1 shall be completed by the RN on duty no less than monthly and collected and retained for a period of no less than one year. Compliance with the requirements of this paragraph shall be reviewed as part of the institution’s QA Program.

• Emergency Medical Response Vehicles

  • Institutions in possession of an EMRV shall implement the following procedure to ensure standardization and readiness:

  • EMRVs are exclusively for the response to and transportation of patients within the grounds of the institution. At no time shall an EMRV be used to transport patients outside of the institution for community medical services.

  • The Warden, or designee, shall ensure EMRVs are maintained and inspected daily for functionality and safety.

  • Designated custody staff shall drive EMRVs to the scene within an institution.

  • EMRVs shall be stocked in accordance with the CDCR 7187-1, Emergency Medical Response Vehicle Inventory Checklist.

  • At the beginning of each shift, designated health care staff shall perform a complete inventory of the EMRV and designated custody staff shall check functionality of the EMRV. The inspections shall be recorded on the CDCR 7187-1.

  • Designated nursing supervisory staff shall conduct random inspections, no less than once per month, of each EMRV and the associated logs. This inspection shall be recorded on the CDCR 7187-1.

  • Completed CDCR 7187-1s shall be collected no less than monthly and retained by the EMRRC for a period of no less than one year.

  • Compliance with the requirements of this paragraph shall be reviewed as part of the institution’s QA Program.

  • All designated vehicles for EMR shall have appropriate mechanisms to secure a patient during transportation and shall have sufficient space for HCFR to maintain control and care of patient.

Emergency Medical Response and Review Committee

• Each institution shall maintain a multidisciplinary EMRRC that is designated to review and analyze all EMRs and EMRS drills. The committee shall meet no less than monthly.

• The EMRRC shall record minutes at each meeting. The minutes shall describe the cases and drills reviewed, recommendations and actions taken, referrals made, and any completed or outstanding action items. The minutes shall be reviewed and approved by committee members prior to signature by the Warden and the CEO and submitted to the institution QMC.

• Clinical Review (Initial Event Review)

  • The CME, or designee, and the CNE, or designee, shall review the documentation and the clinical care delivered during each EMRS incident for known suicide attempts, deaths, and all unscheduled transfers out of the institution within three business days of the incident.

  • When indicated, the CME, or designee, or the CNE, or designee, shall take immediate, appropriate action to prevent repeat events and to protect the safety and security of patients, employees, contractors, volunteers and visitors including, but not limited to:

    • Referral to the CEO, Warden, or the committee designated to review sentinel events in the institution.

    • Gathering information, identifying system and process gaps, and training needs.

    • Developing and implementing Performance Improvement Plans.

    • Communicating with the CME, CNE, relevant Primary Care Teams, TTA staff, and on-call providers regarding departures from the standard of care or policy.

    • Identification of sentinel events and reporting via the Health Care Incident Reporting System.

  • The CME and CNE shall maintain a log of each review conducted, recorded on the CDCR 7189-1, Emergency Medical Response and Review Committee Agenda Template and Minutes. At a minimum, the log shall contain the following information:

    • Patient name and CDCR number.

    • The date and time of the incident.

    • Brief pertinent clinical details of the case and identified opportunities for improvement.

  • For reviews where immediate action is indicated, or in cases which are sentinel events, a more detailed report may be indicated.  It may be necessary to appoint a clinical staff member to further evaluate and prepare detailed reports of those cases for presentation to executive leadership or committees (refer to Section (j)(4) below).

• Process Review (EMRRC QA Review)

  • The following institutional staff shall be voting members of the EMRRC:

    • Warden or designee.

    • CEO or designee.

    • CME or designee.

    • Chief Physician and Surgeon (CP&S) – The CP&S shall serve as the EMRRC chairperson.

    • CNE or designee.

    • Chief Psychiatrist or designee.

    • Supervising Dentist.

    • Emergency Medical Response Coordinator (EMRC).

    • Nurse Instructor.

    • Alarm Response Coordinator (ARC) – The ARC represents training and shall not serve as the Warden designee.

  • The following staff may be assigned to the EMRRC as necessary to support the operation of the committee:

    • Administrative support staff.

    • Community EMS response representatives, when applicable.

    • Fire Chief, or designee.

    • Other personnel as deemed necessary.

  • The EMRRC shall designate in writing an EMRC who shall be at least at the level of an SRN II. The EMRRC shall ensure that the EMRC is supported by administrative staff from the institution’s Quality Management Support Unit and the Health Care Access Unit.

  • The EMRC shall:

    • Assist the CME and CNE in identifying and documenting the daily clinical review of EMRs.

    • Determine the documentation needed for the daily clinical review and for the monthly EMRS review meeting, and ensure the documentation is produced.

    • Ensure completion of and collect Emergency Medical Response Event Checklists.

    • Ensure completion of the initial report for presentation to the committee designated to review EMRs at the next scheduled meeting.

    • Coordinate with the EMRRC chairperson to ensure that cases are reviewed by the committee at the next meeting after the event occurred. Events shall be reviewed within 60 calendar days of their occurrence.

• The EMRRC shall review as applicable, the following documentation. Other relevant documentation shall be reviewed as the circumstances of the event requires.

  • The health record.

  • CDCR 837, Crime/Incident Report, including each applicable supplemental report and attachments.

  • CDCR 7229-A, Initial Inmate Death Report.

  • CDCR 7229-B, Initial Inmate Suicide Report, when available.

  • CDCR 7463, First Medical Responder – Data Collection Tool.

  • CDCR 7186-1.

  • Coroner’s Report of Autopsy, when available.

  • Community Emergency Medical Services Field Report (PCR). The EMRC shall forward a copy of the PCR to Health Information Management for inclusion in the health record.

  • Any other reports as necessary to determine if the emergency response and care provided was appropriate or necessary to evaluate systems, processes, or procedures that need improvement.

• Emergency Medical Response and Review Committee Quality Management Reporting

  • The EMRRC shall submit monthly, quarterly, and annual reports to the institution QMC that analyzes, aggregates, and trends EMRS incidents for the reporting period.

  • The report shall be focused on processes and systems including, but not limited to:

    • Performance scorecards of drills and audits.

    • Monthly analysis and benchmarking of the EMR performance indicators including coordination of activity, timeliness of responders, and clinical outcomes.

    • Total number of EMRS cases evaluated by the EMRC and clinical management.

    • Number of EMRS sentinel events.

    • Performance Improvement Plans.

    • Total number of unscheduled send outs with breakdowns by ambulance, air transportation, or state vehicle.

    • Total number of naloxone utilization cases, with a breakdown based on the provider level, and reported responses.

    • Total number of suicide attempts.

    • Total number of 9-1-1 community EMS activations.

    • Total number of direct dialed requests for urgent and emergent transports.

    • Analysis of the percentage of patients returned to institutions within 24 hours of send out or urgent and emergent transportation requests.

    • Actions taken at Population Management Working Sessions and by care teams in response to patients being sent to a higher level of care.

Policy

• California Department of Corrections and Rehabilitation and California Correctional Health Care Services shall maintain a procedure for emergency medical response training drills.  Emergency medical response training drills shall be conducted at least quarterly and on each shift.  Access shall be provided to clinical skills labs at least quarterly.

Purpose

• Implementation of this policy shall ensure:

• Institutional staff is properly trained in the management of medical emergencies.

• Registered Nurse competency in performance of clinical skills in all applicable nursing protocols.

• Identified deficiencies are remedied.

Responsibility

• The Chief Executive Officer (CEO) and the Warden are responsible for ensuring staff is properly trained in the management of medical emergencies and emergency medical response drills are conducted at least quarterly.

Frequency of Drills

• Emergency medical response training drills shall be conducted at least quarterly and on each shift.

• The drills shall address responses to medical emergencies in all areas of the institution and include participation of health care and custody staff.

• Emergency medical response program staff shall conduct drills in all dental clinics a minimum of once per year.

• The drills may or may not be pre-announced and shall be conducted under varied conditions.

• Each form required for medical emergency drills shall be completed.

Procedure Overview

• Implementation of this procedure shall ensure:

• Institutional staff is properly trained according to emergency medical response guidelines.

• Nursing staff is properly trained in nursing skills lab procedures.

Procedure

• Emergency Medical Response Training Drills

  • The Chief Medical Executive (CME), or designee, the Supervising Dentist, or designee, the Chief Nurse Executive/Director of Nursing (CNE/DON), or designee, the CEO, the Health Care Associate Warden, and the Warden, or designee, shall determine the location, time, and scenario of the drill.

  • The CME, or designee, is responsible for advising and coordinating with the Warden, the Supervising Dentist, and the Chief of Mental Health in advance of the scheduled drill.

  • The Chief of Mental Health, or designee, is responsible for advising the mental health staff of the impending drill and to ensure staff participation.

  • The Supervising Dentist, or designee, is responsible for advising the dental staff of the impending drill and to ensure staff participation.

  • The CEO or Warden, or designee. is responsible for setting up and maintaining control of the proper cardiopulmonary resuscitation mannequins and/or other necessary emergency medical response equipment at the designated drill location.

  • Institutional staff is required to respond immediately to all emergency medical response drills within their designated area.

  • Once the drill is initiated and staff is gathered, the CNE/DON, CME, or designee, shall read the drill scenario to the staff participants.  The participants shall respond to the scenario as if they are responding to an actual emergency situation.

  • The custody, medical, or nursing designee shall ensure that the designated supervisor in charge of monitoring the drill utilizes and submits all appropriate forms. 

  • Documentation required in an actual emergency situation shall be completed during the drill scenario. 

  • Immediately following the drill, the drill coordinator shall conduct a debriefing to allow the participants to evaluate their performance, incorporate lessons learned, and discuss any additional steps or components necessary to remedy identified deficiencies.

  • The drill coordinator shall submit a report to the committee designated to review emergency medical response events.  The report shall include, but is not limited to, the following:

    • Synopsis of the event

    • Date and time of the drill

    • Drill location

    • Participants involved

    • Time frames of all elements, e.g., response time from medical/custody

    • Areas identified as positive or appropriate interventions

    • Recommendations on areas needing improvement or training

    • Development of a corrective action plan

• Nursing Skills Lab

  • The nurse instructor shall ensure that emergency medical response skills labs are scheduled on the education calendar and all nurses have the opportunity to participate in the skills training.

  • A lab facilitator who may be the nurse instructor, supervising nurse, or other identified staff member shall be available during designated lab hours.

  • Documentation of the skills lab training and/or remedial training provided shall be completed on the in-service training form.

  • All skills lab training forms, materials, and documentation shall be maintained and tracked by the nurse instructor or designee.

Policy

• California Department of Corrections and Rehabilitation and California Correctional Health Care Services shall maintain a procedure for auditing and restocking the Emergency Medical Response Bags.  The contents of the bags are found on the Emergency Response Bag Checklist.  Only those items on the checklist shall be kept in the bags.

Purpose

• To establish and maintain the appropriate emergency medical supplies in approved locations.

Responsibility

• The Chief Executive Officer and the Warden are responsible for implementation of this policy.

Procedure

• Implementation of this procedure shall ensure proper audit and documentation of Emergency Medical Response Bag usage.

• The institution shall develop an Local Operating Procedure to ensure:

  • Identification of secure locations for all Emergency Medical Response Bags.

  • Emergency Medical Response Bags are inspected to ensure that the seals are intact.

    • In the event seals are broken, the bags must be audited, fully restocked, and affixed with new seals.

    • An inventory of a sealed compartments is required monthly if the seal on a bag has not been broken and an inventory of that compartment has not been completed in the previous 30 days.

  • Designation of staff to perform audits.

  • Inspections occur on each watch where clinical staff is posted.

• Audit of the Emergency Medical Response Bag shall be documented on the Emergency Medical Response Bag Checklist.  Signature of the auditor is required.

• Designated zippered compartments of each Emergency Medical Response Bag shall be sealed (compartment zippers together) with a numbered plastic seal.

  • When the seal is broken a complete inventory of the contents is required and items are to be refilled or replaced according to the Emergency Medical Response Bag Checklist.

    • The bag shall be inventoried for designated supplies and equipment.

    • Items with expiration dates shall be checked to ensure all items within the bag are within expiration dates.

  • Gloves and safety shears must be stored in the end-zippered pocket of the Emergency Medical Response bag.

    • The end-zippered pocket shall be left unsealed.

    • Visual inspection of the safety shears must be completed as part of the audit/inventory performed every shift.

• All Emergency Medical Response Bag Checklist(s) shall be submitted to the Emergency Medical Response Coordinator, or designee, on a monthly basis and reviewed for completeness.

Policy

• California Department of Corrections and Rehabilitation (CDCR) and California Correctional Health Care Services shall maintain a formal review mechanism to review each emergency medical response incident or drill in the institutions.

Purpose

• To ensure that institutions review emergency medical responses on a regular basis to promote continuous quality improvement related to performance and coordination of emergency medical response activities.

Responsibility

• The Chief Executive Officer (CEO) and the Warden are responsible for implementation of this policy.

Procedure Overview

• Implementation of this procedure shall ensure that emergency medical response incidents are appropriately audited, evaluated, and reported.

General Instructions

• The institution’s committee designated to analyze emergency medical responses shall review the emergency medical response reports at its regular monthly meeting.  The following staff should attend the emergency medical response section of the committee meeting:

  • Warden or designee (Associate Warden for Health Care or Chief Deputy Warden).

  • CEO.

  • Chief Medical Executive (CME) and/or Chief Physician and Surgeon (CP&S).

  • Supervising Dentist.

  • Chief Nurse Executive/Director of Nursing (CNE/DON).

  • Chief of Mental Health, as appropriate.

  • Emergency Medical Response Coordinator.

  • Fire Chief or designee.

  • Other personnel as deemed necessary.

• Confidential documents relevant to the review shall be available to committee members if needed for reference during the meeting.

• Minutes shall be recorded at each meeting, reviewed, and approved by committee members prior to signature by the Warden and the CEO.

Procedure

• Institution Emergency Medical Response Review Process

  • Clinical Review: Each business day the CME, or designee, and the CNE/DON, or designee, shall review the documentation and the clinical care delivered during each emergency medical response incident for suicide attempts, deaths, and all unscheduled transfers out of the institution which have occurred since the prior review.

    • Whenever necessary the CME, or designee, and the CNE/DON, or designee, shall take appropriate action to prevent repeat events and to protect the safety and security of patients and staff including but not limited to:

      • Referral to the CEO, the Warden, and/or the committee designated to review sentinel events in the institution.

      • Gathering information and referring for investigation.

      • Implementing Corrective Action Plans (CAPs).

      • Communicating with the CME, CNE/DON, relevant Primary Care Teams, Triage Treatment Area staff, and on-call providers regarding departures from the standard of care or policy.

    • The CME and CNE/DON are responsible for maintaining a log of reviews to include patient name, date, and brief pertinent clinical details of each case.  In some cases in which actions are taken or in cases which are sentinel events, a more detailed report may be indicated.  It may be necessary to appoint a clinical staff member to further evaluate and prepare detailed reports of those cases for presentation to executive leadership or committees.

  • Process Review:  Each institution shall adapt its existing emergency medical response Local Operating Procedure to implement this procedure including assigning a staff member to the role of Emergency Medical Response Coordinator.

    • The Emergency Medical Response Coordinator shall:

      • Assist the CP&S and Supervising Registered Nurse II in identifying and documenting the daily clinical review of all emergency medical responses.

      • Gather all documentation needed for the daily clinical review and for the monthly emergency medical response review meeting.

      • Complete the Emergency Medical Response Event Checklist.

      • Ensure completion of the initial report for presentation to the committee designated to review emergency medical responses at the next scheduled meeting.

      • Provide clerical support for monthly meetings of the committee which reviews the emergency medical response report.

    • When evaluating each emergency medical response incident the following documents may be utilized:

      • CDCR 837, Crime/Incident Reports (including each applicable supplemental report and attachments).

      • CDCR 7219, Medical Report of Injury or Unusual Occurrence.

      • CDCR 7229-A, Inmate Death Report.

      • CDCR 7229-B, Inmate Death Report/Suicide, when available.

      • CDCR 7462, Cardiopulmonary Resuscitation Record.

      • CDCR 7463, First Medical Responder – Data Collection Tool.

      • CDCR 7464, Triage and Treatment Services Flow Sheet.

      • The health record relevant to the patient’s health condition and treatment prior to the incident under review.  It may be necessary to review up to 3-6 months of medical history prior to the incident.

      • Coroner’s Report of Autopsy, when available.

      • Community Emergency Medical Services Field Report.

      • Any other reports as necessary.

• Quality Management Committee Reporting

  • The Emergency Medical Response Coordinator shall submit monthly, quarterly, and annual reports to the Quality Management Committee that analyzes, aggregates, and trends all the emergency medical response incidents for the reporting period.  This report is focused on processes and systems including:

  • Performance scorecards of drills and audits.

  • Monthly analysis and benchmarking of the emergency medical response performance indicators including coordination of activity, timeliness of responders, and clinical outcomes.

  • Total number of emergency medical response cases evaluated by the Emergency Medical Response Coordinator and clinical management.

  • Number of emergency medical response sentinel events referred to the designated review committee.

  • Summary report of CAPs.

Policy

• California Correctional Health Care Services (CCHCS) shall ensure material and equipment required for patient support during a medical emergency is available and operational at all times.

Purpose

• To ensure availability of equipment necessary for Basic Life Support and Advanced Cardiac Life Support measures during a medical emergency.

Responsibility

• The Chief Executive Officer and Warden, or their designees, are responsible for implementation, monitoring and evaluation of this policy.

Procedure Overview

• Crash cart equipment, drawer, and par levels shall be implemented and maintained in accordance with California Department of Corrections and Rehabilitation (CDCR) 7547, Crash Cart Inventory Report.

• Crash carts shall remain sealed unless performing monthly inventories, replenishing equipment, providing educational in-services, or providing emergency medical response and treatment by licensed health care practitioners lawfully authorized to perform such treatments acting within the scope of their professional licensure.

• Crash cart medications shall be maintained pursuant to the Health Care Department Operations Manual (HCDOM), Section 3.5.22, Emergency Drug Supplies.  Emergency procedures shall be in accordance with the HCDOM, Section 3.7.1, Emergency Medical Response System.

• A standardized crash cart shall be available within or at every Triage and Treatment Area and licensed inpatient unit.

Procedure

• Crash carts shall be secured with numbered seals. The number and integrity of the seal shall be checked each shift and documented on CDCR 7544, Crash Cart Daily Check Sheet. If the seal is not intact, staff shall:

  • Immediately notify the Supervising Registered Nurse (SRN) responsible for the area.

  • Immediately notify Pharmacy.

  • Complete CDCR 7547.

  • Secure the crash cart with a yellow seal.

  • Complete sections of CDCR 7544, corresponding to:

    • Name of SRN notified.

    • Crash Cart Inventory Report completed.

    • Name of Pharmacist notified.

    • Date, Time, Signature, and Printed Name of staff completing the form.

• Staff shall replace missing equipment and comply with applicable sections of the HCDOM, Section 3.5.26, Break-In, Theft/Loss from Pharmacy or Medication Storage Areas.  Numbered seals shall be controlled by the Pharmacy pursuant to the HCDOM, Section 3.5.22 Emergency Drug Supplies. Emergency procedures shall be pursuant to the HCDOM, Section 3.7.1, Emergency Medical Response System Procedure.

• Crash carts without complete equipment supplies shall be secured with a yellow seal until completely restocked, indicated by a red seal.  Par levels for replacement equipment are not prescribed.  If equipment is not replaced within three business days, the SRN responsible for the area shall be notified.  The SRN shall initiate and continue documentation of the occurrence until resolved, and advance the issue as needed.

• A defibrillator performance check shall be completed in accordance with manufacturer’s instructions with the defibrillator unplugged. The check shall be documented on CDCR 7548, Defibrillator Performance Test.

• On the first business day of each month, crash carts shall be inventoried and documented on CDCR 7547.  Equipment shall be restocked as necessary to maintain par levels.  Sterile items shall be checked for package integrity and expiration dates.  Equipment, including sterile items, expiring within 60 calendar days shall be ordered for restocking during the next crash cart inventory.

• Laryngoscope function shall be checked prior to placement in the crash cart and monthly.

• Oxygen cylinders with less than 500 psi shall be replaced.

• Each institution shall adopt Local Operating Procedures to implement, administer, and document the following requirements:

  • Maintain completed CDCR 7544, CDCR 7547, and CDCR 7548 forms for a minimum of one year.

  • Establish and review par levels for replacement crash cart equipment.