Health Care Department Operations Manual

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Chapter 3 – Health Care Operations

Article 7 – Emergency Medical Response

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3.7.4 Emergency Medical Response: Post‑Event Review

  • 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.

  • References

    • National Commission on Correctional Health Care Standard P-A-10, Procedure in the Event of an Inmate Death, 2008

  • Revision History

    • Effective: 08/2008
      Revised: 07/2012