DHCS Medical Emergency Response Guidelines for PCP Clinic – 2020

Emergency health care services are available and accessible 24 hours a day, 7 days a week (Facility Site Review, I. Access/Safety Guidelines, D. )
PROCEDURES:
 Staff can describe site-specific actions or procedures for handling medical emergencies until the individual is stable or under care of local emergency medical services (EMS). (Pg. 5)
 There is a written procedure for providing immediate emergent medical care on site until the local EMS is on the scene (See Ex. Pg. 6).
 When the MD or NPMP is not on site, staff/MA may call 911, and CPR-certified staff may initiate CPR if needed.
 Non-CPR-certified staff may only call 911 and stay with the patient until help arrives.
 Emergency equipment and medication, appropriate to patient population, are available in an accessible location and is ready for use.
 For emergency “Crash” cart/kit, contents are appropriately sealed and are within the expiration dates posted on label/seal.
 Site personnel are appropriately trained and can demonstrate knowledge and correct use of all medical equipment they are expected to operate within their scope of work.
(See Ex. Pg. 4).
 Documented evidence that emergency medication and equipment is checked at least monthly may include a log, checklist or other appropriate method(s). (See Ex. Pg. 2)
EMERGENCY MEDICAL EQUIPMENT:
Minimum emergency equipment is available on site to:
 Establish and maintain a patent/open airway.
 Manage emergency medical conditions.
EMERGENCY PHONE NUMBER LIST:
 Post emergency phone number list that is dated with telephone numbers updated annually and as changes occur (See Ex. Pg. 4). List must include:
 Local emergency response services (e.g., fire, police/sheriff, ambulance), emergency contacts (e.g., responsible managers, supervisors)
 Appropriate State, County, City and local agencies (e.g., local poison control number)
AIRWAY MANAGEMENT:
Clinic must have minimum airway control equipment, to include:
 Wall oxygen delivery system or portable oxygen tank (Portable oxygen tanks are maintained at least ¾ full)
 There is a method/system in place for oxygen tank replacement
 If oxygen tanks are less than ¾ full at time of site visit, site has a back-up method for supplying oxygen if needed and a scheduled plan for tank replacement.
 Oxygen tubing need not be connected to oxygen tank, but must be kept in close proximity to tank.
 Health care personnel at the site must demonstrate that they can turn on the oxygen tank.
 Nasal cannula or mask, oropharyngeal airways,
 Bulb syringe
 Ambu Bag as appropriate to patient population. (Mask should be replaced when they can no longer make a solid seal)
 Various sizes of airway devices appropriate to patient population within the practice are on site.

EMERGENCY MEDICATION/ANAPHYLACTICE REACTION MANAGEMENT: (See Page 2 and 3)

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 DHCS Medical Emergency Response Guidelines for PCP Clinic – 2020

EMERGENCY MEDICATION/ANAPHYLACTICE REACTION MANAGEMENT:

There is a current medication administration reference (e.g. medication dosage chart) available for readily identifying the c orrect medication dosages (e.g. adult, pediatric, infant, etc.). Package inserts are not acceptable as
dosage charts. All emergency medications in the emergency kit/ crash cart must have dosage charts.

Stock

Lot #

Date
Exp.
Anaphylaxis Kit* JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

A written emergency protocol for anaphylaxis treatment should be posted in a prominent place and rehearsed regularly. It should include drug dosages for adults, as
well as telephone numbers and contact details for resuscitation team, emergency medical services, emergency department, etc.
Epinephrine (Anaphylaxis) Anaphylaxis
1:1000
(1) X 1 mL vial of injectable diphenhydramine
(Benadryl) 50 mg/mL
(2) X 1 tab of oral diphenhydramine (Benadryl) 25
mg (Oral)
(3) X 1 mL syringes with safety engineered needles
(ESIP). Suggest: Needle gauge: 25G, needle
lengths: 3 x 1˝; 3 x 5/8˝; 3 x 1.5˝
Oxygen Delivery System – tank at least ¾ full
Oxygen delivered 6-8 L/minute
Oral Airways (various sizes)
Nasal Cannula or Mask
Ambu bag
1 Pocket mask
5 Alcohol swabs
Stock

Lot #

Date
Exp.

Other Emergency Medications JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

Asthma exacerbation, chest pain, hypoglycemia management per American Academy of Family Practice (AAFP) recommendations.
Naloxone ( Narcan®)
Chewable aspirin
Nitroglycerin spray/tablet
Nebulizer or metered dose inhaler
Glucose

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 DHCS Medical Emergency Response Guidelines for PCP Clinic – 2020

EXAMPLE - DOSAGE CHART

2019 Site Review DHCS Guidelines
Emergency Medication\Anaphylactic Reaction Management
Medication Administration Reference (e.g. Medication Dosage Chart)
Anaphylaxis Kit* Adult Pediatric Infant
Epinephrine (Anaphylaxis) Anaphylaxis 0.01mg/kg IM (up to maximum of 0.5mg) 0.01 mg/kg IM (up to maximum of 0.3mg) 0.01 mg/kg IM (up to maximum or 0.3mg)
1:1000 (injectable)
(1) X 1 mL vial of injectable diphenhydramine 10mg to 50mg IV/IM (NTE 400mg/day) 1 to 2 mg/kg/dose IV/IM (NTE 50mg/dose) 1 to 2 mg/kg/dose IV/IM (NTE 50mg/dose)
(Benadryl) 50 mg/mL *If IV route, IV push at a rate of ≤25mg/min *If IV route, IV push at a rate of ≤25mg/min
(2) X 1 tab of oral diphenhydramine Take 25mg to 50mg by mouth Not preferred. Refer to parenteral route or oral solution Not preferred. Refer to parenteral route or oral solution
(Benadryl) 25 mg (Oral)
Oxygen Delivery System – tank at least ¾ full Can consider any oxygen delivery systems if Nasal prongs or nasal catheters preferred; can Nasal prongs or nasal catheters preferred
appropriate consider face mask, bead box, or incubator for older
children
Oxygen delivered 6-8 L/minute 6 to 8 L/minute 1 to 4 L/minute 1 to 2 L/minute
Other Emergency Medications Adult Pediatric Infant
Nasal (Narcan): Spray 4mg (content of 1 nasal Nasal (Narcan): 4mg (content of 1 nasal spray) as a Nasal (Narcan): 4mg (content of 1 nasal spray) as a
spray) in one nostril as a single dose; may repeat single does in one nostril; may repeat every 2-3 single does in one nostril; may repeat every 2-3
every 2-3 minutes in alternating nostrils minutes in alternating nostrils minutes in alternating nostrils
Auto-injector (Evzio): Inject 2mg (content of 1 Auto-injector (Evzio): Inject 2mg (content of 1 auto- Auto-injector (Evzio): Inject 2mg (content of 1 auto-
Naloxone (Narcan®) auto-injector) IM as a single dose; may repeat injector) IM as a single dose; may repeat every 2-3 injector) IM as a single dose; may repeat every 2-3
every 2-3 minutes with another Evzio auto-injector minutes with another Evzio auto-injector minutes with another Evzio auto-injector
Solution injection: Inject 0.4mg to 2mg IM as a Solution injection (age ≥5 years old or ≥20kg): Solution injection (age <5 years old or ≤20kg):
single dose; may repeat every 2-3 minutes up to 2mg/kg IM/SQ; may repeat every 2-3 minutes prn 0.1mg/kg IM/SQ; may repeat every 2-3 minutes prn
10 mg
Chew 160mg to 325mg nonenteric coated aspirin Aspirin is not recommended for patients <18 years of Aspirin is not recommended for patients <18 years of
Chewable aspirin upon presentation or within 48 hours of stroke age who are recovering from chickenpox or flu age who are recovering from chickenpox or flu
symptoms due to association with Reye syndrome symptoms due to association with Reye’s syndrome
Tablet: 0.3mg to 0.4mg sublingually every 5 Safety and effectiveness of oral nitroglycerin in Safety and effectiveness of oral nitroglycerin in
minutes up to 3 doses pediatric patients have not been established pediatric patients have not been established
Nitroglycerin spray/tablet
Spray: Spray 0.4mg (1 spray) sublingually every 5
minutes up to 3 doses
Nebulizer: 2.5mg to 5mg every 20 minutes for 3 Nebulizer: 2.5mg to 5mg every 20 minutes for 3 Nebulizer: 2.5mg every 20 minutes for the 1st hour
doses, then 2.5mg to 10mg every 1 to 4 hours prn doses, then 2.5mg to 10mg every 1 to 4 hours prn prn; if there is rapid response, can change to every 3
Nebulizer or metered dose inhaler MDI (90mcg/actuation): 4 to 8 inhalations every 20 MDI (90mcg/actuation): 2 to 10 inhalations every 20 to 4 hours prn
(albuterol) minutes for up to 4 hours, then 1 to 4 hours prn minutes for 2 to 3 doses; if rapid response, can change MDI (90mcg/actuation): 2 to 6 inhalations every 20
to every 3 to 4 hours prn minutes for 2 to 3 doses; if there is rapid response, can
change to every 3 to 4 hours prn
Glucose 15gm (3-4 tablets) by mouth 10gm to 20gm (0.3gm/kg) by mouth Not preferred. Parenteral route recommended (IV
dextrose or IM glucagon)
7.30.19 Jenny Nguyen, PharmD, SFHP Pharmacy
Department
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 DHCS Medical Emergency Response Guidelines for PCP Clinic – 2020
References:
1. Arnold, J. J., & Williams, P. M. Anaphylaxis: recognition and management. American family physician, 84(10). 2011.
2. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention (GINA). 2018.
3. National Asthma Education and Prevention Program (NAEPP), “Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma Update on Selected Topics - 2002,” J Allergy Clin Immunol, 2002, 110(5 Suppl):141-219.
4. Organization WH. Oxygen Therapy for Children. 2017.
5. Sunehag A, Haymond MW (2017). Approach to hypoglycemia in infants and children. UpToDate Inc. https://www.uptodate.com (Accessed July 29, 2019)
6. UpToDate. Wolters Kluwer. https://www.uptodate.com (Accessed July 29, 2019)

Emergency Contact List [Emergency contact list prominently placed or demonstrated online as easily accessible.]

YOUR CLINIC INFORMATION

Name of Office:
Street Address:
City, Postal Code:
Telephone Number:
Fax Number:
Email:

OFFICE/NURSE MANAGER
Name: Primary Contact #: Alternate Contact #:

EMERGENCY NUMBERS
Fire Department Police Department Ambulance Service

Hospital Poison Control Alarm Company

Site Access/Safety Emergency phone number contacts are posted.

Local emergency response services, emergency contacts (e.g., responsible managers, supervisors), poison control; dated/updated annually.
EXAMPLE CLINIC ________________________________________________________________YEAR ____________
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 DHCS Medical Emergency Response Guidelines for PCP Clinic – 2020

Worksheet
Anaphylaxis Asthma Chest Hypoglycemia Opioid Overdose
Management Exacerbation Pain Management Management

Annual Staff Mock Annual Staff Mock Annual Staff Mock Annual Staff Mock Annual Staff Mock
Verification Training Verification Training Verification Training Verification Training Verification Training

Written protocol for Jan Jan Jan Jan Jan

treatment
Protocol Feb Feb Feb Feb Feb
prominently placed
Adult drug dosage Mar Mar Mar Mar Mar
chart
Pediatric drug Apr Apr Apr Apr Apr
dosage chart
May May May May May

Jun Jun Jun Jun Jun

Jul Jul Jul Jul Jul

Aug Aug Aug Aug Aug

Sep Sep Sep Sep Sep

Oct Oct Oct Oct Oct

Nov Nov Nov Nov Nov

Dec Dec Dec Dec Dec

Instructions: Each year and as indicated, date and initial that the criteria are current and in practice. According to best practices, date and initial the regular occurrences of mock training
with staff.
Rothkopf, L., & Wirshup, M. B. (2013). A practical guide to emergency preparedness for office-based family physicians. Family practice management, 20(2), 13-18.

EXAMPLE: Procedure for Providing Immediate Emergent Medical Care On Site Until the Local EMS is On the Scene.
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 DHCS Medical Emergency Response Guidelines for PCP Clinic – 2020

COMMUNICATION PHASE EMERGENCY RESPONSE

ACTION RESPONSIBILITY ACTION RESPONSIBILITY
Call 911, activate Clinic Staff with health information TRIAGE Check ABCs Primary Care Provider
Emergency Medical Services provided by Primary Care Provider • airway, breathing, circulation
(EMS): • vital signs
Provide address, clinic name, phone# • check blood sugar, if indicated
Describe situation • check for medic alert
Vital Signs Complete brief history and P.E. Primary Care Provider
Level of consciousness Maintain a safe environment for staff Clinic Staff
Degree of urgency and client
Establish Leadership and direct Primary Care Provider MANAGEMENT Obtain required equipment as per Clinic Staff
activities emergency protocol
Obtain immediate assistance within the Primary Care Provider Move client as required Primary Care Provider
office
Use Emergency documentation to note Primary Care Provider Do secondary survey, detailed physical Primary Care Provider
treatments and progress examination
Obtain history from next of kin and Primary Care Provider Assess need for immediate treatment Primary Care Provider
update them on situation
Communicate with and relocate other Clinic Staff Initiate treatment according to Primary Care Provider
clients as needed appropriate protocol with available
Provide patient information and Clinic Staff equipment and medication Primary Care Provider
medication sheet for EMS
Direct staff member to meet EMS team Clinic Staff TRANSFER Reevaluate status and response to Primary Care Provider
in parking lot, hold elevator, etc. therapy
Most responsible primary care provider Primary Care Provider Transfer for definitive care to EMS Primary Care Provider
to sign patient over to EMS
Provide written copy of documentation Clinic Staff
& medication sheet to EMS
MD, PA, NP, or RN to call hospital Primary Care Provider
emergency dept. & update status. Note
on documentation.
MD, PA, NP, or RN to update next of Primary Care Provider FOLLOW-UP Restock Emergency Cart & re-order Clinic Staff
kin. Permission from pt., if possible medication as required
Identify opportunities for improvement Primary Care Team Manager Provide medical follow-up in acute case Primary Care Provider
and implement changes accordingly in collaboration with Primary setting as required
Care Team If critical incident, complete appropriate Team Manager
paperwork and steps for reporting.
Debrief staff

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 DHCS Medical Emergency Response Guidelines for PCP Clinic – 2020

References: Tip – Use Google Scholar to access articles

Department of Health Care Services (DHCS) All Plan Letter 20-004, Facility Site Reviews.
1. Arnold, J. J., & Williams, P. M. (2011). Anaphylaxis: recognition and management. American family physician, 84(10). https://www.aafp.org/afp/2011/1115/p1111.pdf
2. Ebell, M. H. (2011). Evaluation of chest pain in primary care patients. Am Fam Physician, 83(5), 603-5. https://www.aafp.org/afp/2011/0301/p603.pdf
3. Hauk, L. (2017). Management of Chronic Pain and Opioid Misuse: A Position Paper from the AAFP. American family physician, 95(7), 458-459.
https://www.aafp.org/afp/2017/0401/p458.pdf
4. Pollart, S. M., Compton, R. M., & Elward, K. S. (2011). Management of acute asthma exacerbations. American family physician, 84(1). https://www.aafp.org/afp/2011/0701/p40.pdf
5. Rothkopf, L., & Wirshup, M. B. (2013). A practical guide to emergency preparedness for office-based family physicians. Family practice management, 20(2), 13-18. https://www.aafp.org/fpm/2013/0300/p13.html?printable=fpm
6. Toback, S. L. (2007). Medical emergency preparedness in office practice. American family physician, 75(11). https://www.aafp.org/afp/2007/0601/p1679.html
7. US Department of Health and Human Services, National Institutes of Health, & Centers for Disease Control and Prevention. (2014). Guiding principles for the care of people with or at risk for diabetes. National Diabetes Education Programme. https://www.niddk.nih.gov/-
/media/Files/Health-Information/Communication-Programs/NDEP/health-care-professionals/Guiding-Principles-Final_04-25-19.pdf?la=en&hash=52322889BA2325EEFD94CDA37339674D

The material in this document is a knowledge-sharing tool provided by the FSR team to enhance compliance with Facility Site Review requirements. All content is for
informational purposes and may be used and/or modified according to site-specific practices. Ensure appropriate review and approval by site management prior to
adoption.

Feb 2020