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Who is eligible for this program?

Only patients who meet the indigent definition and meet the trauma criteria who are unable to pay for services and for whom there is no third-party coverage in part or in whole for trauma services provided qualify under this funding program. No reimbursement shall be provided for patient care if the patient has the ability to pay for the service but refuses or fails to pay for it. 

When can I bill the program?

To bill County, Contractor must at a minimum show that it has made reasonable efforts to secure payment for the patient by billing (at least monthly) for an additional period of not less than two (2) months after the date Contractor first billed the patient.

What documents do I have to submit to bill the program?

  • A completedOriginalUB-04 form   
  • A completedOriginalTSCE form (Attachment U-1)  


  • AcompletedOriginal Inability to Cooperate form (Attachment U-2) 
  • A printout of the data in the Trauma and Emergency Information System(TEMIS)

Hospitals must ensure that all data elements from UB-04 match the data elements from TEMIS.  Claims eligible for inclusion in the County’s payment methodology shall only include claims for which all required documentation matches TEMIS.

When can an Inability to Cooperate Form (U-2) be submitted?

If a TSCE Agreement form cannot be secured because the patient is unable to cooperate in providing the necessary financial information, then a Contractor certification to that effect (Attachment U-2), Hospital Certification of Inability to Cooperate form must be completed.   

Examples include, but are not necessarily limited to, situations where the patient has expired, or is comatose or otherwise, mentally incompetent. 

What is the difference between Cash/Self and CHIP Eligible?

There is no difference as far as reimbursement goes. They are defined in the Trauma Data
Dictionary as follows:
Cash/Self: Individuals who are not insured and do not qualify for other funding source based on ability to pay in accordance with the hospital’s charity care policy, as determined by the hospital’s finance department. For County facilities this includes ATP (Ability to Pay).
Chip Eligible: Individuals who qualify for California Healthcare for Indigents Program which provides limited funds to compensate for patients who cannot afford to pay for services rendered and for whom payment will not be made through any private coverage or by any program funded in whole or in part by the State or Federal government including Medi-Cal or Victims of Crime.
Some Trauma Centers use both they enter either CHIP or Cash as the first payer, or use only Cash and some use only CHIP. Claims submitted are reimbursed if TEMIS has either CASH/Self or CHIP Eligible in any combination. Technically, all patients for whom claims are submitted should have CHIP Eligible as either the first or 2nd payer, but as long as no other payer is in TEMIS, the County will pay.

What are the policies on refunding the County if the hospital receives payment from a patient or third party payer for claims previously paid by the County?

Any and all payments received by the Contractor must immediately be reported and the County’s payment must be refunded. Each refund should have a Trauma Hospital Payment Refund Form (Attachment B-6) attached.   

What if the hospital has submitted a claim and payment has not been issued by the County, but Contractor is informed that there is Third Party Liability (TPL)?

Contractor must pursue the TPL and withdraw the claim by notifying the County indicating that there is pending TPL to the EMS Agency Reimbursement Coordinator at (562) 347-1590.   

Should the hospital continue to pursue third party payer coverage once the claim has been submitted to the County for reimbursement?

No, the Contractor shall only submit claims that they have determined do not have any other payor source and the patient is indigent.  If after the claims is submitted the Contractor finds out the patient does have insurance coverage, the Contractor shall notify the County and refer the payor to the County as the Contractor subrogates all their rights to the claim once they submit the claim.

What are the procedures if a provider is contacted by a third party representative (e.g., insurance claim adjuster) or a patient’s attorney regarding pending litigation for a previously submitted claim?

Contractor shall indicate that the claim for services provided to their client is assigned and subrogated to the County and refer such representatives to the designated County contact.  (Contractor shall reasonably cooperate with County in its collection efforts).

What rates would the Contractor be paid if patient is admitted (i.e. on June 29th and discharged on July 5th)?

This claim would be part of the fiscal year that ended in June. Payment by County to Contractor for such patients shall be at the rates in effect on the date.

Can a claim be submitted if there is pending third party liability?

Yes, but these claims should not be submitted until the December 31st deadline nears. These claims may not be paid but will be counted towards the Medi-Cal match total.

Who is considered the last resort of payment, the County or Victims of Crime (VOC)?

A victim of Crime is considered the last resort of payment.

Can a provider bill Victims of Crimes Program (VCP) and submit the claim to the Trauma Reimbursement Program?

No, at any point during the claiming period, the hospital has a choice of the following:

  • Submit the claim to VCP and DO NOT SUBMIT to the County or 
  • Submit the claim to the County andDO NOT SUBMIT TO VCP

If the claim is submitted to the County and then a hospital receives payment from VCP the hospital must surrender the payment from VCP to the County. 

What if a payment is received from a third party payer and they are offering less than what the County reimbursed? Can I refuse to take their payment?

No. You must immediately notify the County and refund the County’s payment.

Are in-custody patients covered by this program?

Since In-Custody claims are paid at a low rate, additional funding will be included from the Underinsured bucket when payment is issued to the trauma centers for In-Custody Claims. 

1.What are the procedures if payment is received for In-Custody Claims? 

  • Do not submit claim if payment is received for In-Custody Claim 
  • Update the TEMIS database to indicate Payor 1 as In-Custody. 
  • TEMIS will capture the data for claims considered In Custody.  

2.What are the procedures if no-payment is received on In-Custody claims? 

  • Submit claim if payment is not received for In-Custody Claim   
  • Include a copy of the denial letter from law enforcement or  
  • The patient notes which indicate the reason why the claim was denied.
  • The TEMIS database should indicate Payor 1 as County Indigent.

What is the basis for number of hospital days reimbursed?

The number of hospital days paid will be based upon the number of hospital day room charges on the UB-92, but shall not exceed the number of days calculated between admission and discharge dates. Claims which include hospital day room charges on the UB-92 that exceed the calculated number of days between hospital admission and discharge will be returned for hospitalization, they are not eligible. (The key is the status while hospitalized).

Zika Virus — June 15, 2016

Zika virus is a flavivirus spread by the bite of the Aedes mosquito and is related to denque, yellow fever and West Nile viruses.

Originally reported in Uganda, the virus has now spread to many parts of the world including the United States (See Figures).


Incubation is 2-12 days and only 20% of patients bitten develop symptoms. Transmission between humans can occur via blood transfusion or sexual activity. Symptoms include fever, rash, conjunctivitis, joint pain, headache, and generalized weakness.

One of the most publicized complications is microcephaly in babies born of women infected with the virus during pregnancy (generally in the first trimester of pregnancy). Greater than 4000 cases have been reported in Brazil and now in other areas of the world.

Treatment of the disease is symptomatic meaning treating the fever and symptoms with acetaminophen (Tylenol) and other supportive care such as IV fluids if dehydrated. Ibuprofen (Motrin) should be avoided as co-infections with dengue do occur and use of nonsteroidal anti-inflammatory agents, such as ibuprofen, may increase risk of progression to hemorrhagic fever.

Testing for the virus can occur from blood, urine or cerebrospinal fluid specimens sent to local health departments.

EMS providers should use universal precautions or standard infectious disease precautions (gloves and mask) when evaluating and transporting these patients to the emergency department. Exposure to blood or bodily fluids should be reported per normal guidelines and no additional precautions are necessary. Questions regarding exposures can first be directed to the Medical Alert Center who can contact Public Health.


  1. United States Center for Disease Control and Prevention accessed 7-11-16.
  2. Los Angeles County Department of Public Health accessed 7-11-16.
  3. Los Angeles County Department of Public Heath

The End of Life (AB15) Impacts on EMS System — June 20, 2016

TO: The EMS Community

As many of you are aware, in late 2015, the California Legislature passed the End of Life Act (AB 15), which became law on June 9, 2016. This Act allows for terminally ill patients in California who are mentally competent adults to voluntarily request and receive a prescription for medication to end the patient’s life at a time of their choosing. This allows for a patient to have some control over the end of their life and gives patients dignity and comfort at the time of their death.

The law outlines many safeguards for the patient and includes language that the patient may rescind his/her wish to take the aid-in-dying drug at any time.

In order to prepare the EMS system to care for these patients with respect for their wishes, there have been modifications to a number of key EMS Agency policies including Reference No. 814 “Determination/Pronouncement of Death in the Field” and Reference No. 815 “Honoring Do Not Resuscitate Orders”, Physician Orders for Life Sustaining Treatment, and the End-of-Life Option (Aid-in-Dying drug).

Please review these updated policies on our website under Resources/Prehospital Care Manual. Note a couple of new resources within Reference No. 815: Reference No. 815.3 provides an example of an attestation that the patient intends to take the Aid-in- Dying Drug within 48 hours. An attestation may or may not be available at the time EMS arrives at a home of a patient who has taken the aid-in-dying drug. Reference No. 815.4 is an algorithm, which is intended to provide guidance on the management of these patients. The goal is to honor a patient’s end-of-life option and provide comfort and guidance to the family.

We must also work collaboratively as EMS and hospital-based providers to make the best decisions on care and transport for the patient, and their families.


Marianne Gausche-Hill, MD, FACEP, FAAP

Medical Director, LA County EMS Agency


Reference No. 814, Determination/Pronouncement of Death in the Field

Reference No. 815, Honoring Do No Resuscitate Orders, Physician Orders for Life Sustaining Treatment, and End of Life Option (Aid-In-Dying Drug)

Reference No. 815.3, Sample Final Attestation for an Aid-In-Dying Drug to End My Life in a Humane and Dignified Manner

Reference No. 815.4, End of Life Options Field Quick Reference Guide

Paramedic to Assist caregivers or patient with self-administered emergency medication

In this update I will:

  • Discuss the authority for paramedics to administer emergency medication including hydrocortisone for patients with congenital adrenal hyperplasia (CAH).
  • Define adrenal crisis and its causes
  • List signs and symptoms of adrenal crisis
  • Describe the appropriate field treatment for a CAH patient in the prehospital setting

Congenital adrenal hyperplasia or CAH are any of several types of genetic diseases (autosomal recessive) that can result in excessive or deficient production of sex steroids or cortisol. This can have a profound effect on the reactions of the body to stress including infection.

  • The adrenal glands sit on top of both kidneys and produces hormones including cortisol, aldosterone, and testosterone.
    Adrenal crisis is a life-threatening condition that occurs when there is not enough cortisol produced.
  • Congenital adrenal hyperplasia (CAH) is an autosomal recessive genetic disorder which results in improper hormone synthesis resulting in, with stress such as an infection, adrenal crisis.
  • Causes of adrenal crisis include deficiency anywhere along the pathway to cortisol production and release by the adrenal glands. CAH is one cause. Patients with dysfunction of the adrenal glands themselves (known as Addison’s disease), and those with disease of the pituitary may also have adrenal crisis with stressors.

Any of the following stresses to the normal physiology of a patient with CAH or other diseases of the adrenal gland can result in life threatening consequences:
Physical Stress
Sudden discontinuation of medication
Injury to the pituitary or adrenal gland

Signs and symptoms are not specific for adrenal crisis, so a high level of suspicion for this condition should be maintained for a patient with CAH. These signs and symptoms may include:

  • Nausea
  • Fever
  • Pallor
  • Confusion
  • Weakness
  • Tachycardia
  • Tachypnea
  • Hypotension/shock


Let’s illustrate what we are discussing by presenting a case:
Paramedics respond to the home of a 2 year-old boy
Teenage sister states the boy began to have fever, vomiting and diarrhea several hours ago
She states the child has congenital adrenal hyperplasia
He is wearing a medical alert bracelet that states “adrenal insufficiency”

The boy’s vital signs:
HR 180, RR-30,
Cap refill-delayed 3 secs
LOC- Responds to verbal by moving head and crying
Skins- Hot to touch

Sister states she tried to give the child a double dose (stress dose) of hydrocortisone (Solu-Cortef®) by mouth as prescribed by the physician, but the child immediately vomited it up.
She attempted to contact her parents but they did not answer her phone call.
Her mother usually gives him an IM injection of hydrocortisone (Solu-Cortef®) when he cannot tolerate medication by mouth.
She has his injection kit next to her.

What should the paramedic do?

What can the paramedics do?

Per State of California Title 22, Division 9, Prehospital Emergency Medical Services, Chapter 2, EMT 100063: Scope of Practice of EMT Assist patients with the administration of physician prescribed devices including but not limited to, patient operated medication pumps, sublingual nitroglycerin, and self-administered emergency medications, including epinephrine devices
Paramedics may perform any activity in the scope of practice of an EMT, therefore can assist patients in delivering normally self-administered medications, such as hydrocortisone in this case (other examples of emergency self-administered medications include albuterol, nitroglycerin, or epinephrine via autoinjector)

In summary

  • If a patient has CAH has symptoms of adrenal crisis, the EMT or paramedic can assist the patient, or patient’s caregivers in administering the medication (hydrocortisone (Solu-Cortef®) IM) which falls under both EMT and paramedic scope of practice
  • A paramedic should contact the base hospital with any questions
  • These patients must be transported to the hospital for further evaluation/treatment
  • This medication should be given as soon as possible and can be life saving

Please see attached Presentation for further information 

Hepatitis A Outbreak in Los Angeles County — September 21, 2017

The Los Angeles County Department of Public Health has notified the Emergency Medical Services (EMS) Agency of 10 cases of Hepatitis A amongst our homeless population or others at risk for Hepatitis A infections.

In San Diego County 421 cases of Hepatitis A infections including 16 deaths, primarily affecting homeless persons, injection and non-injection illicit drug users and individuals in dense living conditions with shared restrooms, were reported since November 2016.

At this time we recommend that all EMS Provider Agencies and Police Departments notify their staff who have direct contact with individuals from the identified population, of this outbreak and the need for vigilance relative to PPE use and hand hygiene. Although hand hygiene should be a part of daily clinical care both for the protection of the provider and the patient/client, outbreaks such as these bring this practice into the forefront of prehospital care. Hepatitis A virus is spread by oral contamination with feces which occurs when a person puts their contaminated hand in their mouth. This transmission can be prevented by PPE and good hand hygiene practices. These same practices are important for law enforcement personnel to follow to prevent exposure to disease.

The Center for Disease Control (CDC) recommends the following best practice related to hand hygiene and use of gloves for health care providers:

When and How to Wear Gloves

  • Wearing gloves is not a substitute for hand hygiene. Dirty gloves can soil hands.
  • Always clean your hands after removing gloves.
  • Steps for Glove Use:
    1. Choose the right size and type of gloves for the task
    2. Put on gloves before touching a patient’s non-intact skin, open wounds or mucous membranes, such as the mouth, nose, and eyes
    3. Change gloves during patient care if the hands will move from a contaminated body-site (e.g., perineal area) to a clean body-site (e.g., face)
    4. Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination
      • Failure to remove gloves after caring for a patient may lead to the spread of potentially deadly germs from one patient to another
    1. Do not wear the same pair of gloves for the care of more than one patient

When Should an EMS providers and Law Enforcement Personnel Use Alcohol Based Sanitizers or Wash Hands

  • Before eating
  • Before and after having direct contact with a patient’s intact skin (taking a pulse or blood pressure, performing physical examinations, lifting the patient in bed)
  • After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings
  • After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient
  • If hands will be moving from a contaminated-body site to a clean-body site during patient care
  • After glove removal
  • After using a restroom

When using alcohol-based hand sanitizer:

  • Put product on hands and rub hands together
  • Cover all surfaces until hands feel dry
  • This should take around 20 seconds

Each EMS Provider Agency should alert their providers to the CDC recommendations on who should be vaccinated against Hepatitis A.

Currently the Hepatitis A Vaccine is recommended for the following persons aged 1 year and older:

  • Persons who live/work in a community with a high rate of Hepatitis A (HAV)
  • For men having sex with other men.
  • For drug users.
  • Travelers to countries with high rates of Hepatitis A.
  • Persons with chronic liver disease.
  • Persons who receive blood products to help your blood clot (e.g. Hemophilia).
  • Persons working with HAV-infected animals or work with HAV in research setting.

The Hepatitis A vaccine is currently given to all children after 1 year of age – this occurred after 2000 – thus many of our EMS providers and law enforcement personnel may be unvaccinated. The Hepatitis A vaccine is given in two injections 6 months apart and confers 25 year immunity in most adults.

For the latest updates and recommendations please visit the EMS Agency website at:

Under Important Notice on the landing page is an area listed as Hepatitis A Update. You can click on this to be linked to the most current information from the Department of Public Health. If you have specific questions please send them to and EMS Agency staff will get back to you with a response.

Message from the Medical Director — October 6, 2017

Fentanyl Exposure for EMS Provider — August 30, 2018

Fentanyl use as a drug of abuse has increased in the United States.  EMS providers are increasingly likely to encounter fentanyl in the line of duty.

Facts to know:

  • Fentanyl is a synthetic opioid that is more potent than heroin or morphine
  • Fentanyl can be present in many forms (e.g. tablet, capsule, powder, rocks, solutions)
  • Inhalation of fentanyl as an airborne powder is the most likely exposure route that would lead to harmful effects, but it is less likely to occur than skin contact.
  • Incidental skin contact is not expected to lead to harmful effects if the contaminated skin is promptly washed off with soap and water.

Signs and symptoms of fentanyl exposure include:

  • Respiratory Depression
  • Drowsiness or Unresponsiveness
  • Constricted or Pinpoint Pupils


  • PPE is effective in decreasing the risk of harmful effects from fentanyl exposure
    • Wear gloves to prevent skin exposure
    • NIOSH-approved respirators (“masks”) decrease the risk of inhalation exposure
    • Eye protection can prevent mucous membrane exposure

If exposure occurs:

  • Do not touch your eyes, mouth, nose or any skin after touching a potentially contaminated surface
  • Wash skin thoroughly with soap and water; Do NOT use hand sanitizers as they may enhance absorption through the skin
  • If you suspect clothing contamination, remove them via standard decontamination procedures

If an EMS responder exhibits signs or symptoms of fentanyl exposure:

  • Move away from the source and call for assistance
  • Administer naloxone per departmental protocols
  • Perform rescue breathing/airway management as needed
  • Administer CPR if indicated

US Customs and Border Protection:

Safety Recommendations for First Responders Handout:….pdf

Flea-Borne Typhus? — October 18, 2018

Los Angeles County Department of Public Health (LAC DPH) has identified a number of cases of flea-borne typhus associated with the homeless population in downtown Los Angeles and the Willowbrook area of Compton.

LAC DPH states, “flea-borne typhus, also known as murine or endemic typhus, is a disease transmitted by fleas infected with Rickettsia typhi or Rickettsia felis. Flea-borne typhus is endemic in LAC with cases detected each year. In recent years, the average number of cases reported to LAC DPH has doubled to nearly 60 cases per year; however, geographic clusters of the size are unusual. Most cases occur in the summer and fall months. In LAC, the primary animals known to carry infected fleas include rats, feral cats, and opossums. People with significant exposure to these animals are at risk of acquiring flea-borne typhus”

When should EMS providers suspect typhus?

  • A fever of unknown cause, especially in patients at high risk (e.g., homeless, or those around feral cats or other mammals).
  • Other symptoms include chills, body aches, headache, and rash.

What are recommended actions by emergency departments and other hospital-based clinicians?

Consider a diagnosis of flea-borne typhus in patients with a non-specific febrile illness with headache, myalgia, rash, and laboratory abnormalities including leukopenia, thrombocytopenia, and elevation of hepatic transaminases, without alternate identifiable etiology.

  • LAC DPH asks that all suspected cases of flea-borne typhus, particularly in persons experiencing homelessness and those with exposure to outdoor animals such as stray cats, opossums, pet dogs and cats, be reported to Los Angeles County DPH Acute Communicable Disease Control Program within 1 working day. 
  • Weekdays 8:30 AM – 5:00 PM: call 888-397-3993. For consultation: call 213-240-7941
    – After hours: call 213-974-1234, and ask for the physician on call.

Long Beach Health and Human Services

  • Weekdays 8:00 AM – 5:00 PM: call 562-570-4302
    – After hours: call 213-974-1234, and ask for the physician on call.

Pasadena Public Health Department

    • Weekdays 8:00 AM – 5:00 PM (closed every other Friday): call the Communicable Disease Control Program at 626-744-6089
      – After hours: call 626-744-6043.
  • LAC DPH recommends that treatment for typhus not be delayed for diagnostic testing which includes serologic testing for R.typhi IgG and IgM antibodies. As there can be cross-reactivity with other rickettsiae, LAC DPH also recommends testing for antibodies against R. rickettsii, the causative agent of Rocky Mountain Spotted Fever.
  • Doxycycline is the treatment of choice; the dose of doxycycline for adults is 100 mg orally BID.  Treatment should occur for a minimum of five days or until 48 hours after patient becomes afebrile.

Are there concerns about contracting the disease if EMS or hospital personnel care for such patients?

  • There is no concern for person-to-person transmission therefore, standard precautions and PPE are indicated.
  • No additional methods for cleaning of ambulances after transport of suspected patients are indicated.

If fleas are noted, consider removing clothing and place in a biohazard bag.

Additional Resources

COVID-19 Outbreak: An Update

Where else can I get reliable information about COVID-19?

Should SNFs or receiving hospitals screen EMS providers upon arrival?

The Los Angeles County EMS Agency recommends against SNFs screening EMS providers because every EMS provider is screened by their employer regularly and performs self-monitoring. Extra screening provides no benefit, and may delay patient care.

What personal protective equipment (PPE) should I don prior to entry to a SNF?

Proper PPE for entering a SNF includes a surgical mask, eye protection, and gloves. For any call with aerosol generating procedures an N95 should be donned, and a gown if supplies allow.

What is the Los Angeles Surge Hospital (LASH)?

The Los Angeles Surge Hospital (LASH) is a surge hospital that was opened in response to the COVID-19 pandemic in order to decompress other hospitals and to create more hospital beds within Los Angeles County. The LASH is accepting COVID-19 positive patients only. The LASH accepts patients through interfacility transports only and is not a designated 9-1-1 receiving facility.

What are I/Q sites and should I be responding any differently to them? How can I refer a patient to the I/Q sites?

I/Q sites are “isolation and quarantine” sites that have been set up around the county to safely house COVID-19 test positive patients, suspected COVID-19 patients, or patients under quarantine isolation due to an exposure. Responding to this site should be no different than the standard response, as you should be responding to all calls with a surgical mask, gloves, and eye protection at the minimum. These sites have nursing and medical staff on site that may be able to provide you with more information about the patient. Medical equipment on site is severely limited.

In order to refer a patient to the I/Q sites, a Public Health community volunteer may be contacted and to screen and determine if the patient qualifies for the I/Q sites. A community worker list is available on our website. EMS is not required to make this referral.

What is the Fairview ACS Transfer Package?

Fairvew ACS Transfer Package

Where can I find more information on applying for approval to transport medical patients to an alternate destination during the COVID-19 pandemic?

Alternate destination for transport of EMS patients requiring acute medical care is currently on hold.  The LA County EMS Agency will monitor the outbreak and can implement alternate destinations as the need arises.  Pilot programs transporting patients without acute medical needs to Sobering Centers and Psychiatric Urgent Cares are still in effect.

Are EMS personnel authorized to transport patients to alternate destinations?

Transport to alternate destinations that are not located on a 9-1-1 Receiving Facility campus is not authorized unless your Provider Agency is participating in an approved pilot program.  EMS personnel may be directed by the 9-1-1 receiving facility to an alternate triage/care site ON campus and adjacent to the Emergency Department, such as a triage tent.  The 9-1-1- Receiving Facility is required to submit a plan to the LA County EMS Agency and to the Provider Agencies in the region. See COVID-19 Update # 8 for more information.

What are alternate destinations?

Alternate destinations (AD) are sites outside of the 9-1-1 receiving facility that receive 9-1-1 transports. Transport to these sites is only for patients that are best served in a facility other than the Emergency Department.

Should receiving hospitals screen EMS providers upon arrival?

The Los Angeles County EMS Agency recommends against receiving facilities screening EMS providers because every EMS provider is screened by their employer regularly and performs self-monitoring. Extra screening provides no benefit, and may delay patient care.

When should I doff my PPE?

Doffing should only occur once the patient is off loaded from the gurney and transition of care to hospital personnel is complete.

What should I do if I am performing an aerosol generating procedure (AGP) upon arrival to the receiving facility?

AGPs should be held when entering the Emergency Department until the patient is in an enclosed room where the procedure may resume. Due to the critical nature of many AGPs, it is imperative to have advanced communication with hospital staff to identify the plan for handoff in order to minimize the time that the AGP is paused.  The only instance in which chest compressions and ventilations may continue during transport through the ED hallways is for patients who are intubated with an endotracheal tube and a viral filter in place, which creates a fully closed system. This is not recommended for BMV or King tube placement. See LA County EMS COVID-19 Update #7: EMS Handoffs for more information.

For patients resuscitated from cardiac arrest, why am I staying on scene to stabilize the patient after return of spontaneous circulation (ROSC)?

Re-arrest is common shortly after return of spontaneous circulation (ROSC), occurring in approximately 60% of patients who are resuscitated from out-of-hospital cardiac arrest (OHCA).  Particularly, during the COVID-19 pandemic, avoiding CPR en route to the facility not only improves patient outcomes, but can also reduce exposure risk for EMS providers. Nearly all patients are preload dependent after cardiac arrest and most will require vasopressor support. Rapid on-scene stabilization can prevent re-arrest by initiating volume resuscitation and preparing to administer push-dose vasopressors as needed before the epinephrine administered during resuscitation wears off and the patient begins to decompensate. Once the patient has been initially stabilized with intravenous fluids and push dose epinephrine as needed, the patient can be transferred to the nearest STEMI Receiving Center.  See Treatment Protocol 1210 Cardiac Arrest and the EMS Agency memo for more information.

For patients without return of spontaneous circulation (ROSC), why am I consulting with the Base Physician regarding the decision to transport?

Per Ref. 814, Determination/Pronouncement of Death in the Field, the Base Physician must determine the decision for transport or termination for patients who do not meet criteria for termination of resuscitation in section II.A. This is based on the physician’s assessment of the patient’s chances of meaningful survival. This has not changed during the COVID-19 pandemic. On-scene resuscitation to achieve ROSC prior to transport optimizes the patient’s chances for a good outcome. If futility is determined by the Base Physician, the patient should not be transported to the hospital.

How does treat and refer work? What if the patient still wants transport?

Reference 834.1 Treat and Refer for Ill Patients During the COVID-19 Outbreak is a policy that was created for EMS personnel to identify low acuity patients with COVID-19 related complaints that do not need immediate transport to the Emergency Department. Use Reference 834.2 Low Risk COVID-19 Screening Tool to determine if the patient meets low risk criteria. Patients must have normal vital signs and pulse oximetry 94% or greater to be treated and referred.

If the patient or legal guardian still requests transport after reassurance by EMS personnel, then the patient must be taken to the Most Accessible Receiving facility (MAR) for adults or Emergency Department Approved for Pediatrics (EDAP) for children

If there is a disagreement between TP 1245 and the treatment protocol corresponding with the provider impression, which protocol should be followed?

During the COVID-19 pandemic, direction under TP1245 will supersede any direction that is outlined in the other treatment protocols.

 Is there a treatment protocol for COVID-19 patients?

TP 1245 Potential COVID-19 Patients, is a newly created protocol that is a direct response to the COVID-19 pandemic. This protocol is intended to be used in conjunction with the treatment protocol(s) that correspond to the provider impression(s).  The guidance therein supersedes guidance in the other treatment protocols during the COVID-19 pandemic.  This protocol was developed to outline practices that ensure quality prehospital care, while maximizing provider safety and minimizing exposures in the field.

Where can I find more information on applying for waivers for prehospital care policies during a disaster/emergency declaration?

Reference 1142 Prehospital Care Policy Waivers provides information on which waivers are available during a disaster or emergency declaration. All waivers must be approved by the EMS Agency Director, Medical Director, or their designee.

What are aerosol generating procedures (AGPs)?

AGPs are procedures that can aerosolize COVID-19 particles, such that they are suspended in the air. These procedures include: nebulized treatments, CPAP, BMV, suctioning, laryngoscopy, advanced airway placement, and chest compressions.

Can we reuse PPE between patients/calls?

Surgical masks and N95/P100 respirators can be reused up to 5 times unless if you have been in contact with a patient that screens positive, the mask is visibly soiled, the mask gets contaminated with bodily fluids, or it is used in an aerosol generating procedure. See TP 1245  and CDC guidance for more information.

What is the appropriate level of PPE to wear on calls?

For all calls, the minimum donned PPE consists of a surgical mask, eye protection, and gloves. For any call with aerosol generating procedures, an N95 or P100 respirator, eye protection, gloves, and gown as supplies allow, should be donned.

If I test positive for COVID-19, when can I go back to work?

Testing is recommended for those with symptoms, or in select cases, for those with high-risk exposures. Tests are available through one of the drive-through testing sites by making an appointment online (LACOVID), through your employer, or through your primary care provider.

Where can I get tested for COVID-19?

Testing is recommended for those with symptoms, or in select cases, for those with high-risk exposures. Tests are available through one of the drive-through testing sites by making an appointment online (LACOVID), through your employer, or through your primary care provider.

 What is active monitoring?

Per the Centers for Disease Control and Prevention (CDC), active monitoring is where a local health department or your employer communicates with you on a daily basis to assess for fever or symptoms of COVID-19 (cough, shortness of breath, sore throat, myalgias, malaise).

This differs from self-monitoring where all on-duty EMS providers monitor themselves for fever by taking their temperature twice a day and monitor for symptoms of COVID-19. See CDC’s guidance on monitoring and LA County EMS Agency’s Guidance for more information.

What is considered a high-risk exposure and what should I do if I have experienced one?

A high-risk exposure is one where the EMS responder does not have the proper PPE donned and an aerosol generating procedure (AGP) is performed on a confirmed or suspected COVID-19 patient. AGPs include CPAP, nebulized treatments, suctioning, bag-mask ventilation, laryngoscopy, advanced airway placement, and chest compressions. If this occurs, the EMS provider should self-isolate at home for 14 days and perform active monitoring as described in the recommendations from Centers for Disease Control and Prevention. See COVID-19 Update #5 for more information.