UTSW/BioTel Policy: Destination

Purpose: The purpose of this policy is to guide paramedics in the determination of the appropriate destination hospital for their patients. Refer to the Hospital Destination Matrix below.

Policy: UTSW/BioTel paramedics shall transport patients only to approved hospital emergency departments and shall utilize the guidelines within this policy to assist in their determination of the appropriate receiving hospital. Should there be any question as to the appropriate destination hospital for a given patient, BioTel shall be contacted for consultation.

  1. GENERAL DESTINATION DECISION-MAKING
    Hospital destination decisions for EMS patients shall be prioritized based on the following:
    1. Patient medical need;
    2. Patient preference;
    3. Family or on-site private physician preference (if the patient is unable to provide information).
    4. Paramedics shall follow their respective City and EMS agency guidelines when determining hospital destination. UTSW/Bio Tel paramedics shall transport patients only to approved hospital emergency departments as outlined by each agency’s respective policy concerning patient transport decision-making. If no such guideline exists, adhere to the guidelines in this policy or contact BioTel for assistance.
  1. Patients With Minor, Non-Emergent Medical Conditions
    Patients who do not meet specialty hospital criteria, such as Trauma Centers, Stroke Centers and STEMI Centers, who have normal vital signs and who do not meet any of the "exceptions" listed below, MAY be informed that they will be transported to the closest open and appropriate hospital emergency department.  If that patient refuses transport to the closest open and appropriate ED, then they may be considered to be a “Patient Declining Transport” or “PDT”. 

Exceptions:

  1. Pregnant patients who report receiving prenatal care shall be transported to the ED that is associated with their prenatal care provider.
  2. Patients who are post-op/post-procedure within 90 days and have a chief complaint that could be related to their surgery/procedure shall be transported to the ED of the hospital that performed their surgery/procedure.
  3. Patients undergoing chemotherapy or radiation treatment shall be transported to the ED that is associated with their cancer treatment center.
  4. Consider “sister hospital” relationships. For example, if a patient wants to go to a Baylor Hospital emergency department that is far away, but they have a minor medical condition and normal vital signs, you do not have to take them to the closest ED, but rather, take them to the closest Baylor campus.
  5. Use good judgment. If there are other unique or extenuating circumstances, transport the patient to the hospital you believe is most appropriate, report those circumstances to the receiving hospital staff upon arrival, and document your decision-making process on the ePCR.
  1. Emergent Medical Adult:
    Patients with one or more of the following conditions should be transported to the closest hospital emergency department:
    1. Airway obstruction or respiratory insufficiency with inadequate ventilation;
    2. Status epilepticus;
    3. NON-TRAUMATIC cardiac arrest or post cardiac arrest.
  1. Emergent Medical Pediatric: (including Overdose patients)
  1. Prehospital Trauma Center Triage Criteria – Adult:

    NOTE:  Hospital capabilities change.  Paramedics are advised to contact BioTel or to consult the current version of BioTel Hospital Capabilities Matrix for updated receiving hospital/Trauma Center capabilities.

Trauma patients meeting ANY of these criteria shall be transported to either a Level I or Level II Accredited Trauma Center

  1. Airway:
    1. Endotracheal intubation/advanced airway placement or attempted placement prior to arrival
  2. Breathing:
    1. Respiratory compromise (obstruction, use of accessory muscles/respiratory distress or inhalation injury)
    2. Respiratory rate less than 10 or greater than 29
  3. Circulation:
    1. Post-traumatic cardiac arrest
    2. Heart rate less than 50 or greater than 140
    3. Systolic BP less than 90 (adult)
  4. Disability:
    1. GCS 10 or less secondary to trauma
    2. Decreasing level of consciousness
  5. Event:
    1. Gunshot wound to head, neck or torso
    2. Evisceration
    3. Amputation proximal to the wrist or ankle
    4. Age at least 60 years PLUS ANY Level-II criteria
    5. Viable fetus (estimated at least 24 weeks gestational age) PLUS ANY Level-II criteria
    6. Burn greater than 20% TBSA (Burn greater than 10% should be transported to Parkland, if possible)
    7. Burn greater than 10% TBSA PLUS any other traumatic injury (Transport to Parkland, if possible)
    8. Use of blood products for resuscitation at transferring facility or during transport
    9. “Hot offload”
    10. Emergency Department or Medical Control Physician discretion

Level II Trauma Center Criteria:

  1. High-energy mechanism within 72 Hours prior to presentation:
    1. Fall at least 20 feet (2 stories or greater)
    2. Drowning
    3. Hanging
    4. Non-superficial penetrating injury AT or PROXIMAL TO the knee or elbow
    5. Pedestrian hit by automobile WITH ANY identified injury
    6. Bicyclist hit by automobile WITH ANY identified injury
    7. Motorcycle crash at least 20 MPH WITH ANY identified injury
    8. High-risk Motor Vehicle Crash (MVC), such as: significant intrusion or ejection or death in the same passenger compartment
  2. Anatomic:
    1. Traumatic brain injury and:
      1. GCS 11-13 secondary to trauma, OR
      2. GCS at least 14 with more than 2 organ system injuries
    2. Multiple (2 or more) long-bone fractures
    3. Pelvic fracture (excluding ground-level fall)
    4. Mangled, crushed or degloved extremity proximal to the wrist or ankle
    5. Pulseless extremity
    6. Suspected compartment syndrome
    7. Suspected spinal cord injury or spine fracture with motor deficit
    8. Age at least 60 years PLUS ANY significant trauma (excluding ground-level fall)
    9. Burns – refer to the Burn Center Criteria below
    10. Transfer with known intracranial hemorrhage and GCS at least 10
    11. Emergency Department or Medical Control Physician discretion
Burn Center Criteria – Patients with any of the following criteria should be transported directly to Parkland Hospital, if possible (refer to the BURNS Treatment Guideline):


  1. Prehospital Trauma Center Triage Criteria – Pediatric: ***Refer to the Children’s Medical Center’s Trauma Activation Criteria below.***

Age 0 to 13 years (up to 14th birthday): Patients should be transported to Children’s Medical Center Dallas.

Age 14 years and older: Patients meeting Trauma Center Criteria should be transported to the closest Level I or Level II ADULT Trauma Center.  These Centers include:

  1. Parkland Hospital (LEVEL I)
  2. Baylor University Medical Center (LEVEL I)
  3. Methodist Dallas Medical Center (LEVEL II)
  4. Medical Center of Plano* (LEVEL II) – this facility can receive all trauma patients, EXCEPT:
    1. Pediatric patients under 14 years of age;
    2. Neurotrauma under 18 years of age;
    3. Penetrating eye injuries;
    4. Amputations requiring re-implantation;
    5. Burns.
    6. NOTE: Medical Center of Plano will arrange transfer, if indicated, of any patient with any of the above criteria who might be transported to this facility.
CMC-Dallas Trauma Activation Criteria

 

  1. Acute Stroke:
    Patients at least 14 years of age with signs and symptoms of acute stroke shall be transported according to the following criteria:
    1. Onset of symptoms less than 3.5 hours: Transport to the closest designated stroke center.  If the EMS provider is not certain that the desired destination hospital is a designated stroke center, contact BioTel for consultation.
    2. Onset of symptoms at least 3.5 hours, but less than 12 hours: Unless immediate intervention (e.g. ABCs, cardiac arrest, etc.) is required, these stroke patients should be preferentially transported to a comprehensive-capable stroke facility, if such a facility is available with less than 15 minutes of additional transport time.  If the EMS provider is not certain that the desired destination hospital is a comprehensive-capable stroke center, contact BioTel for consultation.
    3. Onset of symptoms at least 12 hours, or unknown last-known-normal time: Transport to the closest designated stroke center.

    4. Pediatric patients less than 14 years of age with signs and symptoms of acute strokes should be transported to Children’s Medical Center Dallas (not Legacy) or to Medical City Children’s Hospital: contact BioTel for destination instructions.
  1. Acute ST-Elevation MI:
    Patients with signs and symptoms of acute STEMI shall be transported to the closest hospital with catheterization lab capabilities, according to the following hierarchy:
    1. Patients who are unstable and would experience a significant delay in their care by transport to a preferred hospital with catheterization capabilities shall be transported to the closest hospital with those capabilities.
    2. Patient preference for transport to a specific Receiving hospital that has cath lab capabilities.
    3. Family or private physician preference (if patient unable to provide information) for transport to a specific Receiving hospital that has cath lab capabilities.
    4. Patients without a preference shall be transported to the closest Receiving hospital that is has cath lab capabilities.
  1. Amputations and Devascularization Injuries:
    Patients with the following injuries may be transported to the Microsurgical Specialty Care Facility of their choice or to the closest microsurgical center, if the patient has no preference:
    1. Isolated amputation or partial amputation distal to the ankle or wrist
    2. Extensive facial, lip, or ear avulsion
    3. Penile amputation
    NOTE: If the patient meets trauma triage criteria, transport to a Trauma Center.
Patients with simple avulsion lacerations of the distal phalanx will be transported to any open Receiving hospital, or the closest open Receiving hospital, if the patient has no preference.
  1. Burns:
    Patients OF ANY AGE with any the following criteria shall be transported to the Parkland Hospital Burn Center:
    1. Burns greater than 10% of the total body surface area (TBSA), regardless of depth
    2. Burns involving the face, eyes, ears, hands, feet, perineum, genitalia or major joints
    3. Full thickness or 3rd-degree burns in any age patient
    4. Electrical burns (including lightning)
    5. Chemical burns
    6. Inhalation injury, including smoke inhalation
    7. Burns associated with traumatic injuries (e.g. fractures)
    8. Burns in patients with pre-existing medical conditions or comorbidities (e.g. elderly, immunosuppressed, diabetic, cardiac history)
    9. Patients who meet Trauma Triage Criteria and who have burns and/or smoke inhalation
    10. Pediatric burn patients who do not meet Trauma Triage Criteria.
  1. Obstetrics:
    Pregnant patients with the following conditions should be transported to the closest Obstetrics Specialty Care facility:
    1. Breech presentation partially delivered
    2. Limb presentation
    3. Vaginal hemorrhage with shock
    4. Cord prolapse or nuchal cord                                           
    5. Actively seizing or status-post seizure
    6. No prenatal care during pregnancy
    7. All other pregnant patients with a pregnancy related medical problem should be transported to the Obstetrics Specialty Care Facility of their choice, or the closest open Obstetrics Specialty Care Facility, if the patient has no preference.
  1. VA Patients:
    Patients who report that they are Veterans, who do not meet specialty care criteria (e.g. STEMI, Stroke, Trauma), and who express the preference to be transported to the VA Hospital may be transported there.

However, it may not be necessary to transport Veterans directly to a Veteran’s hospital:

  1. Veterans may call 911 for emergency transport to the closest non-VA hospital. If hospitalization is required, the hospital will contact the nearest VA hospital within 24 hours to arrange transfer.
  2. The VA may be able to arrange and pay the health care of eligible Veterans outside of VA medical facilities-but only in certain, limited circumstances:
    1. When the Veteran meets eligibility criteria:
    2. When there is a medical need;
    3. When VA medical facilities (or “sharing agreement” facilities) are unavailable.
Patients who are not Veterans shall NOT be transported to the VA, unless they have an unstable airway and the VA hospital is by far the closest emergency department.
  1. Psychiatric Patients:
    1. Nearly all patients for whom 911 is called for evaluation of an acute psychiatric disorder will require “medical clearance” before they are evaluated by psychiatric emergency services and may be transported to any receiving hospital emergency department for medical clearance.
    2. Paramedics cannot “medically clear” patients in the field.
    3. Paramedics shall perform a standard patient evaluation unless the patient refuses consent for such an evaluation, or unless the patient is combative and it unsafe to evaluate the patient.
    4. Paramedics may not transport patients directly to Green Oaks Hospital or to any other primary psychiatric facility.
    5. Patients under Emergency Detention may be transported to any hospital emergency department for medical clearance; however, patients under police arrest should be transported to Parkland Hospital.
    6. Psychiatric patients maintain the right to determine treatment and therefore they may refuse evaluation and treatment. They CANNOT refuse transport without BioTel MD consultation.
    7. Patients under Emergency Detention can also refuse evaluation and treatment, but they CANNOT refuse transport.
    8. Any patient exhibiting signs and symptoms of EXCITED DELIRIUM MUST be transported by ambulance to a hospital emergency department.
  2. Pediatric Psychiatric Patients:
    1. Age 0 to 12 years (up to 13th birthday): Patients should be transported to Children’s Medical Center**
      1. NOTE: **CMC Dallas can evaluate patients up to 18th birthday, if they are NOT violent or in custody.
      2. Children’s Legacy: same criteria as CMC Dallas
    2. Age 13 years or older: Patients should be transported to closest appropriate facility.
      1. NOTE: Texas Health Resources Plano can evaluate patients at least 12 years of age.
  3. Alleged Sexual Assault Patients:

    State Bill 1191 states that all hospitals must have the ability either to conduct a forensic exam on an alleged Sexual Assault patient, or to make arrangements to transfer the patient to the nearest, designated treatment facility, or to a “Center of Excellence”, such as Parkland Hospital or Texas Health Presbyterian Hospital Dallas.
    1. Dallas County Available Resources
      1. Females 0 to 13 years of age (up to 14th birthday): Patients may be transported to CMC Dallas.
      2. Females 14 years of age and older: Patients may be transported either of these hospitals:
        1. Parkland Hospital ED (OB ICC), or
        2. Texas Health Presbyterian Hospital Dallas
      3. Males 0 to 16 years of age (up to 17th birthday): Patients may be transported to CMC Dallas.
      4. Males 17 years of age and older: Patients may be transported to either of these hospitals:
        1. Parkland Hospital ED, or
        2. Texas Health Presbyterian Hospital Dallas
    2. Collin County Available Resources
      1. Females 0 to 13 years of age (up to 14th birthday): Patients may be transported to CMC Legacy.
      2. Females 14 years of age and older: Patients may be transported either of these hospitals:
        1. Medical Center of Plano, or
        2. Texas Health Presbyterian Hospital Plano
      3. Males 0 to 16 years of age (up to 17th birthday): Patients may be transported to CMC Legacy.
      4. Males 17 years of age and older: Patients may be transported to either of these hospitals:
        1. Medical Center of Plano, or
        2. Texas Health Presbyterian Hospital Plano
  4. Intoxicated Patients:
    Patients believed to be simply intoxicated by alcohol and/or other street drugs may be transported to Parkland Hospital for possible enrollment in the Dallas Serial Inebriate Project.
    1. Paramedics CANNOT “medically clear” patients for transport by police to jail or to the City Detention Center.  However, paramedics may, after a complete evaluation, make a determination that a patient does not appear to require transport by ambulance.
    2. Paramedics MUST transport patients by ambulance to a receiving hospital emergency department if they have ANY of the following criteria:
      1. Glasgow Coma Score less than 13;
      2. Pulse rate less than 60 or greater than 120;
      3. Systolic blood pressure less than 90;
      4. Diastolic blood pressure greater than 110;
      5. Respiratory rate less than 12 or greater than 24;
      6. Oxygen saturation less than 95%;
      7. Capillary blood glucose analysis (BGA) level less than 60 or greater than 300;
      8. Active hemorrhage;
      9. Bruising or hematoma above clavicles indicating the need for spinal precautions;
      10. Witnessed seizure within the last hour;
      11. ANY signs or symptoms of Excited Delirium;
      12. Inability to ambulate with limited assistance;
      13. A law enforcement officer reports that he/she is NOT comfortable transporting the patient by means other than ambulance.
  5. Multi Casualty Incident (MCI):
    In the event of a Multi-Casualty Incident (MCI), destination decisions will be determined by the Incident Transport Officer, in consultation with BioTel and the EMS Medical Director on-site, if available.