Universal Protocol Section 1 BARS Protocol(s) Age Appropriate depressive) - Difficult or unable tounablewake or Difficult to but normally Asleep, responds sedated Drowsy, appears activity) awake and(normal Quiet activity verbal) Overt(physical or active, continuously Extremely or requires restraint Violent,

– – – – – – – Agitated but disruptive Agitated not but violent Agitated, disruptive, not andviolent Agitated 1 2 3 4 5 6 7 physical verbal or stimuli Altered Mental Status Altered Mental Alcohol Intoxication abuse Toxin / Substance withdrawal / overdose / effect Medication Depression Bipolar (manic disorders Anxiety

Differential • • • • • • • • ” ” ” ” UP 17 UP Page 3 Page if available Establish rapport Assess and score: BARS and score: Assess Screen for scene safety Notify Destination Destination or Notify Screen patient for weapons for patient Screen Contact Medical Control Contact Identify major problem or crisis Identify major problem or crisis Behavioral Activity Rating Scale Create a quiet and safe environment Anxiety, agitation, confusionAnxiety, agitation, Affect change, bizarre thoughts, Delusional behavior violent Combative Expression of suicidal / homicidal thoughts Mental Health / Substance Abuse Substance / Mental Health What happened to upset you? to upset happened What now? right feeling How are you you? to upset happened What now? right feeling How are you Triage and Alternative Destination Triage and Alternative “ “ “ “ Genuine respect for feelings / circumstances Active listening Eye contact and at meet at eye level Only 1 provider talks to patient to limit stimuli stimuli unnecessary Decrease condition causing behavioral disturbance behavioral condition causing Assess for underlying medical or traumatic

• • • • • Signs Symptoms andSigns Assess for suicidal and/or homicidal thoughts

• • • • • • • • • P Behavioral Behavioral Health Crisis Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS and be approved Policy follow the to document System by OEMS Change changes Any must NC Protocol this local EMS or Call for help Call for help UP 19 Exit to UP 18 Behavioral Protocol(s) Stage prior to arrival Excited Age Appropriate Injury to self or threats to others Injury to self tag Medic alert Substance abuse / overdose Diabetes Situational crisisSituational Psychiatric illness/medications Syndrome / Violent Violent / Syndrome Revised

Call for additional resources Call for additional 11/01/2020 • • • • History • • Wthdraw from scene until safe from scene Wthdraw Agitation / Sedation Guide Universal Protocol Section 2

in

like illness - escalation, restraint, and/or and/or restraint, escalation, - s story ’ ” Diphenhydramine 50 mg IV / IO / IM / PO 50 mg IV / IO / Diphenhydramine t understand) ’ cuffed behind back as this prevents proper - s story, use your body language to convey listening) ’ Schizophrenia or schizophrenia s crisis) ’ UP 17 UP ” …?” What caused you to call 911 today? you to call 911 What caused ” “ in pediatrics. in

…” …” You seem angry. ” “ Behavioral Behavioral Health Crisis down restraint procedure. - ended questions (questions that cannot be answered with a yes/no) m not sure I understand, can you can understand, sure I m not index of suspicion for underlying medical or traumatic disorder causing or contributing to behavioral - ’ - I You look upset. Tell me how we can help you? can help Tell me how we that about more me Tell index of suspicion for medical, trauma, abuse, or neglect causes: neglect or abuse, trauma, for medical, suspicion index of Medical causes more likely in ages < 12 or > 40. < more likely in ages Medical causes 12 or > 1 mg/kg IV / IO / IM / PO scene or immediately upon their arrival. circulatory status. “ “ “ Eye contact, nodding your head, periodically repeating back part of patient “ assessment and could lead to injury. take law enforcement during transport. -

Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS and be approved Policy follow the to document System by OEMS Change changes Any must NC Protocol this local EMS Domestic , child or geriatric abuse/neglect. child or geriatric Domestic violence, May present extremities. and upper neck face, of the typically or spasms movements muscle involuntary causing Condition like drugs to antipsychotic reaction an adverse Typically movements. motor with difficult trunk neck and with contorted give When recognized administration. with your may occur and Haloperidol or adults All patients who receive either physical or chemical restraint must be continuously observed by ALS personnel on on by ALS personnel observed must be continuously restraint or chemical either physical who receive All patients or respiratory patients the impact could that way a such is patient restrained any transport or position not Do etc. stroke, sepsis, injury, shock, head hypoxia, abuse, substance overdose, hyperglycemia, Hypoglycemia, Emotional labeling (naming emotions patient is demonstrating, validating emotions information) to process for patient of silence a period to allow (okay pause Conversational misuse Substance Bipolar / Reactions / Stress / Anxiety Depression Ask Open patient to summarize be able engaged, (stay Active listening Encouraging (remain positive, convey interest in patient if you don repeat or to rephrase (ask patient questions Clarifying Patient should not be transported with upper extremities hand Consider multidisciplinary coordination with law enforcement to verbal approach de Any patient who is handcuffed or restrained by Law Enforcement and transported by EMS, must be accompanied by by be accompanied EMS, must by and transported Enforcement by Law restrained or who is handcuffed Any patient May add page 3 to protocol for specific for local mental health and / or substance misuse resources or destinations. or resources misuse substance and / or health mental local for specific for 3 to protocol page May add Maintain high Maintain Extrapyramidal reactions: Restraints: Behavioral health disturbance incidents are increasing and commonly involve the following: the involve and commonly increasing are incidents disturbance health Behavioral disturbance. techniques communications General Maintain high Maintain Recommended Exam: Mental Status, Skin, Heart, Lungs, Neurologic status Neurologic Lungs, Heart, Status, Skin, Mental Exam: Recommended if necessary. scene withdraw from or stage, assistance, Call for priority. is the main safety Crew / responders Law Enforcement: Revised

11/01/2020 • • • • • • • Pearls • • • Behavioral CIT Paramedic (Optional)

Complete EMS CIT Behavioral This is a continuation of the Evaluation and Screening for Health Data Sheet Mental Health and Substance Abuse Procedure

Alternative Destinations other than Hospital ED Call Access Line for all referrals: Complete EMS CIT Behavioral Contact Number Assessment Form If appropriate, contact Mobile Crisis: Contact Number

□ Blood/Vomit/Difficulty Breathing/Acute Medical Issue □ Blood Glucose <70 or >250 & symptomatic □ Head Trauma or fall in past 7 days □ In and out of consciousness □ Seizure activity in past 24 hours □ Unable to speak or walk □ On IVC or Emergency Custody Transport to YES □ Violent or Aggressive Emergency Department □ Provider can't see within 2 hours at alternative site □ Acute Withdrawal □ Hospital transport requested by patient UniversalSection Protocol □ BP ≥210/130 or ≥180/110 and symptomatic Notify Destination or □ BAC > .35 □ Oxygen Dependent Contact Medical Control

NO

□ Suicidal (with plan and/or intent) □ Homicidal Ideation Triage and Alternative Contact Destination □ Psychosis (auditory/visual hallucinations or ) YES □ Request for Detox Provider Mental Health / Substance □ Med Request during 8:00 am and 3:00pm and client can Abuse not wait until next day for meds

NO

□ No current Contact Mobile Crisis □ Anxiety/Panic Treatment YES □ Tearful crying with no suicidal plan or intent No Transport Contact Number □ Med request in which EMS/Mobile Crisis able to triage If needed and client is "ok" to go M-F for meds.

Alternative Destinations / Crisis Providers For Centerpoint

County

Resource Agency Resource Agency Resource Agency

Hours of Operation Hours of Operation Hours of Operation

Revised Protocol 6 11/01/2020 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 3