Tenn. Comp. R. & Regs. 1200-12-01-.21 - DESTINATION DETERMINATION

Sick or injured persons who are in need of transport to a health care facility by a ground or air ambulance requiring licensure by the State of Tennessee should be transported according to these destination rules.

(1) Trauma patients - The goal of the pre-hospital component of the trauma system and destination guidelines is to minimize injury through safe and rapid transport of the injured patient. The patient should be taken directly to the center most appropriately equipped and staffed to handle the patient's injury as defined by the region's trauma system. These destinations should be clearly identified and understood by regional prehospital personnel and should be determined by triage protocols or by direct medical direction. Ambulances should bypass those facilities not identified by the region's trauma system as appropriate destinations, even if they are closest to the incident.
(2) Beginning no later than six (6) months after the designation of a trauma center in any region, persons in that region, who are in need of transport who have been involved in a traumatic incident and who are suffering from trauma or a traumatic injury as a result thereof as determined by triage at the scene, should be transported according to the following rules.
(a) Adult (greater than or equal to fifteen (15) years of age) and Pediatric (less than fifteen (15) years of age) Trauma Patients will be triaged and transported according to the flow chart labeled "Field Triage Decision Scheme" in "Resources For Optimal Care of the Injured Patient: 1999," or any successor publication. The Pediatric Trauma Score shall be used as published in "Basic Trauma Life Support for Paramedics and Other Advanced EMS Providers," Fourth Edition, 2000. Copies of the charts are available from the Division.
1. Step One and Step Two patients should go to a Level 1 Trauma Center or Comprehensive Regional Pediatric Center (CRPC), either initially or after stabilization at another facility. EMS field personnel may initiate air ambulance response.
2. Step One or Step Two pediatric patients should be transported to a Comprehensive Regional Pediatric Center (CRPC) or to an adult Level 1 Trauma Center if no CRPC is available. Local Destination Guidelines should assure that in regions with two CRPC's or one CRPC and another facility with Level 1 Adult Trauma capability, that seriously injured children are cared for in the facility most appropriate for their injuries.
3. For pediatric patients, a Pediatric Trauma Score of less than or equal to 8 (<=8) will be considered as a cutoff level for Step One patients.
4. Local or Regional Trauma Medical Control may establish criteria to allow for non-transport of clearly uninjured patients.
5. Trauma Medical Control will determine patient destinations within thirty (30) minutes by ground transport of a Level 1 Trauma Center or CRPC.
(b) Exceptions apply in the following circumstances:
1. For ground ambulances, when transport to a Level I Trauma Center will exceed thirty (30) minutes, Trauma Medical Control will determine the patient's destination. If Trauma Medical Control is not available, the patient should be transported to the closest appropriate medical facility.
2. For air ambulances, Step One patients will be transported to the most rapidly accessible Level I Trauma Center, taking safety and operational issues into consideration. Step Two, Three, and Four patients will be transported to a Level I Trauma Center as determined by the air ambulance's Medical Control. The Flight Crew will make determination of patient status on arrival of the air ambulance.
3. Air ambulances will not transport chemical or radiation contaminated patients prior to decontamination.
4. If the Trauma Center chosen as the patient's destination is overloaded and cannot treat the patient, Trauma Medical Control shall determine the patient's destination. If Trauma Medical Control is not available, the patient's destination shall be determined pursuant to regional or local destination guidelines.
5. A transport may be diverted from the original destination:
(i) if a patient's condition becomes unmanageable or exceeds the capabilities of the transporting unit; or
(ii) if Trauma Medical Control deems that transport to a Level I Trauma Center is not necessary.
(c) Utilization of any of the exceptions listed above should prompt review of that transport by the quality improvement process and the medical director of the individual EMS providers.
(d) Trauma Medical Control can be accomplished by a Trauma or Emergency Physician on duty at a designated Trauma Center or by protocols established in conjunction with a Regional Level I Trauma Center.
(3) Pediatric Medical Emergency - Pediatric patients represent a unique patient population with special care requirements in illness and injury. Tennessee has a comprehensive destination system for emergency care facilities in regards to pediatric patients where there are variable levels of available care, as defined in Rule 1200-08-30-.01.
(a) There are circumstances in pediatric emergency care as determined by local medical control where it would be appropriate to bypass a basic or a primary care facility for a general or comprehensive regional pediatric center.
1. Examples of such circumstances include, but are not limited to the following
(i) On-going seizures
(ii) A poorly responsive infant or lethargic child
(iii) Cardiac arrest
(iv) Significant toxic ingestion history
(v) Progressive respiratory distress (cyanosis)
(vi) Massive gastrointestinal (GI) bleed
(vii) Life threatening dysrhythmias
(viii) Compromised airway
(ix) Signs or symptoms of shock
(x) Severe respiratory distress
(xi) Respiratory arrest
(xii) Febrile infant less than two months of age.
2. Pediatric medical emergency transport may be diverted from the original destination if the patient's condition becomes unmanageable or exceeds the capability of the transporting unit, in which case the patient should be treated at the closest facility.
3. Pediatric medical emergency air ambulance transports must go to a Comprehensive Regional Pediatric Center.
(b) Pediatric trauma patients should be taken to trauma facilities as provided in paragraph (2).
(4) Any patient who does not qualify for transport to a Trauma Center or a Comprehensive Regional Pediatric Center should be transported to the most appropriate facility in accordance with regional or local destination guidelines.
(5) Adults or children with specialized healthcare needs beyond those already addressed should have their destination determined by Medical or Trauma Control, by regional or local guidelines, or by previous arrangement on the part of patient (or his/her family or physician).
(6) A transport may be refused or an alternate destination requested. If so, non-transport of the patient, or transport of the patient to an alternate destination shall not violate this rule and shall not constitute refusal of care.

Notes

Tenn. Comp. R. & Regs. 1200-12-01-.21
Original rule filed October 15, 2002; effective December 29, 2002.

Authority: T.C.A. ยงยง 4-5-202, 68-140-504, 68-140-505, 68-140-509, and 68-140-521.

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