Procedure Manual

Miscellaneous Procedures

Delayed Off-Load

Inordinate delays in transferring care can adversely affect the transported patient, as well as reduce the emergency response capabilities of the EMS System. This procedure applies to the transfer of care once an EMS patient arrives on hospital property.

General Principles During Delayed Offload Process:

  • Once on hospital property, the receiving facility assumes responsibility for all further medical care delivered to EMS transported patients.
  • With the exception of life threatening situations (cardiac arrest, airway emergencies or imminent delivery of a newborn), or medical treatments started prior to arrival (nebulizers, CPAP, IV fluids), Orange County EMS personnel are only authorized to perform passive monitoring while awaiting bed assignment.
  • The OCEMS System Protocols are not applicable when in the ED (these protocols are intended for prehospital use only). All patient care shall be dictated by appropriate hospital personnel when on hospital property. In accordance with this, Orange County EMS Medical Control should not be contacted for orders after ED arrival.
  • The passive monitoring phase shall be limited to 45 minutes during EMS Operational Green Status (normal operations), and 15 minutes during EMS Operational RED Status.

Delayed Off-load Procedure:

  • In addition to the radio report given during transport, contact should be made with the ED charge nurse within 2 minutes of arrival to give a verbal report.
  • After arrival communicate all patient medical needs to the ED charge nurse or designee.
  • If off-load has not been accomplished at the 30 minute post-arrival mark:
    • Advise the ED charge nurse that the unit will return to service in 15 minutes (45 minutes post-arrival).
    • Prepare all documentation during this interval for hand delivery to the ED charge nurse.
  • If off-load has not been accomplished at the 45 minute post-arrival mark:
    • Contact authorized supervisor for approval to proceed with off-load onto temporary stretcher or wheelchair.
    • The final decision to move a patient should be made by an agency supervisor in accordance with agency specific policies.
    • For patients who will be placed in wheelchairs, assure the following:
      • Patient has no alteration in mental status.
      • Patient is not at obvious risk of falling or suddenly losing consciousness (i.e. seizures, syncope or severe vertigo).
      • Patient tolerates the seated position without significant discomfort.
      • No change in general splinting position or immobilization status occurs for the purpose of placing patient in a wheelchair.
  • Advise the patient of the move, and determine if moving the patient can be done safely.
  • In the event a patient refuses to be moved, communicate with supervisor for further instructions.
  • Move the patient safely, so as not to worsen or exacerbate pain or discomfort.
  • Notify the ED charge nurse or designee (face-to-face communication) of the patient’s location and condition at the time of the move; hand-deliver all documentation.
  • Document pertinent details of the process, including the name of the ED staff member who received the final report, and the time final report was given.

Once the patient is off-loaded, the unit should return to service immediately (do not linger on hospital property any longer then is necessary).

EMS Operational RED Status:

At times of critical operational overload, crews are needed to immediately return to service. Delays in returning units to service under these conditions may constitute a threat to public safety. For the Orange County EMS System, this status will be announced by MEDCOM over every hospital frequency.

  • Offload delays during EMS Operational RED Status should not exceed 15 minutes:
    • When giving initial report, advise the ED charge nurse of EMS Operational RED Status.
    • If awaiting bed assignment when EMS Operational RED Status is announced, advise the ED charge nurse or designee of the change, and that the unit will return to service in 15 minutes.
    • If off-load has not been accomplished at the 15 minute mark, contact authorized supervisor for approval to proceed with off-load onto temporary stretcher or wheelchair.
    • Follow all of the patient safety steps listed above when off-loading patients during EMS Operational RED Status.
    • Once the patient is off-loaded, the unit should return to service immediately.

No Bed Assignment/No Offload After Specified Time Limit:

When a patient cannot be safely moved to a temporary stretcher or wheelchair, in accordance with the 45 or 15 minute time limits notify agency supervisor of the inability to physically transfer the patient.

Continue the passive monitoring process, assuring the patient’s well-being is protected as much as possible. The supervisor should gather details of the interaction, including patient condition, reason why move was not accomplished and name of the ED staff member involved. The supervisor may request MEDCOM to page the Office of the Medical Director (OMD) staff-member on call if assistance is needed. Every case will be evaluated for areas of improvement.

Double Sequential External Defibrillation (DSED)

This procedure is only to be used for persistent and continuous ventricular fibrillation that has failed to convert after at least five shocks.


  • Assure all other essential interventions have been performed and potential causes of the arrest have been addressed
  • Continue high quality chest compressions while preparing for DSED
  • Using a second monitor/defibrillator, apply second set of external defibrillation pads in the Anterior/Posterior position
    • Assure that the pads do not make contact with each other

  • Charge both defibrillators to 360 joules while minimizing interruptions in chest compressions
  • If the monitor continues to show Ventricular Fibrillation prepare to deliver shock by loudly clearing the patient of any contact with rescuers (CLEAR!)
  • Simultaneously depress the shock button on both monitors, delivering a combined shock of 720 joules
  • Immediately resume chest compressions
  • Perform a pulse check and rhythm check after approximately 2 minutes
  • If Ventricular Fibrillation persists DSED can be repeated as needed