A Guide to EMS Point-of-Entry
Developed by the Metropolitan Boston
EMS Council Public Information and
Education Resources (PIER) Committee
Purpose
To provide medical professionals
with an overview of Point-of-Entry
Protocols in accordance with 105
CMR 170.000.
Background
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There was an identified shared need (EMS
providers, citizens, hospital staff) to understand,
articulate, and implement the appropriate use of
the Point-of-Entry system in Region IV and the
Commonwealth.
As new treatment modalities have been
developed and implemented in the pre-hospital
arena, there has been confusion regarding where
patients are transported. This presentation was
developed to address these issues.
Objectives
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Provide a guide to the MADPH/OEMS
approved regional point-of-entry plans
Define Point-of-Entry
Define Closest Appropriate Facility
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ST Elevation Myocardial Infarction (STEMI)
Trauma/Burns (Adult and Pediatric)
Appropriate Health Care Facility
Destination based on Patient’s Specific
Condition and Need
Stroke
Pertinent Regulations
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105 CMR 170.020 Point-of-Entry Plan - a plan
that is designed to ensure that EMTs transport a
patient(s) in their care to the closest appropriate
health care facility.
105 CMR 170.357 Point-of-Entry Plans - Each
ambulance service shall ensure that its EMTs
deliver patients in accordance with regional pointof-entry plans approved by the Department. No
ambulance service shall develop a point-ofentry plan independent of a Departmentapproved regional point-of-entry plan.
(emphasis added)
**Department refers to the Massachusetts Department of Public
Health and all of its related agencies**
Pertinent Regulations cont.
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105 CMR 170.020 - Appropriate Health
Care Facility - an emergency department,
either physically located within an acute
care hospital licensed by the Department
pursuant to 105 CMR 130.000 to provide
emergency services, or in a satellite
emergency facility approved by the
Department pursuant to 105 CMR
130.821, that is closest geographically or
conforms to a Department approved
point-of-entry plan.
Closest Appropriate Facility

Under EMS System Regulations (105 CMR 170.355
Responsibility to Dispatch, Treat and Transport), EMS Services
are required to “transport a patient to an appropriate health
care facility” which is interpreted by OEMS as being the
“closest, by driving time, hospital emergency department.”
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Sometimes, a patient’s medical condition makes it
more appropriate to take the patient to a hospital
that is not the closest. Under the definition at 105
CMR 170.020, an “appropriate health care facility”
can also be one designated in a Departmentapproved point-of-entry plan. The Department
currently has approved condition-specific point-ofentry plans.
These patients require early notification to the
receiving facility through the CMED network.
ST Elevation Myocardial Infarction
(STEMI) Point-of-Entry
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STEMI - patients with signs and
symptoms of ST elevation myocardial
infarction (STEMI) being managed at
the paramedic level are transported to
the most clinically appropriate facility.

http://www.mbemsc.org/provider_info_items/view/113
Trauma/Burns Point-of-Entry
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Trauma (traumatic injury) – Tissue or
organ injury, or both, sustained by
the transfer of environmental energy.
(Regional Trauma Systems; Optimal Elements Integration and
Assessment; Systems Consultation Guide 2008)
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Levels of Trauma Centers
(Centers for Disease
Control and Prevention. Guidelines for Field Triage of Injured
Patients. Recommendations of the National Expert Panel on Field
Triage. MMWR 2009; 58 (No. RR-1) pg 5.)
Trauma/Burns Point-of-Entry
 Level
I-
Regional resource hospital
that is central to trauma care system.
Provides total care for every aspect of
injury, from prevention through
rehabilitation. Maintains resources and
personnel for patient care, education and
research (usually in university-based
teaching hospital). Provides leadership in
education, research and system planning
to all hospitals caring for injured patients
in the region.
Trauma/Burns Point-of-Entry
 Level
II - Provides comprehensive
trauma care, regardless of severity of the
injury. Might be most prevalent facility in
a community and manage the majority of
trauma patients or supplement the
activity of a Level I trauma center. Can be
an academic institution or a public or
private community facility located in an
urban, suburban, or rural area. Where no
Level I Center exists, is responsible for
education and system leadership.
Trauma/Burns Point-of-Entry
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Level III - Provides prompt
assessment, resuscitation, emergency
surgery, and stabilization and arrange
transfer to a higher level facility when
necessary. Maintains continuous
general surgery coverage. Has transfer
agreements and standardized
treatment protocols to plan for care of
injured patients. Might not be required
in urban or suburban area with
adequate Level I or II centers.
Trauma Centers in MA
Stroke Point-of-Entry
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Definition

Stroke - when a blood vessel that
carries oxygen and nutrients to the
brain is either blocked by a clot or
bursts. When that happens, part of the
brain cannot get the blood (and
oxygen) it needs, so it starts to die.
(Stroke Association Definition)
Stroke Point-of-Entry
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Primary Stroke Service (PSS) - a hospital
that must provide emergency diagnostic and
therapeutic services 24 hours-a-day, seven
days-a-week to patients presenting with
symptoms of acute stroke. These services are
needed to ensure that every patient who
arrives within hours of the start of their stroke
symptoms and is eligible can be treated
with thrombolytics.
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PSS designation requires that hospitals follow
very specific stroke protocols for patient
assessment and care and commit to
continuous education of the public about
warning signs and symptoms of stroke. (MADPH)
Stroke Centers in MA
Statewide Point of Entry Plan for
Appropriate Health Care Facility Destination
Based on Patient’s Specific Condition and Need

This point-of-entry plan addresses other circumstances
when, because of the patient’s specific medical needs,
the patient would clinically benefit from going to a
more distant hospital emergency department.
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An ambulance service may transport an emergency
patient not covered by a condition-specific Department
approved point-of-entry plan (i.e., stroke or trauma) to a
hospital other than the closest, based on the patient’s
medical condition and need.
However, this point-of-entry plan would not require a
service and its EMTs to deviate from taking such a patient
to the closest hospital emergency department, when not
permitted by service policy.
Statewide Point of Entry Plan for
Appropriate Health Care Facility Destination
Based on Patient’s Specific Condition and Need

Unstable patients: Transport to the
closest hospital emergency department,
or as required under a condition-specific
Department-approved point-of-entry
plan.
An unstable patient is one whose vital signs
have significantly changed (either upwards or
downwards) from normal ranges, in the
absence of interventions. See EMS textbooks
for normal ranges of vital signs.
If there is any question about the stability
of the patient, transport to the closest
hospital.

Statewide Point of Entry Plan for
Appropriate Health Care Facility Destination
Based on Patient’s Specific Condition and Need
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Stable patients:
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Based on an appropriate assessment of the patient
EMTs may consider transporting a patient to a hospital other than the
closest, if the more distant hospital is more appropriate to the patient’s
specific medical condition and needs, based on the following factors:
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The patient’s current physician and medical records are there
the patient has recently been discharged from that hospital
the patient has had previous hospitalizations there
the patient’s complex medical history is followed at the hospital
The patient’s specific medical condition needs one of the following
 Burn Unit, Obstetrics, STEMI (Percutaneous Coronary Intervention (PCI)
capability), Pediatrics
The additional time required to transport the patient to the more distant hospital
does not exceed 20 minutes*
The care capabilities of the EMTs (Paramedic, Intermediate or Basic) are
appropriate to the patient’s needs during transport.
The available EMS resources in the system at the time of the call would be capable
of handling the additional transport time for this unit.
*(Multiple hospitals for which estimated transport time from the
patient is less than 10 minutes are considered to be of
equal transport distance.)*
Ambulance Service Levels
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Basic Life Support
Intermediate Life Support
Advanced Life Support
Critical Care Transport
Levels of Pre-Hospital Provider
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First Responder
Emergency First Responder (FR,
BLS, ILS, ALS)
EMT - Basic
EMT -Intermediate
EMT - Paramedic
Summary
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The closest hospital may not be the most
appropriate destination for your particular
medical condition.
The level of EMS service and provider
certification may have an impact on the
facility where you are initially transported.
Point–of-Entry Plans are designed to
provide the most appropriate acute care
facility for a patient’s medical condition,
thus optimizing care and outcome.
Other Resources
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STEMI –
http://www.mbemsc.org/provider_info_items/view/113
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Stroke -
http://www.mbemsc.org/files/provider_info_items/rstrokepointofentryplan20
050.PDF
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Trauma -
http://www.mbemsc.org/files/provider_info_items/TraumaPOE0.PDF
Questions