BOARD OF SUPERVISORS HEALTH COMMITTEE PRESENTATION. BOARD OF SUPERVISORS HEALTH COMMITTEE PRESENTATION January 28, 2013 ALAMEDA COUNTY EMS

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1 BOARD OF SUPERVISORS HEALTH COMMITTEE PRESENTATION January 28, 2013

2 EMS SYSTEM OVERVIEW

3 EMS SYSTEM OVERVIEW Response system consists of dispatch, first responder agencies, transporting ambulance providers, and hospitals Coordinated system began in 1973 with new position of Coordinator of EMS and Disaster Planning Ben Mathews was first Coordinator EMS District formed in 1984 assessment measure passed with over 80% to fund countywide paramedic service Reaffirmed in 1997 with 81.3% majority for Measure C Current assessment is $27.68 per unit

4 EMS MISSION STATEMENT Alameda County EMS ensures the provision of quality emergency medical services and prevention programs to improve health and safety in Alameda County. Vision Statement Alameda County EMS will explore new frontiers while creating an environment where collaboration and consensus building thrive among staff and stakeholders.

5 LOCAL EMS AGENCY (LEMSA) Alameda County EMS is a division of the Health Care Services Agency EMS Director responsible for system oversight Agency is designated to plan, implement, and evaluate local EMS system Charged by state with implementing statutes, regulations, and local policies Latest EMS System Plan approved by state EMS Authority in June, 2011

6 LEMSA RESPONSIBILITIES Procurement of emergency ambulance services for countywide Exclusive Operating Area (EOA) Monitoring of contract compliance Also contracts with Fire Department first responder agencies for Advanced Life Support services (FRALS) Additonal contracts with three Trauma Centers and County Dispatch Center (ACRECC)

7 EMS SYSTEM RFP & TRANSITION

8 RFP AND TRANSITION Countywide paramedic service began in 1986 American Medical Response (AMR) provided ambulance service in EOA for 21 years started with RFP process in 1990 Early 2010 RFP competitive process opened for qualified companies to bid on contract for largest EOA Following rigorous review process, Paramedics Plus LLC (based in Texas) chosen Four cities excluded from EOA since they provide their own ambulance transport Alameda, Berkeley, Albany, and Piedmont

9 TRANSITION (CONTINUED) Paramedics Plus had over a year to plan for implementation of new system AMR was a good partner during planning phase New provider began service at midnight on November 1 st 2011 Many AMR EMTs and Paramedics were hired stipulation in contract System experienced only minor issues considering complexity of transition on 11/1/11

10 TRANSITION (CONTINUED) Lucas Device for better CPR Lifepak 15 monitor/defibrillators Common radio frequency between fire and ambulance New ambulances (modular design) New System Status Plan ( Marvlis system) Hydraulic stretchers

11 TRANSITION (CONTINUED) New dispatch system also implemented with new contract Medical Priority Dispatch System (MPDS) MPDS provides more robust call screening and pre-arrival instructions (national standard) New electronic patient care reporting system also implemented gathers data from first responder and transport agencies

12 EMS SYSTEM 911 AMBULANCE PROVIDER CONTRACT

13 OVERVIEW AND SUMMARY OF CONTRACT Contract is a high performance contract between county and provider agency (one of the most strict in the country) Contractor (Paramedics Plus) agrees to provide all services in accordance with applicable state code (Health & Safety Code Division 2.5) and regulations (Title 22, Division 9) Contractor must supply all resources necessary to meet response time standards and numerous other required performance measures Contractor must increase resources at its own expense to meet increased demand for services

14 CONTRACT (CONTINUED) Paramedics Plus ambulances are dispatched by ACRECC support is provided to dispatch center for system upgrades, workstations, computer aided dispatch (CAD) components Each ambulance and supervisor vehicle has necessary radio equipment for system-wide communications Vehicles have mobile computers also

15 CONTRACT (CONTINUED) Contract maintains strict response time standards for urban, suburban/rural, and wilderness areas Calls are categorized based on severity (Alpha, Bravo, Charlie, Delta, Echo) Fines are assessed for noncompliance with response time standards MPDS Dispatch Category METRO/URBAN SUBURBAN/RURAL WILDERNESS Echo 08:30 min. 14:00 min. 18:00 min. Delta 10:30 min. 16:00 min. 22:00 min. Charlie 15:00 min. 25:00 min. 28:00 min. Bravo 15:00 min. 25:00 min. 28:00 min. Alpha 30:00 min. 40:00 min. 40:00 min

16 CONTRACT (CONTINUED) Additional sections of contract include: Staffing (one EMT and one paramedic) for more serious calls Transport destination up to patient unless specific policies apply (i.e. trauma activation, STEMI, CVA) Mutual aid during disasters Vehicle/equipment requirements Electronic PCR system data submission for use in quality improvement efforts Also includes unique partnership with hiring of EMS Corps graduates

17 EMS SYSTEM DISPATCH & FIRST RESPONSE

18 DISPATCH AND FIRST RESPONSE 18 Public Safety Answering Points (PSAPs) in county that receive calls Two centers are nationally accredited Emergency Medical Dispatch (EMD)/MPDS centers Oakland Fire and ACRECC EMD centers provide pre-arrival instructions on topics such as CPR, choking, bleeding control, and childbirth Begins care before responders arrive on scene Calls are reviewed for appropriateness much like review of clinical care provided to patient

19 DISPATCH AND FIRST RESPONSE (CONT.) Following fire departments provide ambulance transportation: City of Alameda, Albany, Berkeley, Piedmont Following fire departments provide First Responder Advanced Life Support (FRALS): Alameda County Fire, Fremont, Hayward, Livermore/Pleasanton and Oakland these departments all have contracts with EMS and are financially compensated with pass-through funds from contract provider

20 DISPATCH AND FIRST RESPONSE (CONT.) First response agencies provide initial assessment and treatment on scene Provide report to arriving ambulance crew Assist with moving of patient to ambulance Provide extrication and other specialized rescue services as needed FR personnel ride-in with ambulance to help with seriously ill or injured patients

21 EMS SYSTEM PERFORMANCE AND CLINICAL QUALITY

22 Ambulance Zones

23 Alpha Level Calls Nov Nov 2012 Zone 2 Alpha Zone 3 Alpha Zone 4 Alpha Zone 5 Alpha Compliance % 100.0% 99.0% 98.0% 97.0% 96.0% 95.0% 94.0% 93.0% 92.0% 91.0% 90.0% 89.0% 88.0% 87.0% 86.0% 85.0% 84.0% 83.0% 82.0% 81.0% 80.0% 79.0% 78.0% 77.0% Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12

24 Bravo Level Calls Nov Nov 2012 Zone 2 Bravo Zone 3 Bravo Zone 4 Bravo Zone 5 Bravo Compliance % 100.0% 99.0% 98.0% 97.0% 96.0% 95.0% 94.0% 93.0% 92.0% 91.0% 90.0% 89.0% 88.0% 87.0% 86.0% 85.0% 84.0% 83.0% 82.0% 81.0% 80.0% 79.0% 78.0% 77.0% Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12

25 Charlie Level Calls Nov Nov 2012 Zone 2 Charlie Zone 3 Charlie Zone 4 Charlie Zone 5 Charlie Compliance % 100.0% 99.0% 98.0% 97.0% 96.0% 95.0% 94.0% 93.0% 92.0% 91.0% 90.0% 89.0% 88.0% 87.0% 86.0% 85.0% 84.0% 83.0% 82.0% 81.0% 80.0% 79.0% 78.0% 77.0% Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12

26 Delta Level Calls Nov Nov 2012 Zone 2 Delta Zone 3 Delta Zone 4 Delta Zone 5 Delta Compliance % 100.0% 99.0% 98.0% 97.0% 96.0% 95.0% 94.0% 93.0% 92.0% 91.0% 90.0% 89.0% 88.0% 87.0% 86.0% 85.0% 84.0% 83.0% 82.0% 81.0% 80.0% 79.0% 78.0% 77.0% Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12

27 Echo Level Calls Nov Nov 2012 Zone 2 Echo Zone 3 Echo Zone 4 Echo Zone 5 Echo Compliance % 100.0% 99.0% 98.0% 97.0% 96.0% 95.0% 94.0% 93.0% 92.0% 91.0% 90.0% 89.0% 88.0% 87.0% 86.0% 85.0% 84.0% 83.0% 82.0% 81.0% 80.0% 79.0% 78.0% 77.0% Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12

28 STATISTICAL SIGNIFICANCE (COMPLIANCE) AVERAGE CALLS PER MONTH Zone 2 Zone 3 Zone 4 Zone ALPHA BRAVO CHARLIE DELTA ECHO

29 Echo Level Calls Nov Nov 2012 Zone 2 Echo Zone 3 Echo Zone 4 Echo Zone 5 Echo Compliance % 100.0% 99.0% 98.0% 97.0% 96.0% 95.0% 94.0% 93.0% 92.0% 91.0% 90.0% 89.0% 88.0% 87.0% 86.0% 85.0% 84.0% 83.0% 82.0% 81.0% 80.0% 79.0% 78.0% 77.0% Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12

30 Echo Nov Nov 2012 (Adjusted) Zone 2 Zone 3 Zone 4 Zone 5 Compliance % 100.0% 99.0% 98.0% 97.0% 96.0% 95.0% 94.0% 93.0% 92.0% 91.0% 90.0% 89.0% 88.0% 87.0% 86.0% 85.0% 84.0% 83.0% 82.0% 81.0% 80.0% 79.0% 78.0% 77.0%

31 EMS SYSTEM Performance and Clinical Quality

32 PERFORMANCE AND CLINICAL QUALITY (CONT.) Increase the percentage of SCA victims who receive effective bystander CPR AHA s CPR Anytime for Family & Friends CPR7-all 7 th graders/families in Alameda County trained in CPR ~10,000 7 th graders trained each school year ( )

33 NEW 2012 Custom CPR7 Box

34 COUNTYWIDE YIELD 45,000 Community members exposed to the skill set of CPR annually!

35 PERFORMANCE AND CLINICAL QUALITY BYSTANDER CPR Year # VF/VT # Bystander CPR % of Bystander CPR % % % % % Total % Table 4: Number and Percent of Bystander CPR ( )

36 CROWD SOURCING FOR OHCA

37 PERFORMANCE AND CLINICAL QUALITY (CONT.) Automatic External Defibrillator (AED) Program EMS Agency has been assisting with placing AEDs throughout county for several years certain requirements such as training and medical direction apply Start of AEDs throughout county (that we are aware of some are placed without going through us) 203 were placed last year - for total of 1357 in county Paramedics Plus contributes ten per year per contract Approximately 30 citizen uses per year 5 to 10 survive to hospital discharge

38 PERFORMANCE AND CLINICAL QUALITY (CONT.) 40% SYSTEMS APPROACH TO CARDIAC ARREST Cardiac Arrest Survival 30% 28% 28% 32% % Survival 20% 10% 0% % 13% 10% Ventricular Fibrillation / Pulseless Ventricular Tachycardia ACLS Updates: (2005 AHA) Changes to Drug, Defibrillation and CPR. One MPDS Center AEDs required in health clubs. Changes to intubation procedures Intensive airway and enhanced CPR training by Dr. Levitan. CPR in the schools pilot project. Res-Q-Pod CPR device added. Re-emphasis on CPR technique. CPR7 program implemented. Two MPDS Centers Mechanical CPR trial Induced hypothermia. Introduction of cardiac arrest centers. Enhancements for Prehospital Cardiac Arrest Resuscitation

39 PERFORMANCE AND CLINICAL QUALITY (CONT.) REGIONAL VARIATION IN SURVIVAL Survival to Discharge, V Fib Survival to Discharge, SCA and Received ACLS

40 PERFORMANCE AND CLINICAL QUALITY (CONT.) STEMI: Treatment for STEMI is time sensitive: For patients that meet inclusion criteria (60%) of EMS activations, International guidelines as well as the American Heart Association recommend hospital door to intervention time is less than 90 minutes. ALCO STEMI Receiving Centers average time: 54 minutes. ALCO EMS 911 median dispatch to hospital time: 35 minutes Countywide 911 to intervention time: 89 minutes

41 PERFORMANCE AND CLINICAL QUALITY (CONT.) STROKE: Treatment for acute ischemic/occlusive stroke is time sensitive: For patients that meet inclusuon criteria (20%) of EMS activations, International guidelines as well as the American Heart Association and American Stroke Association recommend IV fibrinolytic intervention started within 60 minutes of hospital arrival. ALCO STROKE Receiving Centers average time: 66 minutes. ALCO EMS 911 median dispatch to hospital time: 34 minutes Countywide 911 to intervention time: 100 minutes

42 PERFORMANCE AND CLINICAL QUALITY (CONT.) Sepsis Alert Program Sepsis is potentially life-threatening infection High mortality rate 20 to 50% New program started December 1 st 2010 Screening Tool designed to identify potential sepsis patients - sepsis alert is called into receiving hospital Goal is to begin therapy in ED as quickly as possible (antibiotics) study with two hospitals

43 SYSTEMS BASED APPROACH STROKE 8 Centers TRAUMA 3 Centers STEMI & CARDIAC ARREST 6 Centers SEPSIS All 13 Hospitals

44 EMS SYSTEM YEAR ONE LESSONS

45 YEAR ONE LESSONS Paramedics Plus did a good job of setting up their system were ready to go when the switch was flipped Transition took good collaboration between P+, EMS Agency, Fire Departments, ACRECC, and other stakeholders New dispatch system and patient care reporting system also worked well from outset ACRECC running at approximately 99% compliance

46 YEAR ONE LESSONS Some challenges were identified during first several months of contract however: - some confusion as to workforce representation (eventually resolved) - workforce engagement issues - equipment issues (lack of familiarity) - scheduling and overtime issues

47 YEAR ONE LESSONS Survey was done by EMS Agency five months after transition to gauge workplace attitudes/issues Changes were made in some provider policies and procedures (including scheduling) Committees established with workforce to work on issues identified (equipment for example) Operational changes occurred

48 YEAR ONE LESSONS Electronic PCR system took time to fully implement in all fire departments Issues were identified with PCR system various interfaces, access to data, ease of use Contract with vendor for system maintenance expired in December after one year need identified for continued support from vendor New contract being developed with input from various stakeholders goal is to have system that provides good record-keeping and useful data for quality improvement purposes

49 RECOMMENDATIONS Future Contract Changes Clean up language about upgrade and downgrade of calls Minimum number of calls in subcategory ( bucket ) before fines are calculated Rate analysis

50 EMS SYSTEM FUTURE ISSUES

51 Insured Patients Destination Distribution (Greater than 50 Transports - Nov 2011-Nov 2012) San Leandro Hayward Alameda County - Highland Hospital (ACMC) Alameda County - John George Psychiatric Pavilion Children's Hospital and Research Center Eden Medical Center Kaiser Permanente - Hayward San Leandro Hospital St. Rose Hospital Washington Hospital San Leandro Hayward Willow Rock Center

52 Uninsured Patients Destination Distribution (Greater than 50 Transports - Nov 2011-Nov 2012) San Leandro Hayward Alameda County - Highland Hospital (ACMC) Alameda County - John George Psychiatric Pavilion Children's Hospital and Research Center Eden Medical Center Kaiser Permanente - Hayward San Leandro Hospital St. Rose Hospital Washington Hospital San Leandro Hayward Willow Rock Center

53 SUMMARY Alameda County has a high performance EMS system second to none nationally An effective transition was accomplished in 2011 new provider, PCR and dispatch systems Some growing pains were experienced - identified issues have been resolved or will be System still has some areas for improvement but will continue to evolve with stakeholder commitment and input

54 QUESTIONS?

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