Santa Clara County Emergency Medical Services Agency. Semi-Annual Report. To the Board of Supervisors Health and Hospital Committee.

Transcription

1 Santa Clara County Emergency Medical Services Agency Semi-Annual Report To the Board of Supervisors Health and Hospital Committee November January 1 to August 31, 2014

2 Table of Contents Table of Contents... 1 EMS Agency Activities... 2 Ebola Preparedness and Response... 2 Hospital Diversion and Delay of Ambulances at Hospital Emergency Departments... 3 Training and Education... 4 Rural/Metro serving as County Ambulance... 7 EMS Trust Fund... 7 EMS Trust Fund Revenue... 8 EMS Trust Fund Expense... 9 EMS Agency Fee Schedule EMS System Descriptive Statistics Prehospital Clinical Care and Quality Improvement Rural/Metro Response Times Air Ambulance Transports Hospital and Specialty Care Facilities Hospital Volume and Destinations Hospital Diversion of Ambulances Trauma System Stroke System STEMI Care System

3 EMS Agency Activities This semi annual report emphasizes the eight month period from January 1, 2014 through August 31, 2014, and includes information and data from calendar year 2013 to provide context and precedent to the reader. Ebola Preparedness and Response The Santa Clara County Emergency Medical Services (EMS) Agency, in collaboration with the Department of Public Health and County Health Officer, has acted rapidly and comprehensively in response to the threat of Ebola. The EMS system s efforts started in late July by reeducating EMS providers about proper infection control techniques and the use of Personal Protective Equipment (PPE). As the outbreak expanded, the EMS System began to distribute information form the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) to stakeholders to inform emergency responders of the scope of the Ebola outbreak and to identify the signs and symptoms of the disease. The Ebola epidemic is the largest Ebola outbreak in history. Ebola is at epidemic levels in Guinea, Liberia, and Sierra Leone. Following identification of the case in Dallas, Texas, The EMS Agency instituted specific Ebola screening methods within the EMS System to quickly identify potential Ebola cases within Santa Clara County. This immediate action was necessary to protect pre hospital providers should they encounter a patient that potentially has the disease, and to provide mechanisms to immediately notify the County Health Officer and the Centers for Disease Control and Prevention. The EMS Agency released an Administrative Order on October 8, 2014, that revised Santa Clara County Prehospital Care Policies relating to infection control and implemented a new policy regarding Ebola Virus Prevention and Control. These policies define different types of infection control precautions, define minimum equipment inventories, treatment guidelines, and created a screening mechanism for the Ebola virus. These policies also prescribe the practice by which emergency responders identify suspect cases and rapidly notify the Health Officers and EMS command staff. As the epidemic evolves, care standards and CDC guidance continue to change. The EMS Agency and Public Health Department are working to ensure our policies remain consistent with current guidelines. The EMS Agency has convened a committee of EMS 2

4 System stakeholders, including representatives from fire agencies, ambulance providers, communications centers, and hospitals. This committee is working together to ensure that prudent policies and procedures are in place to properly identify, treat and transport a potentially Ebola infected patient. The EMS Agency will continue to review the tools, conduct exercises and make any corrections to the guidance as needed. All responding agencies have initiated training activities. While there is a very low likelihood that an Ebola infected person may present to the Santa Clara County EMS System, there is a very high likelihood that system responders will be able to safely identify, treat and transport this patient appropriately. Hospital Diversion and Delay of Ambulances at Hospital Emergency Departments In summer of 2014, the Santa Clara County EMS Agency, collaborating with hospitals in Santa Clara County, the County Communications Department, and Rural/Metro, hosted a Lean Six Sigma Black Belt Course to provide advanced statistical process control training to EMS System stakeholders and to statistically evaluate the root causes of extended wall times in Santa Clara County. Generally defined, wall times are the time interval starting when the ambulance arrives at the emergency department (ED) and ending when emergency department staff accepts responsibility for the patient and moves that patient off the ambulance gurney. The results of this project were surprising. The conventional wisdom that most of the wall time delays were attributable to hospitals failing to rapidly accept care of the patient was statistically proven inaccurate in most instances in Santa Clara County. In fact, this study identified that the mean time interval starting from the ambulance patient arriving in the emergency department and ending when the ambulance was available for another response was minutes. Of that time, a mean of 1.57 minutes was used to enter the facility, a mean of minutes was used to place the patient in a bed and to transfer care to the hospital, and a mean of minutes was used by the ambulance crew to restock and to complete paperwork. Thus we learned that most of the wall time delay was attributable to the EMS crews restocking and completing their paperwork. While this study had a small sample size, its findings are significant. In many instances, the current practice of automatically placing ambulances back in service during slow 3

5 periods at 30 minutes may increase out of service times. Therefore, EMS practices are being revised to create a culture that strives for 20 minute hospital drop times for all patients transported to hospital emergency departments, and hospitals are investigating new methods of emergency department intake of ambulance patients. While this problem will be solved in the long term, this study shows the importance of understanding, defining and measuring the problem, before solving the problem. If the EMS Agency would have tried to unilaterally reduce extended wall times through regulatory fiat, before truly understanding the problem, the results would have angered stakeholders, but not reduced wall times. This study is a great example of the EMS System emerging as a learning and quality focused meta organization. Training and Education Training From January 1, 2014, to August 31, 2014, the Santa Clara County EMS Agency provided 1,293 hours of continuing education to 244 EMS personnel. From October 2013 to February 2014 over 2,400 providers complete the annual EMS Update Training. This mandatory annual training emphasizes policies and protocols that have been revised; however, this training cycle also included education and assessment training on the Santa Clara Assessment for Missed Posterior Stroke (S.C.A.M.P.S) Trial. EMS System Training and Education Videos EMS Training and Education The Santa Clara County EMS Agency created and released the following videos as educational resources for those who live, work and play in Santa Clara County. Each video provides insight into the 911 Emergency Medical Services System and feature some of the equipment used by the EMS professionals in the Santa Clara County EMS System. Totals Training Opportunities 9 Number of Prehospital personnel in attendance Number of Continuing Education Hours provided 244 1,293 4

6 The Santa Clara County EMS System Overview video provides a summary of the services provided in the Santa Clara County EMS System. AN INSIDE LOOK: Santa Clara County 911 Ambulances This video provides an orientation to the capabilities and equipment contained within Santa Clara County 911 Ambulances known as "Medic" units. Santa Clara County EMS RADIO SYSTEM and COMMUNICATIONS PROCEDURES This video provides guidance for the use of the Santa Clara County s EMS Communication System. Santa Clara County Multiple Patient Management Plan MPMP This video provides an overview of how to implement the Santa Clara County Multiple Patient Management Plan while responding to a multi causality incident (MCI). Public Education From January 1, 2014, to June 30, 2014, the EMS Agency promoted six public education campaigns related to emergency medical services. These monthly campaigns included Medical Alerts, the Santa Clara County Emergency Alert System (AlertSCC), Pool Safety, 5

7 Stroke Awareness, Preventing Snake Bites and Pull to the Right for Sirens and Lights. Each month the EMS Agency provides educational campaign materials to every fire department and ambulance company within the Santa Clara County EMS System. These materials include educational flyers, postcards, posters, and pamphlets to pass out to the community, and talking points for use during presentations. By coordinating the public education campaigns for all providers within the EMS System, the public message is consistent, regardless of which organization provides the message. This minimizes the possibility of misinformation and assures a coordinated message countywide. Social Media The EMS Agency actively uses social media to promote and distribute information about EMS events. As a result, the number of people following the EMS Agency s Facebook page has 6 Santa Clara County EMS Agency November 2014

8 doubled since last year. On the EMS Agency s Facebook page or Twitter feed, you will find information about monthly educational campaigns and training announcements, recognition of EMS providers and information about EMS meetings and forums. An example of recognition shared on the Agency s Facebook and Twitter feed was the Proclamation issued in recognition of EMS Week held in June of This provided a way for the EMS Agency to share the event with the many EMS Providers that were unable to attend the Board of Supervisors meeting. The EMS Agency s Twitter feed Rural/Metro serving as County Ambulance Rural/Metro of California, operating as County Ambulance, has provided emergency paramedic ambulance service for the Santa Clara Emergency Medical Services (EMS) System since July 1, The Santa Clara County EMS System continues to be stable, and assures that every person who calls 911 for a medical emergency will receive an emergency paramedic ambulance and trained first responders. From January 1, 2014, through August 30, 2014, Rural/Metro met contractual response time performance standards, every month, in all five zones, for emergency and nonemergency calls. Detailed information about EMS System performance, including Rural/Metro s response time performance statistics, is provided later in this report. EMS Trust Fund The EMS Trust Fund s purpose is to provide funding for projects with a countywide benefit to EMS System providers, enhance the services provided within the EMS System and to improve the delivery of 911 emergency medical care in the County. The EMS Trust Fund is a backward looking fund; that is, funds collected in one year are expended the following year. This process provides policy and spending oversight by the Board of Supervisors, and provides adequate time to consider spending allocations in the context 7

9 of strategic EMS System change. EMS Agency plans to bring its FY16 EMS Trust Fund Recommendations to the Health and Hospital Committee for review and approval in March EMS Trust Fund Revenue The EMS Trust Fund is funded with revenues from liquidated damages (fines) from the contracted 911 paramedic ambulance provider (Rural/Metro) for failing to meet per call response time standards; monthly zone response time standards; or for failing to meet other contract stipulations, such as maintaining minimum ambulance availability or avoiding ambulance breakdowns. Month / Year Amount July 2013 $183,000 July 2013 Rural/Metro Bankruptcy Relief ($183,000) August 2013 $209,250 September 2013 $217,750 October 2013 $272,500 November 2013 $271,750 December 2013 $278,280 January 2014 $238,750 February 2014 $281,000 March 2014 $278,280 April 2014 $249,000 May 2014 $182,500 June 2014 $330,500 TOTAL $2,809,560 Average Monthly Liquidated Damages $234,130 The amount of these liquidated damages is significantly greater than the amount of liquidated damages in previous 911 paramedic ambulance service contracts. However, the greater amount of liquidated damages is primarily due to a substantially more expensive fine structure. In some cases, fine levels in the Rural/Metro contract are ten times greater than in prior contracts. 8

10 EMS Trust Fund Expense EMS Trust Fund expenses are approved by the Health and Hospital Committee and the Board of Supervisors before the start of the fiscal year. The EMS Agency routinely provides detailed financial reports to the Health and Hospital Committee about the EMS Trust Fund. This EMS Trust Fund summary discusses how expenditures from the EMS Trust Fund improve emergency medical services within Santa Clara County. Category A: Reserve At the Board of Supervisors direction, starting in Fiscal Year , a reserve category was established in the EMS Trust Fund. This amount, which is at least 20% of the EMS Trust Fund, is placed into reserve and used only for significant strategic projects that benefit the EMS System with a long range focus. Following approval by the Board of Supervisors, these funds could also be used if the EMS System experiences an unanticipated financial burden, such as the failure of an ambulance provider or an extraordinary increase of cost of service or supplies, or a material decrease in systemwide third party payor reimbursement. During the Fiscal Year, $575,000 of the EMS Trust Fund monies was placed into reserve. Category B: Training, Education and Recognition Funding authorized in this category was used for annual training, education, exercises, and recognitions. Funds were used in the following subcategories: EMS System Information to the Public Training (which is not funded by grants or other sources) Exercises (which are not funded by grants or other sources) EMS Provider and committee member recognition, and EMS Week During the Fiscal Year, $235,000 was allocated to training, education, and recognition. Category C: Benefit to EMS System Stakeholders Funds were allocated from this category to assist EMS System Stakeholders with onetime or short term needs. During Fiscal Year , funds were allocated to the fire 9

11 departments within Santa Clara County to provide hardware to support the County EMS System Data Project. This funding will provide fire departments with the ability to enter and transmit patient care data from the scene of an emergency; rather than waiting to enter data until the unit has returned to a fire station. This allocation was essential to creating a comprehensive EMS System data collection and analysis capability. During the Fiscal Year, $200,000 was allocated to short term and one time projects that benefit EMS System Stakeholders, such as manikins to help emergency responders improve their ability to secure patients airways and to better analyze EMS System clinical data. Category D: Strategic Initiatives Projects in this category emphasize initiatives that strategically advance the Santa Clara County EMS System, often in the longer term. During FY , funds were allocated to the implementation of the 10 Goals in the EMS System Strategic Plan. Implementation of the EMS System Strategic Plan is necessary to allow the County EMS System to adapt to the anticipated care and reimbursement changes associated with the federal Affordable Care Act and national health care reform. Implementation of the 10 Goals in the strategic plan would allow the County EMS System to continue to provide excellent clinical care, to better target patient needs to resources, to assure operational efficiency, to remain financially stable, and have high levels of patient and stakeholder satisfaction. Monies were also allocated to fund further development of the Comprehensive EMS Data System. Category D funds were also spent to support the development of the Integration of hospitals into the Comprehensive EMS Data System, to support development of the Sobering System, Six Sigma Training, and the Public Health Department Operations Subsidy. During Fiscal Year , $1,640,000 was allocated to strategic projects and $750,000 was provided as a general subsidy to the Public Health Department. EMS Agency Fee Schedule The EMS Agency relies on fee for service fees for funding operations, including systemwide planning, policy and clinical protocol development, analysis, and operational and clinical quality improvement. The EMS Agency has not increased its fees since July 1,

12 The EMS Agency did not request a fee modification from the Board of Supervisors for Fiscal Year 2014, because unprecedented changes in the EMS System operations and EMS Agency planning and quality improvement linked to the EMS System Strategic Plan will occur in starting in the second half of Fiscal Year The current fee structure is listed on the following page: Fiscal Year 2015 EMS Agency Fee Schedule ITEM/SERVICE FEE INDIVIDUAL FEES EMT Certification $50 EMT Re Certification (biennial) $50 Paramedic Local Accreditation $150 Identification Card $20 Replacement ID Card (certification, accreditation, system ID) Photocopying COMPANY FEES Ambulance Service Permits (annual fee) 11 $20 $4.75 (1 st page) $.10/ea. Addl. Basic Life Support $5,500 Advanced Life Support $6,000 Critical Care Transfer $6,000 Air Ambulance Service $8,000 Ambulance Vehicle Permits (annual fee) Basic Life Support $950 Advanced Life Support $950 Critical Care Transfer $950 Air Unit $950 Non Transport BLS/ALS Unit $800 Education Program Certification (every 4 years) EMT Program $1,000 Paramedic Program $5,000 Prehospital Continuing Education $1,000 Specialty Care Designation (annual fee) Trauma Center Designation $100,000

13 Stroke Center Designation $10,000 STEMI Receiving Center Designation $10, Receiving Center Designation $10,000 EMS System Descriptive Statistics Listed in the following tables are statistics that describe the characteristics of the Santa Clara County EMS from January 1, 2014, through August 30, Daytime Population Resident Population Geographic Size Proportion of Rural/Urban Land The County of Santa Clara 2.2 million 1.8 million 1,132 square miles 2/3 rural Municipalities System Call Volume January through August 31, 2014 Annualized Total Responses 73, ,022 Total Events with Ground Ambulance Transports 48,521 83,778 Total Patients Transported by Ground Ambulance 48,987 83,977 EMS Aircraft Response EMS Aircraft Transports Ground Ambulance Interfacility Transports January through August 31, 2014 Annualized Ground Ambulance (Jan August 2014) 28,843 49,445 Ground Ambulance ,982 Ground Ambulance ,254 Ground Ambulance ,322 Specialty Center Patients January through August 31, 2014 Annualized Stroke Patients 1,

14 Trauma Patients 3, STEMI Patients Pre Hospital Care Provider Agencies Fire Departments 11 Ground Ambulance Services 11 Air Ambulance Services 2 Pre Hospital Care Personnel Emergency Medical Technicians 2,489 Paramedics 754 Mobile Intensive Care Nurses 22 Accredited EMS Field Supervisors 17 Permitted EMS Assets Fire Apparatus 159 Private Ground Ambulances 216 Private Air Ambulances 3 Private EMS Non Transport Units 16 Communications Centers Public Safety Answering Points (PSAPs) 13 Secondary PSAPs 10 Private Ambulance Dispatch Centers 10 Air Ambulance Dispatch Centers 2 Acute Care Facilities Acute Care Hospitals 12 Emergency Departments 11 Level 1 Trauma Centers 2 Level 2 Trauma Centers 1 Base Hospitals 1 Burn Centers 1 Stroke Centers 10 STEMI Centers 8 County Managed Medical and Health Disaster Resources Field Treatment Site Trailers 8 13

15 Specialty Services Trailers 3 Chem Packs 8 Medical Health Operations Center 1 EMS Radio Caches 7 Disaster Medical Support Units 2 Prehospital Training Programs Emergency Medical Technician 7 Paramedic 2 EMS Fellowship 0 Prehospital Clinical Care and Quality Improvement Rural/Metro Response Times Ambulance Response Times to Emergency Calls The chart below identifies Rural/Metro s response times to Code 3 (emergency red light and siren) calls by month from January 1, 2014, through August 30, 2014, in each of the five ambulance subzones within Santa Clara County. The response time standard is 90% or greater, and is represented by the yellow horizontal line on this graphic. During the January 1, 2014 to August 31, 2014 reporting period, Rural/Metro met contractual response time standards in each of the five subzones, every month. 14

16 County Ambulance Code 3 Response Time Compliance by Month % 98.00% 96.00% 94.00% 92.00% 90.00% 88.00% 86.00% Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Overall Zone 1 Zone 2 Zone 3 Zone 4 Zone 5 County Ambulance Code 3 Response Times Code 3 Response Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Overall 93.30% 92.64% 92.83% 91.67% 94.03% 93.97% 92.66% 92.58% Zone % 92.07% 93.03% 91.38% 94.19% 93.46% 92.12% 92.65% Zone % 91.58% 92.46% 90.19% 94.09% 93.45% 91.50% 91.60% Zone % 93.41% 92.69% 92.86% 94.06% 94.01% 94.63% 93.70% Zone % 93.34% 92.85% 91.64% 93.40% 93.83% 91.82% 92.02% Zone % 90.62% 93.68% 91.45% 95.81% 97.12% 92.33% 92.62% Ambulance Response Times to Non Emergency Calls The chart below identifies Rural/Metro s response times to Code 2 (non emergency) calls by month from January 1, 2014, through August 31, 2014, in each of the five ambulance subzones within Santa Clara County. The response time standard is 90% or greater, and is represented by the yellow horizontal line on this graphic. During the January 1, 2014 to August 31, 2014 reporting period, Rural/Metro met contractual response time standards in each of the five subzones, every month. 15

17 County Ambulance Code 2 Response Time Compliance by Month % 98.00% 96.00% 94.00% 92.00% 90.00% 88.00% 86.00% Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Overall Zone 1 Zone 2 Zone 3 Zone 4 Zone 5 County Ambulance Code 2 Response Times Code 2 Response Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Overall 94.60% 92.70% 94.60% 93.32% 94.79% 95.62% 93.18% 94.23% Zone % 95.34% 94.95% 95.64% 95.95% 96.87% 97.06% 95.83% Zone % 92.64% 93.72% 93.44% 96.27% 95.89% 91.67% 93.20% Zone % 90.79% 95.02% 93.36% 94.73% 96.30% 92.72% 92.67% Zone % 91.63% 93.74% 91.09% 92.13% 93.55% 91.48% 94.78% Zone % 95.24% % 94.12% 98.04% 97.35% 94.74% 95.83% Fire Department First Responder Response Times Fire Department First Responder Response Times to Emergency Calls The chart identifies fire department response times to Code 3 (emergency red light and siren) calls by month from January 1, 2014, through August 31, 2014, for each of the first responder fire departments within Santa Clara County. Fire departments should achieve a response time of 90% or greater, and those who achieve a response time of 95% or greater are exempted from any response time liquidated damages incurred during that month. 16

18 The San Jose Fire Department has complied with the 90 th percentile response time performance standard three times during the Janaury 2014 through August 31, 2014 period. While this performance does not allow the City of San Jose to cure its continuing Breach of Annex B, which is the voluntary reimbursement agreement, it appears that since the Board of Supervisors action in February 2014, the San Jose Fire Department s response time performance is trending toward gradual improvement. In February 2014, the Board of Supervisors directed its Management Audit Division to conduct a limited scope of management audit of the San Jose Fire Department s 911 EMS response policies and procedures to identify the issues impeding the department s ability to respond to emergency medical 911 calls in accordance with the goals specified in the agreement between the County and City, and to make recommendations that would enable the City to achieve the performance goals. The findings and recommendations of the final audit report have not been released and are not included in the report. A summary of the final audit report will be included in the next EMS Agency s Semi Annual Report to the Board of Supervisors Health and Hospital Committee in May % 98% 96% 94% 92% 90% 88% 86% 84% 82% Fire Department Code 3 Response Time Compliance by Month 80% Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Gilroy Milpitas Morgan Hill Mt. View San Jose Santa Clara Santa Clara Co. So. Santa Clara Co. Sunnyvale 17

19 Fire Department Code 3 First Responder Response Time Compliance by Month Code 3 Response Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Gilroy 98.54% 98.18% 96.79% 98.18% 98.78% 99.59% 98.05% 98.45% Milpitas 98.27% 95.28% 96.60% 97.36% 96.04% 96.72% 95.17% 96.46% Morgan Hill 95.16% 95.65% 98.34% 98.33% 99.54% 96.32% 95.81% 95.48% Mt. View 96.76% 97.40% 97.20% 95.78% 95.33% 96.51% 97.61% 97.28% San Jose 88.06% 87.66% 88.75% 90.39% 88.94% 90.31% 92.53% 88.95% Santa Clara 96.54% 95.67% 96.91% 95.47% 95.40% 95.13% 96.07% 93.91% Santa Clara Co % 95.25% 96.10% 97.17% 96.30% 95.31% 95.39% 95.96% So. Santa Clara Co % 90.24% 97.03% 95.45% 94.12% 96.33% 90.91% 90.99% Sunnyvale 97.78% 98.36% 98.81% 98.35% 98.25% 98.79% 99.20% 98.28% Fire Department Response Times to Non Emergency Calls The chart below identifies fire department response times to Code 2 (non emergency) calls by month from January 1, 2014 through August 31, 2014 for each of the first responder fire departments within Santa Clara County. Fire departments should achieve a response time of 90% or greater, and those who achieve a response time of 95% or greater are exempted from any response time liquidated damages incurred during that month. Several fire departments choose to respond Code 3 to all incidents. 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% Fire Department Code 2 Response Time Compliance by Month 80% Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Mt. View San Jose Santa Clara Santa Clara Co. 18

20 Fire Department Code 2 Response Time Compliance by Month Code 2 Response Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Mt. View % % % % % % 97.44% 97.87% San Jose 94.46% 93.67% 96.18% 96.55% 96.55% 96.50% 97.86% 97.30% Santa Clara 98.52% 98.58% 95.47% 98.47% 96.64% 98.62% 99.21% 97.35% Santa Clara Co % 98.73% % 99.37% % 98.67% 99.45% 99.35% Air Ambulance Transports Air ambulance utilization continued at relatively low levels during the first half of The number of air ambulance dispatches and transports shown in this chart is based on the first eight months of This volume of responses and transports has remained relatively static since approximately The EMS Agency considers this volume of air ambulance responses and transports appropriate. Air Ambulance Utilization by Year Responses Transports Year Dispatches Transports Utilization Percent % % % % % % % 19

21 % % % % % 2014 (8 months) % Hospital and Specialty Care Facilities Hospital Volume and Destinations From March 1, 2014, through August 31, 2014, there were 37,782 ambulance transports from the 911 System to hospitals within Santa Clara County. Santa Clara Valley Medical Center continues to demonstrate the highest volumes Ambulance Destination by Hospital March - August 2014 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 El Camino Los Gatos El Camino Mt. View Good Samaritan Kaiser San Jose Kaiser Santa Clara O'Connor Regional San Jose Saint Louise Stanford VA Palo Alto VMC Ambulance Destination by Hospital Hospital Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Total El Camino Los Gatos El Camino Mt. View ,923 Good Samaritan ,501 Kaiser San Jose ,329 Kaiser Santa Clara ,887 O'Connor ,364 Regional San Jose 1,080 1,120 1,116 1,072 1,033 1,145 6,566 20

22 Saint Louise ,493 Stanford ,916 VA Palo Alto VMC 1,308 1,259 1,318 1,273 1,242 1,264 7,664 Total 6,441 6,286 6,474 6,245 6,008 6,328 37,782 Hospital Diversion of Ambulances Hospital diversion levels have dropped significantly over this six month period. EMS Agency policy limits hospitals to no more than 36 hours of diversion per month and all facilities have met this benchmark. This standard is represented by the yellow horizontal line on this graphic. There was a significant increase in the hours noted for stroke service advisory. This was attributed to a mechanical failure and resulted in a 124 hour CT/stroke diversion. This issue has been resolved and the agency does not anticipate any further problems Ambulance Diversion by Hospital March-August, 2014 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 El Camino - Los Gatos El Camino - Mt. View Good Samaritan Kaiser - San Jose Kaiser - Santa Clara O'Connor Regional - San Jose Saint Louise 21

23 Total Monthly Hours of "AMBULANCE DIVERSION" Status Hospital Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Total El Camino Los Gatos El Camino Mt. View Good Samaritan Kaiser San Jose Kaiser Santa Clara O'Connor Regional San Jose Saint Louise Stanford VA Palo Alto VMC Total Trauma System Between January 1, 2014, and June 30, 2014, 3,923 trauma patients were seen in the Santa Clara County trauma system. This includes 3,257 adults and 323 pediatric patients (pediatric age range is 0 to less than age 15). Eighty percent of trauma patients were transported to a trauma center by ambulance, while eleven percent of trauma patients were transported to a trauma center by an air ambulance. Effort continues to standardize the trauma system within the Bay Area through the Regional Trauma Care Committee. This committee is evaluating inter facility trauma transfers and working to increase outreach to non trauma centers in order to facilitate an ease of transfers for seriously injured patients. County of Origin Santa Clara County is the primary county of origin for trauma patients that enter the Santa Clara County trauma system, producing 44% of the volume of trauma patients. Other counties refer some of their trauma patients to Santa Clara County, producing significant proportions of the total trauma volume in Santa Clara County. Those counties include: Alameda County at 2%; San Mateo County at 13%; Monterey County at 5%; San Benito County, and Santa Cruz County at 3%. 22

24 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Injury by County of Origin January June 2014 Santa Clara Alameda Monterey San Benito Santa Cruz San Mateo Mechanism of Injury Ninety three percent of the injuries in the Santa Clara County trauma system are caused by a blunt mechanism of injury, such as motor vehicle/motorcycle injuries, pedestrians struck by car, and bicycle accidents. The remaining seven percent are caused by penetrating mechanisms of injury, such as gunshot wounds and stabbings. These percentages have remained constant for the past four years. Disposition from the Emergency Department Fifty one percent (51%) of trauma patients are admitted to the hospital. Forty eight percent (48%) of trauma patients are discharged from the emergency department. Less than one percent (0.80 %) of trauma patients expired in the emergency department. Stroke System The Santa Clara County Board of Supervisors approved a stroke care system developed by the Santa Clara County Emergency Medical Services Agency in March of This evidence based system provides patients the opportunity to be transported to the closest, specially designated hospital, which can provide immediate stroke care to patients who show symptoms of an acute stroke. 23

25 The need for rapid intervention is based on clinical evidence that treatment with an anti clotting drug (IV tpa) within three and a half hours of the onset of their symptoms may prevent and possibly reverse the effects of the blocked circulation to the brain. The Santa Clara Stroke System was designed with two specific goals. The first goal is to increase the number of patients who arrived in the emergency department at the stroke center within the time necessary to allow administration of anti clotting agents. The second goal is to educate the public about stroke symptoms, and the need to call if symptoms are present. January 1, 2014 through June 30, 2014 Performance Data Criteria County Performance Data Percentages Total Stroke Volume 1, % Total Number of Ischemic Strokes 1,003 80% Total Strokes Transported by EMS % Total Strokes Self Transported % Total patients by interfacility Transfer 96 8% % of Ischemic Stroke treated by IV tpa 17% National Average (1 8%) STEMI Care System Santa Clara County s STEMI (S T Elevation Myocardial Infarction) Care System continues to be regarded as a model system of care. A STEMI is a serious type of heart attack associated with higher rates of morbidity and mortality. Patients identified by paramedics as STEMI Alert patients, based on a 12 lead electrocardiogram, are treated rapidly with Percutaneous Coronary Intervention (PCI), which includes balloon angioplasty and stents, to open the blockage in the artery. The median length of stay in the hospital after the procedure is two days. From January 2014 through June 2014, 94% of the patients treated with Percutaneous Coronary Intervention had median door to balloon (D2B) of less than 90 minutes, versus a national benchmark of 75% of cases treated in 90 minutes or less. 24

26 Median door to balloon times for patients that arrive by EMS is 55 minutes, well below the national benchmark of 58 minutes. The median time for those who arrive by other methods is considerably higher with a rate of 77 minutes. Criteria Jan to Jun 2014 Jan to Jun 2013 Total cases with documented STEMI Median Door to Balloon time in Minutes % of PCI cases were 95% of PCI Cases were Goal Met (D2B <90 min 75% of cases performed in less than 90 performed in less than 90 National standard) minutes minutes Total STEMI cases brought by EMS Total STEMI Cases who selftransported Total STEMI Cases brought by Interfacility transport