EMERGENCY MEDICAL SERVICES COMMITTEE

Transcription

1 County of Santa Clara Public Health Department Emergency Medical Services Agency 976 Lenzen Avenue, Suite 1200 San José, CA voice fax EMERGENCY MEDICAL SERVICES COMMITTEE Chair: Health Advisory Commissioner Harry Hall Thursday, December 6, :30 pm 3:00 pm (Voting Members Requested to RSVP by November 27, 2012) Santa Clara County Sheriffs Department Auditorium 55 West Younger Avenue San Jose, CA All reports and supporting material are available for review on the Santa Clara County EMS Agency website at and in the EMS Agency s offices at least one week prior to the meeting. This information is also available the day of the meeting. ( Indicates supporting documentation attached. Indicates committee action required). 1. Call to Order / Roll Call (Commissioner Hall) 2. Introductions and Announcements (Commissioner Hall) 3. Public Comment Period (Staff) This portion of the meeting is reserved for persons desiring to address the EMS Committee on a Committee-related matter not on the agenda. Speakers are limited to two (2) minutes. A division of the Santa Clara County Public Health Department Page 1 of 157

2 Calendar Items (Commissioner Hall) Calendar items matters may be of an informational nature, not requiring an action/vote; or may require the Committee to take an action based on nature of the material presented. 4. Approval of October 4, 2012 Meeting Minutes 5. Summary of Items Presented to Board of Supervisors or Health & Hospital Committee (Natividad) Stakeholder Committee Meeting Schedule Posted to: 7. EMS System Update (Staff) A. EMS System Strategic Assessment and Planning Process () (Petrie) B. Sobering System Planning (Petrie) C. California EMS Authority 2012 Awards () (Petrie) D. Santa Clara County EMS Provider Recognition Solicitation i. Request to form EMSCO subcommittee E. EMS System Exercises: i. Multiple Patient Management Plan ii. Children s Recovery Center 8. Medical Director Report Clinical Care (Dr. Rudnick) () 9. EMS Trust Fund () (Petrie and Davies) A. Accept Revenue and Expenditure Report on the Status of the 2013 EMS Trust Fund () (Natividad) B. Review and Approve Staff Recommendations for Approval of Fiscal year 2013 Category C Project Funding () (Davies) Page 2 of 157

3 C. Approve EMS Trust Fund Funding Packet Application and Guide () (Davies) 10. Exclusive Operating Area Contract Status (Blain) A. County EOA Update January through September, 2012 i. Accept Rural/Metro Response Time Performance Report () B. Accept Fire Department Response Time Performance Report () C. Palo Alto EOA Update Accept Verbal Report 11. Hospital Destination, Diversion, and Advisory Status Report (Petrie) () 12. Member Roundtable and Reports 13. Next Meeting and Adjourn (Commissioner Hall) March 7, 2013 from 1-3 pm at the Sheriffs Department Auditorium, 55 West Younger Avenue, San Jose, CA Venue and Parking Instructions Visitor parking is available at the County building parking lot designated Visitor areas. No food or uncapped beverages are permitted in the training room. This meeting will be recorded. Page 3 of 157

4 Emergency Medical Services Committee Sheriff s Department Auditorium, 55 W Younger Avenue October 4, to 1500 Hours Meeting Minutes Item Discussion Action 1. Call to Order/Roll Call Chairman Harry Hall called the meeting to Meeting called to order. order at 1:06 p.m. A quorum was present. 2. Introductions and Announcements Jeff Misner, United EMS Workers As noted. John Hosmon, EMT/FTO Ross Fay CalStar Bill Bullard Abaris Group Jennifer Larault, Regional Medical Arendi Kolchak, Office of Board of Supervisor Liz Kniss 3. Public Comment No members of the public provided None comment. Consent Calendar 4. Approval of June 7, 2012 Meeting Minutes Without discussion, the committee approved the consent calendar. M/S/C June 7, 2012 Meeting Minutes approved as presented. M/S/C J. Silva/M. Norman 5. Summary of Approved or Pending Board of Supervisors and Health & Hospital Committee Items Approved: A. September 12, Health and Hospital Committee EMS Strategic Plan Update B. September 12, Health and Hospital Committee Inebriate Care system Update. Pending Items: C. September 12, Health and Hospital Committee Approve agreement with California Emergency Medicals Services Authority relating to the transfer of a Disaster Medical Support unit (DMSU) Without discussion, the committee approved the consent calendar. M/S/C Approved as presented. M/S/C Summary of Approved BOS & HHC items approved as presented. M/S/C K. Kehmna/J. Silva 1 Page 4 of 157

5 6. Approval of Meeting Dates for Calendar Year A. March 7, 2013 B. June 6, 2013 Regular Calendar 7. Proposed Changes to EMS Committee Michael Petrie presented proposed changes to EMS Committee: Request that the Health and Hospital Committee revise the Committee s Standing Rules to require only one Health Advisory Commissioner instead of two, in considering a quorum Changes to committee agenda and focus to emphasize the committee s role in monitoring the function and performance of the EMS System Remove the EMS Stakeholder meeting minutes from agenda. A weblink will be provided for the meeting minutes. Provide a written Medical Director s report. Meeting Dates for Calendar Year 2013 approved as presented. M/S/C K. Kehmna/J. Silva Proposed changes to EMS Committee accepted as presented. 8. EMS System Update A. EMS System Strategic Assessment and Planning Process B. Sobering System Planning Michael Petrie reported: The consultant hired to write a 3-5 year strategic plan, the Abaris Group conducted 100+ interviews with Stakeholders. A preliminary draft assessment plan was submitted and will soon be released to members of committee. The next action is a series of four Strategic System Assessment and Planning community meeting starting November and ending in January, The training schedule will be sent to committee members. Mr. Petrie updated on the planning process for a Sobering System for Santa Clara County. Members of the Health and Hospital Committee and other County and Hospital staff Information only. 2 Page 5 of 157

6 C. Comprehensive EMS Data Project D Multiple Patient Management Plan Full- Scale Exercise 9. Medical Director Report Clinical Care requested detailed information to determine the most cost effective way to address patient transport issues. To plan is to build a model similar to the facility in San Francisco. The preferred site for the center would be near the geographic area where most calls are generated to reduce transport times. Josh updated on the EMS Data Project process. The Fire Departments are finishing transition and will be on the same patient care platform. This process will be enhanced after the completion of the data project which will allow all providers to be on a common reporting platform. Michael Petrie announced a Full-Scale Training exercise will be held from October at the Berryessa Century Theatres, San Jose. A Handout was provided. A VIP Invite to be sent to all members for October 24 at 12:30-1:30pm for an Executive Exercise Briefing. A report from Dr. Eric Rudnick outlined the Continuous Quality Improvement (CQI) plans to expand CQI and the excellent care being delivered to the public. The EMS Agency is bringing Six Sigma training to the County for all providers to further enhance their efforts to analysis of CQI raw data which is abstracted and culled from patient care records (PCRs). This process will be enhanced after the completion of the data project and all providers on a common reporting platform (epcr). Information only. 3 Page 6 of 157

7 10. EMS Trust Fund A. Accept Written Report on the Financial Status of the EMS Trust Fund Patricia Natividad presented the Financial Status of the EMS Trust Fund (January 1- August 31, 2012) Written report on Fund Financial Status of Trust Fund accepted as reported. B. Review and Approve Staff Recommendations for Approval of Fiscal Year 2013 Category C Project Funding Josh Davies reviewed on the EMS Trust Fund Staff Recommendations for Approval of Fiscal Year 2013 Category C Project Funding and specific actions for the committee. The EMS Agency staff recommends that the EMS Director allocate $250,000 of budgeted and board-approved Category C Trust Funds to support the Santa Clara County Comprehensive EMS Patient Care Data Project. Kenneth Horowitz requested that more detailed information be provided to support recommendations for item 10.B. Michael Petrie recommended that agenda item10.b be moved to the next meeting agenda to allow time for new members to review projects. The projected timelines will still be met. Chairman Harry Hall concurred that the agenda item should be moved the December meeting. Agenda Item 10.B. was moved to December 6, 2012 meeting agenda. Abstained: K. Horowitz C. Accept Verbal Report on the Status of Current EMS Trust Fund 11. Exclusive Operating Area Contract Status A. County EOA Update i. Accept Rural/Metro Response Time Performance Report ii. Accept Status of Deliverables. Josh Davies updated the status of Current EMS Trust Fund projects related to Training and Exercises which include: The EMS Conference 2013 County allocation of funds to support the RFP process for the Data Project An RFP for production of Service Announcement Videos Josh Davies reported on 2nd quarter of 2012 Response Time for Rural Metro. Rural Metro met response time standards in all zones for emergency and non-emergency calls for each month. Information only. 4 Page 7 of 157

8 Michael Petrie reported that the EMS Agency is not prepared to present a written report at this time on the status of deliverables of Rural Metro-Santa Clara County contract. B. Accept Fire Department Response Time Performance Report. C. Palo Alto EOA Update Accept Verbal Report 12. Hospital Destination, Diversion, and Advisory Status Report Josh Davies reported that the fire departments response time performance for last six months (Jan- June 2012) met standards for emergency and non-emergency calls each month. The only one variance was for the City of San Jose, however they are back to meeting 90% performance response rate. Josh Davies reported that an EOA update was not received from City of Palo Alto. Michael Petrie reported on the status of hospital destination, diversion and hospital advisory status levels. Information only. 13. Member Roundtable and Reports Michael Petrie reminded members of the EMS Agency Events: The EMS Conference is scheduled for May 22-23, A Save the Date flyer was distributed. The first Six Sigma Course Offering will be held from October 8-12, The first 2 days will cover Yellow Belt training and the last 3 days will cover Green Belt training. 14. Next Meeting The next meeting will be held on December 6, 2012 from 1:00 to 3:00pm at the Sheriff s Department Auditorium. 15. Adjournment There being no further business, the meeting was adjourned at 2:37pm Information only As noted. Meeting adjourned. 5 Page 8 of 157

9 MEMBERS PRESENT Harry Hall, Chair, Health Advisory Commission Kenneth Horowitz,, Health Advisory Commission Jo Coffaro, Hospital Council of Northern CA Steven Drewniany, Santa Clara County Police Chief s Tom Haglund, County City/County Managers Randy Hooks, Permitted Non-911 Ambulance Provider Ken Kehmna, Santa Clara County Fire Chief s Assoc. Rick Kline, Santa Clara County Trauma Surgeons John Kralyevich, Private Service EMT/Paramedic Ginger Miramontes, Emergency Department Managers Elaine Nelson, South Bay Emergency Medical Directors Mark Norman, 911 Contracted Ambulance Provider James Silva, Santa Clara County Medical Association MEMBERS ABSENT Jose Chavez, Public Safety Sector Paramedic/EMT Michelle Woodfall, Santa Clara Trauma Managers STAFF PRESENT Michael Petrie, Director Eric Rudnick, Medical Director Josh Davies, Section Manager Patricia Natividad, Management Analyst Lilia Felix-Villalobos, Executive Assistant 6 Page 9 of 157

10 County of Santa Clara Emergency Medical Services System Emergency Medical Services Agency 976 Lenzen Avenue, Suite 1200 San Jose, CA voice fax Date: December 6, 2012 To: From: Subject: Santa Clara County EMS Committee Members Patricia Natividad Senior Management Analyst Summary of Approved or Pending Board of Supervisors and Health and Hospital Committee Items Health and Hospital Committee Pending Board Items: 2011 Santa Clara County Emergency Medical Services Plan Update November 20, 2012 Adopt the 2011 Santa Clara County Emergency Medical Services Plan Update and authorize submission to the California Emergency Medical Services Authority. There is no impact on the General Fund. The Santa Clara County Emergency Medical Services (EMS) Plan Update provides a framework for the ongoing development and enhancement of the County's EMS System. The Plan requires the County to validate adherence to various regulatory requirements and guidelines. Pursuant to Section of the California Health and Safety Code, each local EMS Agency must develop and submit an annual update of its approved EMS Plan to the California Emergency Medical Services Authority. The 2011 EMS Plan fulfills the statutory requirement and brings the EMS Agency's plan up-to-date. The annually updated EMS Plan must be adopted by the Board of Supervisors prior to submission to the State. Plans are submitted annually for the previous year (retrospective review). Health and Hospital Committee Approved Board Items: Santa Clara County Emergency Medical Services Agency Annual Report for FY12 November 20, 2012 Accept semi-annual report from Emergency Medical Services (EMS) Agency relating to the status of the EMS Agency and EMS System for the period January 1, 2012 through June 30, The annual report provides the performance the Santa Clara County EMS system, using metrics and indicators to identify the effectiveness of the system, including first responders; the contracted paramedic ambulance provider; non-emergency ambulance providers; air ambulance providers; hospitals; trauma, stroke, and cardiac care specialty centers. In future reports, we will integrate clinical care and patient satisfaction metrics and indicators. A division of the Santa Clara County Public Health Department Page 10 of 157

11 Report on Update of Status of Sobering Center November 20, 2012 Accept report from Public Health Department relating to providing business case, outline of Sobering Center and operations, site location, financing and operational logistics; recommendation to fund Project Manager from EMS Trust Funds; and, issuance of Request for Information (RFI) on November 21, The core group of stakeholders, including the Public Health Department, Santa Clara Valley Medical Center, Valley Homeless Healthcare Program, the Mental Health Department, Department of Alcohol and Drug Services, Custody Health Services and Destination: Home recommends that a three year pilot program be established to evaluate the overall system benefits of a Sobering Center. It is also recommended that the County seek a qualified vendor to staff and run the day-to-day operations of the Sobering Center. Potential vendors would be asked to submit their cost of operations. This model is used successfully in other Counties, including Alameda. In addition, a Project Manager would be secured to detail out the financial and operational plan of bringing a Sobering Center to fruition. The Project Manager would play a lead role in the completion of a financial pro forma and business plan as well as assist with drafting an RFP for Operations of the Sobering Center. It is anticipated that is would be a 4-6 month endeavor, supported fully by previously budgeted and authorized EMS Trust Funds. The Project Manager would report to the Department of Alcohol and Drug Services or the Department of Mental Health and would work with all key departments and stakeholders. Presuming that the financial and operational logistics and information gained in the RFI are affirmative, SCVHHS would anticipate bringing a final report and recommendation to the Health and Hospital Committee in the late spring of If authorized by the Board of Supervisors, SCVHHS would anticipate the release of an RFP by the summer of 2013, with the expectation of having an operational sobering center in place by the fall of A division of the Santa Clara County Public Health Department Page 11 of 157

12 County of Santa Clara Emergency Medical Services System Emergency Medical Services Agency 976 Lenzen Avenue, Suite 1200 San Jose, CA voice fax Date: December 6, 2012 To: From: Subject: Santa Clara County EMS System Stakeholders Josh Davies CEM EMS Section Chief 2013 EMS System Stakeholder Meeting Schedule The 2012 EMS System Stakeholders Meeting Schedule has been attached and will be posted shortly to the Santa Clara County EMS Agency website at The Santa Clara County EMS System is currently participating in a strategic assessment which will result in implementing improvements throughout our System. It is likely that changes will be made to various stakeholder advisory committees to make them more diverse, efficient, and streamlined. Therefore, advisory committee meetings have been scheduled for the first six months of 2013 rather than a full year. Paramedic Accreditation Examinations, Santa Clara County EMS System Orientation, and the annual EMS Train-the-Trainer program have been scheduled for the full year. Thank you for your continued support of our Emergency Medical Services System. If you should have any questions, please feel free to contact Michael Cabano, EMS Specialist, at the number provided or by at [email protected]. Attachment: Emergency Medical Services System Stakeholder Meeting Schedule 2013 A division of the Santa Clara County Public Health Department Page 12 of 157

13 County of Santa Clara Emergency Medical Services System Emergency Medical Services Agency 976 Lenzen Avenue, Suite 1200 San Jose, CA voice fax Emergency Medical Services System Stakeholder Meeting Schedule 2013 EMS System Advisory Committees Meeting Description Location Date/Time MEDICAL CONTROL ADVISORY COMMITTEE Hours The Medical Control Advisory Committee serves as a clinical care advisory body to the EMS Medical Director. This stakeholder meeting is attended by provider agency medical advisors, quality assurance and improvement personnel, emergency department, and other physicians, EMS provider agency coordinators/educators, private agency representatives, Base Hospital representatives. Standard Agenda EMS Medical Directors Report Specialty Care Programs Update Clinical EMS Quality Improvement Plan Updates Medical Control Review EMS Best Practices Review Santa Clara Fire Department Training Center 1900 Walsh Avenue Santa Clara, CA February 28 May 16 PREHOSPITAL PROVIDERS ADVISORY COMMITTEE Hours The Prehospital Providers Advisory Committee is the primary EMS System Stakeholder Committee. The Committee provides the opportunity for information sharing for all EMS Program Managers and EMS support personnel. Standard Agenda EMS Education & Training Communications EOA Performance Policy Review EMS System Operations EMS Program Managers Updates A division of the Santa Clara County Public Health Department Page 13 of 157

14 Quality Assurance and Improvement Committees Meeting Description Location Date This Committee serves as a clinical care advisory body to the EMS Medical Director in January 3 regard to the Santa Clara County Cardiac Care System. April 4 CARDIAC CARE SYSTEM QUALITY IMPROVEMENT COMMITTEE Hours STROKE CARE SYSTEM QUALITY IMPROVEMENT COMMITTEE Hours PREHOSPITAL CARE SYSTEM QUALITY IMPROVEMENT COMMITTEE Hours TRAUMA CARE SYSTEM QUALITY IMPROVEMENT COMMITTEE Hours *CE from EMS AIR RESOURCE UTILIZATION QUALITY IMPROVEMENT COMMITTEE Hours EMS COMMAND & CONTROL QUALITY IMPROVEMENT COMMITTEE This is not an open meeting. Membership is required for participation in this quality improvement session. This Committee serves as a clinical care advisory body to the EMS Medical Director in regard to the Santa Clara County Stroke Care System. This is not an open meeting. Membership is required for participation in this quality improvement session. This Committee serves as a clinical care advisory body to the EMS Medical Director in regard to the Santa Clara County Prehospital Care System. This is not an open meeting. Membership is required for participation in this quality improvement session. This Committee serves as a clinical care advisory body to the EMS Medical Director in regard to the Santa Clara County Trauma Care System. This is not an open meeting. Membership is required for participation in this quality improvement session. This Committee reviews the operational aspects of EMS Air Resources use within the Santa Clara County EMS System. Clinical issues are routed to appropriate committees. This is an open meeting. Membership is not required for participation in this quality improvement session. This quality improvement review addresses the operational aspects of EMS response including incident review, planning for events, WMD/disaster medical services, and provider agency operational reports. EMS Agency Park Alameda Conference Room 976 Lenzen Avenue San Jose, CA EMS Agency Park Alameda Conference Room 976 Lenzen Avenue San Jose, CA Valley Specialty Center 751 S. Bascom Avenue Conference Room BQ160 San Jose, CA Valley Specialty Center 751 S. Bascom Avenue Conference Room BQ160 San Jose, CA Public Health Department Conference Room # Lenzen Avenue San Jose, CA Public Health Department Conference Room 720 Empey Way San Jose, CA January 17 April 18 February 7 April 4 June 6 January 15* March 20 May 21* April 7 February 13 May Hours Open to Santa Clara County EMS System providers only. Page 14 of 157

15 EMS Program Managers Meeting Description Location Date/Time EMS Program Managers Hours The EMS Program Managers meeting is for the individual who serves as the operational and financial agent of the department or company. This executive level meeting focuses on strategic initiatives and system-wide projects. Santa Clara Fire Department Training Center 1900 Walsh Avenue Santa Clara, CA April 11 Appointed Membership Meeting Description Location Date/Time EMERGENCY MEDICAL SERVICES COMMITTEE Hours The Emergency Medical Services Committee (EMSCo.) is comprised of a diverse cadre of representation to provide the EMS Agency and the Health Advisory Commission with community and stakeholder-based input that foster enhancement of the EMS system. Sheriff s Department Auditorium 55 W Younger Avenue San Jose, CA March 7 June 6 Examinations, Orientations, and Mandatory Training Meeting Description Location Date/Time PARAMEDIC ACCREDITATION EXAM Hours The Paramedic Accreditation Exam is a mandatory exam that all new paramedics and paramedic Interns must pass in order to receive their Paramedic Accreditation or paramedic intern authorization. The examination covers Santa Clara County Prehospital Care Policy. EMS Agency Park Alameda Conference Room 976 Lenzen Avenue San Jose, CA February 12 April 16 June 11 August 13 October 8 December 5 Note: Those not signed-in by the 0900 hours on the day of the exam will not be permitted to test. SANTA CLARA COUNTY EMS SYSTEM ORIENTATION Hours The EMS System Orientation is a mandatory course that all new paramedics and EMT s must attend. The orientation provides an overview of the Santa Clara County EMS System operations. Note: Credit will not be given to those not signed-in by the 1015 hours or those that do not attend all of the program hours. Valley Specialty Center 751 S. Bascom Avenue Conference Room BQ160 San Jose, CA January 10 March 7 May 16 July 11 September 5 November 7 EMS Update: Train-the-Trainer Hours The EMS Update 2013 Train the Trainer program is designed to provide mandatory system update information to EMS System Educators so they may provide training to their own personnel. Santa Clara Fire Department Training Center 1900 Walsh Avenue Santa Clara, CA October 10 Page 15 of 157

16 County of Santa Clara Emergency Medical Services System Emergency Medical Services Agency 976 Lenzen Avenue, Suite 1200 San Jose, CA voice fax Date: December 6, 2012 To: From: Subject: Santa Clara County EMS Committee Members Michael Petrie EMS Director EMS System Strategic Assessment and Planning Process Issue The EMS Agency is requesting that you review and accept the attached Santa Clara County EMS System Assessment, with the understanding that this document is evolutionary, subject to change, based upon stakeholder input. Committee discussion and acceptance of the document provides committee members a forum to formally ask questions of the EMS Agency and to provide their opinions and recommendations to the EMS Agency. History In June 2012, the EMS Agency hired The Abaris Group to conduct a strategic assessment of the Santa Clara EMS System, and based upon that assessment; to develop a strategic plan for the Santa Clara EMS System. The EMS System Strategic Assessment started in early July. This project was intentionally scheduled to start soon after the US Supreme Court decided the Affordable Care Act (PPACA) cases, which are materially influencing national health care policy. The EMS System Strategic Assessment and Planning Process is evaluating the opportunities and threats facing the EMS System from national, regional, and local influences. The assessment is considering threats and opportunities in the context of the strengths and weaknesses of the EMS System, and is emphasizing a 3 to 7 year planning horizon, focusing on: 1) maintaining or improving clinical care; 2) improving patient satisfaction; and, 3) improving operational efficiency, and assuring cost effectiveness and the financial solvency of the EMS System. The project is divided into three phases. Phase 1 is the strategic assessment of the EMS System. During this phase, the consulting firm conducted individual and group interviews with key EMS System stakeholders. They reviewed EMS System policies, procedures, and clinical protocols, and examining financial and operational records and reports. The EMS Agency released their first draft of the Santa Clara County EMS System Assessment in early November, Future Phases During Phase 2, the Abaris Group will develop the EMS System Strategic Plan, based on the information derived during Phase 1. Phase 2 started on November 1, 2012 and is expected to conclude by February 28, During this period, the EMS Agency will host a number of strategic visioning and planning workshops, at which time we will present best practice options for the system, dialogue with EMS stakeholders, and develop the EMS System s Mission, Vision, Values, Goals, and Objectives. A division of the Santa Clara County Public Health Department Page 16 of 157

17 During Phase 3, the Abaris Group will develop the Implementation Plan, based on the EMS System Strategic Plan developed in Phase 2. Phase 3 is planned to begin on March 1 and conclude by March 15, The Implementation Plan will provide best practice recommendations on implementing the goals and objectives in the EMS System Strategic Plan. Options 1) Accept the Santa Clara County EMS System Assessment as presented. 2) Accept the Santa Clara County EMS System Assessment and provide comment or recommendations. 3) Other actions, as determined by the EMS Committee. Recommendation 1) Accept the Santa Clara County EMS System Assessment and provide comment or recommendation as you consider appropriate. Page 17 of 157

18 Santa Clara County EMS System Assessment Phase I November 2012 Prepared for The County of Santa Clara EMS Agency by The Abaris Group Martinez, CA Page 18 of 157

19 Table of Contents Acknowledgements... 1 Executive Summary... 2 Project Overview... 5 Health Care and Emergency Medical Services Environment... 6 Emergency Care & Hospital Data/Projections Overview... 7 Hospital Emergency Departments... 7 Emergency Medical Services Data... 8 Ambulance Diversion and Off load Delays Hospital Data Psychiatric Care County Demographics Overview Health Insurance Coverage Emergency Medical Services System Overview Emergency Medical Services Agency Prehospital Providers Specialty Care Public Education Disaster Preparedness Data Management Project Communications System Overview Public Safety Answering Points Computer Aided Dispatch System Radio System Medical Priority Dispatch System Mobile Area Routing and Vehicle Location Information System System Status Coordinator Staffing and Personnel Emergency Medical Services Agency Coordination Emergency Medical Services Consolidated Dispatch i Santa Clara County EMS System Assessment Phase I October 2012 Page 19 of 157

20 Clinical Care and Continuous Quality Improvement Clinical Care Emergency Medical Services Committees Continuous Quality Improvement Industry Trends and Best Practices Overview Dispatch Triage and Awareness Alternate Transportation and Destination High System User Diversion Primary and Mobile Healthcare Health Care Innovation Awards Beacon Community Program San Diego Key Study Take Aways Observations/Recommendations Next Steps Appendices A: Interview List B: County Ambulance Response Time Maps C: County Population Density Map ii Santa Clara County EMS System Assessment Phase I October 2012 Page 20 of 157

21 Table of Contents Figures 1. ED Visits, Treatment Stations, and EMS Ground Transports EMS Historical and Projected 911 System Call Volume for Ground Transport County Ambulance Responses by Priority and Population Designation County Ambulance Response Times City of Palo Alto Response Times Responses by City Hospital Transport Volume by Facility EMS Utilization per 1,000 population Payer Mix, Payer Mix, Before Reform and Full Implementation ED Visits by Level of Severity ED Discharges ED Discharges Classified as ED Care Not Needed Percentage of ED Visits that Resulted in Admission Projected ED Visits ED visits per station projections Additional ED stations needed to equal national benchmark Projected ED Visit Volume by Payer Projected EMS Visit Volume by Payer Ambulance Diversion Hours County Ambulance Offloads > 15 Minutes County Ambulance Wall Time Evaluation County Ambulance Los Unit Hours General Acute Care Inpatient Services Licensed Bed Occupancy Rates Staffed Bed Occupancy Rates Psychiatric Inpatient Services Residency of Psychiatric Patients Discharged from Santa Clara County EDs Population of Bay Area Counties Population of Santa Clara County Cities Total Population by City Santa Clara County Race Race Breakdown Sex and Age Household Income Expected Annual Job Growth Rate Population Projections Population Projections for Jurisdictional Boundaries Health Insurance Coverage iii Santa Clara County EMS System Assessment Phase I October 2012 Page 21 of 157

22 40. Health Insurance Coverage Impact of Affordable Care Act in Santa Clara County First Responder Agency EMS Volume Air Ambulance EMS Volume Hospital Specialty Center Volume Impact of New Trauma Centers Data Management Project System Requirements Analysis Process Anticipated Architecture and Process of Data Management Project Public Safety Answering Points Radio System Medical Dispatch Presumptive Problem Medical Priority Dispatch System Industry Best Practices City by City Comparison of Tele nursing Programs San Francisco Encounters by Referring Parties Spokane Diversions to Sobering Center by Referring Parties MedStar Community Paramedic Flow Chart MedStar Community Paramedic Program, 12 month Retrospective Review Beacon Community Program San Diego Sample CQI Committee Structure Draft Strategic Planning Process iv Santa Clara County EMS System Assessment Phase I October 2012 Page 22 of 157

23 Acknowledgements The Abaris Group would like to thank the Santa Clara County Health and Hospital System, Public Health Department, and the Emergency Medical Services (EMS) Agency for the opportunity to partner with Santa Clara County as it identifies opportunities to improve the EMS system and the implemention of the strategic recommendations. Most importantly, The Abaris Group acknowledges all of the public and private EMS system stakeholders, who took the time to share their thoughts, opinions, and suggestions on how to serve the EMS needs of the people of Santa Clara County. The stakeholders demonstrated an exemplary level of commitment for the EMS system. In addition to performing approximately 150 interviews and attending a number of the EMS committee meetings, observation sessions were conducted with different EMS organizations, including County Ambulance contractor crews and supervisors, County Communications dispatchers, EMS Specialists, and fire department first responders. Their input, combined with the experience of The Abaris Group s consultants, and data collected and analyzed form the basis for this report. Participating Agencies & Providers American Medical Response Bradshaw Consulting Rural/Metro of California ( County Ambulance contractor) California Department of Forestry and Fire Protection (CAL FIRE) Rural/Metro West (interfacility transport) San Jose Communications Center El Camino Hospital San Jose Fire Department El Camino Hospital Los Gatos Santa Clara Fire Department Gilroy Fire Department Santa Clara County Communications Golden State Ambulance Santa Clara County EMS Agency (SCCEMSA) Good Samaritan Hospital San Jose Santa Clara County Fire Department Hospital Council of Northern California Santa Clara County Mental Health Department Kaiser Medical Center San Jose Santa Clara County Public Health Department Kaiser Medical Center Santa Clara Santa Clara Valley Medical Center Milpitas Fire Department Silicon Valley Ambulance Mountain View Fire Department St. Louise Regional Hospital O Connor Hospital San Jose Stanford Hospital Palo Alto Fire Department Stanford Life Flight Regional Medical Center of San Jose Sunnyvale Department of Public Safety Royal Ambulance WestMed Ambulance 1 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 23 of 157

24 Executive Summary Santa Clara County has taken a proactive step with the initiation of this emergency medical services (EMS) assessment and accompanying strategic planning process. The health care environment will undergo many profound changes in the next three to five years where the County s EMS delivery system will either be reacting to these mandated changes or will create their own roadmap to prepare for such changes through local EMS initiatives such as those that may be taken by local stakeholders under the leadership of the County and its EMS Agency through this project. As local EMS stakeholders and the County define its own future EMS roadmap, the community will deliver the EMS system to an era of innovation, thus embracing the opportunities available with these upcoming health care changes. The Abaris Group was selected to conduct an assessment, create a strategic plan through a collaborative stakeholder process, and to develop a comprehensive implementation plan for the Santa Clara County EMS system. Approximately 150 stakeholders have been interviewed as part of the strategic assessment to date, as well as dozens of observation hours conducted with ambulance staff, field supervisors, EMS Specialists, first responders, and EMS dispatchers. The current EMS system is meeting the needs of the almost 2.2 million Santa Clara County residents and visitors to the county. The latest contract for the exclusive operating area (EOA) ambulance service began in July 2011 and the County Ambulance contractor 1 has been meeting and exceeding the response time standards set within the agreement with only one exception in the first month of service. The Santa Clara County EMS Agency (SCCEMSA) monitors the agreement to ensure compliance and is also responsible for designating receiving hospitals and recognizing specialty care centers, provider licensing, prehospital training, and disaster preparedness. Out of the ten receiving hospitals within the county, there are three trauma centers, nine stroke centers, eight cardiac specialty centers, and one burn center. These hospitals provide a higher level of care and treatment in their respective specialties, which benefits the community through decreased morbidity and mortality rates. While the EMS system is working well, there is not only a strong community desire to continue to progress the EMS system to both meet the current health care challenges in the community but to plan and prepare to optimize service in the future in anticipation of the Patient Protection and Affordable Care Act (PPACA or ACA otherwise known as Health Reform in this report) and other health care changes anticipated. 2 The new health care delivery system of the future will emphasize accountability and value and move away from the current paradigm of payments that are now largely driven based on services delivered. Some of these innovations are already under consideration by the County (i.e., inebriate center, mental health wrap around services, etc.) others are being tested around the country as is noted in this report. 1 County Ambulance is a term used to denote the provider of the County Service Area EOA, which is currently served by contract with Rural Metro California. 2 Pub.L , 124 Stat. 119, to be codified as amended at scattered sections of the Internal Revenue Code and in 42 U.S.C. 2 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 24 of 157

25 There are also opportunities to enhance the level of service currently provided. Through a collaborative process, specific recommendations will be selected for implementation within the EMS system and other potential EMS system innovations. These recommendations will be evaluated by the EMS stakeholders during the upcoming strategic planning workshops. A few of the larger opportunities for the stakeholders to consider which, as described in this report, include: Consider consolidating the EMS/fire communication centers Currently, there are 12 different portals for a public member to enter the system due to the number of decentralized communications centers in Santa Clara County. These 12 centers transfer the caller to one of the other eight centers for fire department first responder dispatch. Most of the fire department dispatch centers manually call the ambulance dispatch center and verbally relay the call information previously captured. In addition, there are six separate dispatch centers that provide emergency medical dispatch (EMD) pre arrival instructions following different protocols and policies. A consolidated center would lower response times, provide simultaneous dispatch of first responder and ambulance resources, and allow for better quality control and staff training. Many of these findings were supported by the Santa Clara County Grand Jury Report of Replace or upgrade Santa Clara County s Computer Aided Dispatch (CAD) system The current CAD system does not allow for the full integration of features that could improve response times within the EMS system and the level of geo coding that would allow for more precise call tracking, trending and system changes. This includes longitude and latitude coordinates, dispatcher instant messaging, system status optimization, and report export capabilities. These features are available and should be incorporated into the county s CAD system. While there are changes planned to add features, there should be an analysis to determine whether upgrading or replacing the current CAD is most cost effective long term. Standardize radio band and frequency There are four separate and distinct radio bands currently in operation within the county. First responders and ambulance crews are dispatched on separate channels. While the ambulance crews have the capability to talk on the fire dispatch frequencies, there are apparent policies in place to limit this to tactical and mutual aid channels. Only the County Ambulance contractor field supervisors and EMS Duty Chiefs are permitted to communicate on the fire dispatch frequencies. This hampers sharing of pertinent information such as scene safety, report on conditions, updated patient location, and other details that may affect crew safety and patient care. The Silicon Valley Regional Communications System (SVRCS) 3 May 19, 2011 Santa Clara County Civil Grand Jury Report Can You Hear Me Now Emergency Dispatch in Santa Clara County 3 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 25 of 157

26 is planning to replace existing public safety radio systems with a countywide digital radio infrastructure in the newly allocated 700MHz band. This new radio system has the potential to incorporate all EMS stakeholders on the same frequencies for improved communication. Establish a coordinated Continuous Quality Improvement (CQI) process The SCCEMSA should establish a CQI committee with responsibility for oversight and coordination of all quality assurance and improvement activities within the EMS system. Currently, there is no overarching body responsible for putting all of this information together in a comprehensive picture of the patient experience. This leads to a fragmented approach with no coordination or cohesion between programs or services. The CQI system should be expanded to include call intake, priority dispatch and caller instructions within the CQI framework. The system should also consider and implement a Just Culture methodology for quality review that is in place in many health care entities in the country. Research community paramedicine and other delivery innovations There are now a number of community paramedic programs and other EMS system innovations across the country that are designed to improve service, reduce unnecessary utilization, duplication and lower costs. Once the unique needs of the Santa Clara County EMS system are quantified through a data driven strategic planning process, there may be an opportunity to implement key EMS program innovations for Santa Clara County that addresses the specific challenges faced by this community and that need to be addressed ahead of Health Reform. Consider the development of a community collaborative on EMS patient off load delays Delays of EMS patient hand offs to emergency department (ED) personnel (> 15 minutes) are estimated to happen approximately 25 percent of the patients and even more at some EDs. While there is some controversy over the collection methodology of the actual times it is clear that there is a problem and it has significant federal policy and local system cost implications. The region should consider establishing a community collaborative to assist in addressing the problem, such as has been done in a number of communities in and outside California. 4 It will be the responsibility of the EMS leadership and stakeholders to review these recommendations. The second phase of the project will allow for open discussion of enhancement opportunities through facilitated workshops with subject matter experts sharing firsthand knowledge of EMS system possibilities. Finally, the selected recommendations and strategic plan should be implemented during the final phase of this project, which will determine the future course of the Santa Clara County EMS system. 4 Patel, P. MD, Derlet D, Vinson, D, Williams M, Wills, J, Ambulance Diversion Reduction: The Sacramento Solution, Journal of Emergency Medicine, October Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 26 of 157

27 Project Overview The Santa Clara County strategic EMS system assessment and planning project is a collaborative and integrated process that incorporates the counsel and participation of the EMS committees and system stakeholders including fire districts and departments, hospitals and specialty hospital centers, prehospital training programs, and the EOA contracted and non contracted county ambulance providers. Phase I System Assessment This initial assessment phase, represented in this report, evaluates the capabilities, opportunities and threats facing the EMS delivery system, from a national, regional, and local influence standpoint. This evaluation also considers the strengths and weaknesses of the EMS system with a goal to developing a three to seven year plan, focusing on maintaining or improving clinical care, improving operational efficiency, better targeting resources to patient needs, and assuring cost effectiveness and financial solvency of the EMS system. The scope of this assessment and planning is limited to the EMS system and its interfaces with other systems. As a longer term strategic plan process, planning assumptions are not limited by the current environment, including current law or technology. Phase II EMS System Strategic Planning Based on the results of the system assessment phase, a three to seven year EMS system strategic plan will be developed during Phase II. The desired output of this planning process is a strategic plan that identifies the EMS system s mission, vision, values, goals, and objectives. The strategic plan will be an essential guide for the future development of the Santa Clara County EMS system. Phase III Comprehensive Implementation Plan Upon completion of the EMS system strategic plan, the third and final phase of the project will develop a comprehensive implementation plan for the EMS strategic plan. The implementation plan will address each phase of the approved plan and include guidance for implementing each project. 5 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 27 of 157

28 Health Care and Emergency Medical Services Environment Health care is undergoing unprecedented changes and will continue to undergo these changes for the next 20 years with a particular emphasis on the next three to five years. The population is aging and it is expected that those that get admitted to the hospital will be of higher acuity. This is being driven by the growth of specialty centers and an increase in outpatient health care which is increasingly becoming a revenue center for hospitals by increasing hospital admissions but only for the sicker patients that cannot be cared for in the outpatient settings. These factors and other factors and technology will lead to fewer but higher acuity hospital admissions. Hospitals and their physician providers are under increased scrutiny for lowering unnecessary utilization and these entities are now under payment incentives (and disincentives) to reduce unnecessary and expensive services. These payment models that encourage outcomes, value and not merely paying for the delivery of services but looking for the value of these services have not included emergency medical services (EMS) delivery services to date. Perhaps the largest trend is the impact that is now and will continue to be felt with Health Reform. Provisions of Health Reform have already begun (i.e., health coverage expansion for populations such as young adults, reduction of lifetime insurance payment benefit caps, eliminating pre existing conditions, expanded payment for wellness services) and will significantly expand over the next three to five years. Foremost is the increase in coverage which is expected to drive the uninsured rate even in a state as high as California to fewer than five percent with a resultant increase in the number of insured either through a health exchange or Medi Cal product. While this will have a profound impact on the number of insured, the method to pay for this coverage will largely come from approximately $780 billion in proposed Medicare payment reductions mostly through reductions in unnecessary services and a push to outpatient and home health services. In California alone, these reductions are estimated to be $60 billion with the impact in Santa Clara County estimated at approximately $2.6 billion. 5 Key to these reductions is the elimination of waste which the Institute of Medicine recently estimated was 30 percent of health care spending in 2009 or $750 billion. 6 EMS has largely been ignored with these latest rounds of cost costing and incentive/disincentive pay by Medicare but this field cannot be ignored for too many years in the future. Thus, this is a driving reason for this study and the strategic planning process planned for this project. There are many initiatives being trialed across the country attempting to evaluate and limit waste, redundancy and unnecessary services. Care coordination and alignment of incentives are large topic areas for this area including the concept of Accountable Care Organizations (ACOs). 7 To date, EMS delivery systems have not been part of these initiatives. 5 Book, R., Ramlet, M. What is the Regional Impact of Medicare and Medicare Advantage Payment Reductions, University of Minnesota, September Institute of Medicine: Best Care at Lower Cost: The Path to Continuously Learning Health Care in America (Sept. 6, 2012) 7 ZwsGjtrMCFUlxQgodP2sA4Q 6 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 28 of 157

29 Emergency Care & Hospital Data/Projections Overview The following is a summary of key emergency care data related to the capacity and demand of emergency care services in Santa Clara County 8. Hospital Emergency Departments There are 10 hospitals in Santa Clara County with EDs. 9 In 2011, these ten hospitals received 456,131 visits (see Figure 1). In total, there are 248 ED treatment stations (i.e., ED beds). The largest ED is at Stanford Hospital (37 beds), followed by Kaiser Permanente Santa Clara Medical Center (32 beds). However, Santa Clara Valley Medical Center is the busiest ED in the county, with 73,478 visits in 2011 (24 beds). Santa Clara County emergency medical services (EMS) ground ambulance providers transported 68,895 patients in 2011 an increase of 6.8 percent from 2010 (64,507). EMS transports most often were delivered to Santa Clara Valley Medical Center which represented almost 20 percent of its ED volume. The hospital also has the highest ratio of ED visits to treatment stations in 2011 (3,062). Over the past five years, Santa Clara County ED visits increased 14.5 percent compared to 16.1 percent within California. However, the number of ED treatment stations has increased only 8.8 percent versus 15.5 percent statewide. As a result, the number of ED visits per treatment station increased from 1,747 to 1,839 (5.3 percent) between 2007 and The statewide ratio grew only slightly from 1,677 to 1,685 (0.5 percent). Using historical population trends, 911 system volume is expected to grow to 74,221 ground transports in 2015 and 78,715 by 2020 (see Figure 2). Santa Clara County ED Visits, Treatment Stations, and EMS Ground Transports 2011 Treatment ED Visits per SCC EMS Percent Hospital ED Visits Stations Station Volume SCC EMS El Camino Hospital 41, ,483 7, % El Camino Hospital Los Gatos 11, , % Good Samaritan Hospital San Jose 32, ,309 6, % Kaiser Permanente San Jose Medical Center 48, ,732 7, % Kaiser Permanente Santa Clara Medical Center 60, ,887 7, % O'Connor Hospital 53, ,312 6, % Regional Medical Center of San Jose 61, ,852 12, % Santa Clara Valley Medical Center 73, ,062 14, % St. Louise Regional Hospital 23, ,887 2, % Stanford Hospital 50, ,376 3, % VA Hospital Palo Alto n/a n/a n/a 613 n/a Total 456, ,839 69, % California Total 12,075,139 7,165 1,685 n/a n/a Sources: OSHPD Hospital Annual Utilization Data, 2011; Santa Clara County EMS Semi Annual Report, May 2012 Notes: The number of ED treatment stations shown does not show other treatment space outside their licensed ED capacity that may be used by hospitals. VA Hospital Palo Alto does not submit ED visit or station data to OSHPD. Figure 1 8 Certain projections on volume and capacity need are made in this report that is based on historical utilization trends. Should key patient utilization management models be instituted, these projections would need to be updated. 9 The VA Hospital Palo Alto is included in this count of 11 hospitals but their data is not included in this report as the VA does not report data to the Office of Statewide Health Planning and Development (OSHPD) 7 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 29 of 157

30 Santa Clara County EMS Historical and Projected 911 System Call Volume for Ground Transport Historical 5 year average Projected 80,000 74,221 78,715 80,000 69,600 70,000 70,000 60,000 60,000 50,000 50,000 40,000 40,000 30,000 30,000 20,000 20,000 10,000 10, Source: Santa Clara County EMS annual reports, Source: The Abaris Group, 2012 Note: Based on ABAG population projections & historical EMS volume Figure 2 EMS Data The Abaris Group requested and received one year of EMS response data from the County Ambulance contractor and Palo Alto Fire Department for the period of July 2011 through June The data received included both emergency and non emergency response information for the system. It is important to note that the data received was in a raw format; that is, it had not been reviewed and cleaned for duplicate responses. These can occur for a variety of reasons including multiple unit responses, cancelled calls, re assigned calls, dispatch errors, administrative functions, etc. The Abaris Group estimates that these duplicate responses account for no more than 5 percent of the overall volume. County Ambulance Responses by Priority and Population Designation July 2011 June 2012 Response Priority Metro % of Overall Total Urban % of Overall Total Suburban % of Overall Total Rural % of Overall Total Total % of Overall Total 2 26, % % % % 27, % 3 70, % 1, % 1, % % 74, % Total 96, % 1, % 2, % 1, % 101, % Source: County Ambulance Data, July 2011 June 2012 Note: 11 records did not have a population density designation Figure 3 Figure 3 displays the County Ambulance response breakdown for calls by response priority (2 = non emergency, 3 = emergency) and the population density for the area of the response for this time 8 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 30 of 157

31 period (see Appendix B for response time maps). As anticipated, the overwhelming majority of responses fell within the Metro/Urban population densities. Figure 4 displays the response time data for this time period, broken down by 4 minute increments and by response priority and population density for the area of the response. 87,887 responses fell within minutes (86 percent), which is the most stringent response time requirement for the County Ambulance Service. City of Palo Alto Response Times Response Time Responses % of Total < 4 minutes % 4 7:59 minutes 2, % 8 11:59 minutes 1, % 12 15:59 minutes % > 16 minutes % Total 4, % Source: City of Palo Alto, July 2011 June 2012 Figure 5 scene times and 867 were removed from the data set. Therefore, the resulting response time table contains 4,671 valid response times. The data table from the City of Palo Alto included ambulance responses only and no times for fire engine or truck first responders. Figure 6 provides response location information by city. As anticipated, San Jose dominates the system responses with 56 percent of all emergency responses in the county. Based on fiscal year 2012 reports from Santa Clara County EMS Agency (SCCEMSA), there were in 607 mutual aid requests to the City of Palo Alto. Responses by the Palo Alto Fire Department are also included in this table and while Stanford is not a city, it is a census designated location and as such is tracked separately by the City of Palo Alto. Figure 7 lists the transports for this period by receiving facility. Only the County Ambulance contractor transports County Ambulance Response Times by Priority and Population Designation Response Time Response Priority Metro/ Urban Suburban Rural/ Wilderness Total Less 4 2 3, ,692 minutes 3 22, ,476 Between 2 12, , , ,762 Between 2 5, , , ,695 Between 2 1, , minutes or greater Records w/o 2 3, ,998 response 3 7, ,355 Total 97,940 2,599 1, ,727 Source: County Ambulance Data, July 2011 June 2012 Figure 4 Figure 5 shows the response times for the City of Palo Alto for the same timeframe (July 2011 through June 2012). The original table contained 5,559 records. However, similar to the County Ambulance data, there were a number of records with blank at Responses by City City Count % of Total San Jose 59, % Not Available* 7, % Santa Clara 6, % Sunnyvale 6, % Palo Alto** 4, % Mountain View 3, % Milpitas 3, % Gilroy 2, % Campbell 2, % Cupertino 2, % Los Gatos 2, % Morgan Hill 1, % Los Altos 1, % Saratoga 1, % Stanford** % Los Altos Hills % Monte Sereno % Other % Total 106, % Source: County Ambulance and City of Palo Alto, July 2011 June 2012 Notes: * Includes both Palo Alto and unincorporated responses ** From the City of Palo Alto Data 4,660 records from the City of Palo Alto 9 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Figure 6 Page 31 of 157

32 were available for this study. Transport volumes are highest for Santa Clara Valley Medical Center and Regional Medical Center of San Jose. As noted in the county demographics section, this volume is expected to increase over the coming years. It will become critical for the system to do everything possible to improve ED throughput and reduce/eliminate ambulance crew waiting times to turnover patients. The utilization rate was 37.3 EMS ground transports per 1,000 people in Santa Clara County in This is slightly down from the five year Santa Clara County EMS Utilization per 1,000 population, June 2011 July 2012 Los Gatos Campbell San Jose Santa Clara Gilroy County Average Los Altos Morgan Hill Mountain View Milpitas Sunnyvale Saratoga Cupertino Los Altos Hills Monte Sereno EMS Utilization per 1,000 Residents Sources: Rural Metro, 2012; US Census Bureau Note: Does not include any reponses into Palo Alto. Utilization based on July 2011 population estimates Figure 8 average of 38.1 ground transports per 1,000 people. Utilization data by city show that Los Gatos, Campbell, San Jose, Santa Clara, and Gilroy all had Ambulance Responses by Destination Hospital Count % Total Valley Medical Center 15, % Regional San Jose 11, % El Camino Hospital 7, % Kaiser Santa Clara 7, % Santa Teresa Hospital 6, % Good Samaritan Hospital 6, % O'Connor Hospital 6, % Saint Louise Hospital 2, % Stanford University Hospital 1, % Los Gatos Hospital % Palo Alto VA Hospital % Emergency Psych. Service % Kaiser Fremont % Washington Township Hospital % HEL* % Kaiser Redwood City % Hazel Hawkins Hospital % OTH* % Dominican Sisters Hospital % Sequoia Hospital % Dry Run 33, % Total 101, % Source: County Ambulance, July 2011 June 2012 Note: * No Listing Available Figure 7 higher utilization of Santa Clara County EMS than the county average (see Figure 8) patient level ED data from Office of Statewide Health Planning and Development (OSHPD) was used to examine ED payer mix (see Figure 9). The most common type of payer that resulted in an ED discharge (i.e., did not require hospital admission) was commercial insurance (37 percent) followed by Medi Cal (23 percent). The uninsured (i.e., Self Pay ) accounted for 12 percent of all ED discharges. EMS payer mix data was obtained from the County Ambulance provider and the City of Palo Alto. Compared with the ED payer mix, there are approximately 40 percent more Medicare patients and half the number of Medi Cal patients in the EMS system. However, the percentage of EMS uninsured is almost double that of the ED payer mix. Santa Clara County Payer Mix ED Payer Mix, 2010 EMS Payer Mix, Medicare 15% Medi Cal 23% Self Pay 13% Commercial 37% Other 12% Medicare 26% Medi Cal 13% Commercial 36% Self Pay 24% Other 1% Source: OSHPD Emergency Department Dataset, 2010 Source: The Abaris Group estimate based upon data provided by Rural/Metro and Palo Alto Fire Department, 2012 Figure 9 10 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 32 of 157

33 By the ED and EMS payer mix will change due to full implementation of the Patient Protection and Affordable Care Act (PPACA, see Figure 10). For both ED and EMS, commercial payers are expected to rise to 44 and 48 percent, respectively. Conversely, the uninsured, which accounted for 24 percent of all EMS transports is expected to fall to 6 percent. Santa Clara County Payer Mix 50.0% 45.0% 40.0% Changes in ED Visit Payer Mix due to the ACA, * 37.4% 43.7% Before Reform (2010) Full Implementation ( ) 60.0% 50.0% Changes in EMS Transport Payer Mix due to the ACA, * 47.7% Before Reform (2010) Full Implementation ( ) 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 25.8% 22.5% 12.9% 3.3% 40.0% 30.0% 20.0% 10.0% 36.1% 13.1% 19.2% 23.5% 5.9% 0.0% 0.0% Commercial Medi Cal Self Pay Commercial Medi Cal Self Pay * Note: Projections for are based on full ACA implementation estimates for Santa Clara County by Insure the Uninsured Project. Source: The Abaris Group estimate based upon ED data obtained from OSHPD and ACA impact projections from Insure the Uninsured Project. Source: The Abaris Group estimate based upon data provided by Rural/Metro and Palo Alto Fire Department, 2012 and ACA impact projections from Insure the Uninsured Project. Figure 10 Overall, ED visit acuity in Santa Clara County has been trending towards less acute ED visits (see Figure 11). From 2007 to 2011, the number of visits classified as either minor or low/moderate severity changed from 24.6 to 29.1 percent; an increase of 18 percent. ED Visits by Level of Severity % 30% 20% 10% 0% Minor Low/Moderate Moderate Severe w/o Threat Severe w/ Threat Source: OSHPD Hospital Annual Utilization Data, 2011 Figure Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 33 of 157

34 To examine this finding in more detail, ED visits were analyzed using the New York University (NYU) ED Algorithm. The analysis focuses on all ED visits discharged (i.e., not admitted) from a Santa Clara County ED in The algorithm classifies patients based on their primary discharge diagnosis (i.e., ICD 9) as either non emergent, emergent but treatable in a primary care setting, or ED care needed. The algorithm does not classify drug/alcohol, psychiatric, or patients with an injury. Findings from the algorithm show that 42 percent of ED discharges could be classified as not needing ED care (see Figure 12). Santa Clara County ED Discharges 2010 Non Emergent Emergent/Primary Care Treatable Emergent ED Care Needed Preventable/Avoidable Emergent ED Care Needed Not Preventable/Avoidable Drug/Alcohol Psych Injury 12% Unclassified 20% 4% 2% 22% 12% 6% 22% Source: NYU ED Algorithm, OSHPD Emergency Department Dataset, 2010 ED care not needed Figure 12 NYU ED Algorithm Definitions: Non emergent The patient s initial complaint, presenting symptoms, vital signs, medical history, and age indicated that immediate medical care was not required within 12 hours; Emergent/Primary Care Treatable Based on information in the record, treatment was required within 12 hours, but care could have been provided effectively and safely in a primary care setting. The complaint did not require continuous observation, and no procedures were performed or resources used that are not available in a primary care setting (e.g., CAT scan or certain lab tests); Emergent ED Care Needed Preventable/ Avoidable Emergency department care was required based on the complaint or procedures performed/resources used, but the emergent nature of the condition was potentially preventable/avoidable if timely and effective ambulatory care had been received during the episode of illness (e.g., the flare ups of asthma, diabetes, congestive heart failure, etc.); and Santa Clara County ED Discharges Classified as ED Care Not Needed 60% Percentage 60, % 50% 50, % 38.1% 38.4% 40% 40,000 Total Visits 43,221 55,201 30% 20% 30,000 20,000 20,177 22,832 10% 10,000 0% Self Pay Medi Cal Commercial Medicare Non emergent Emergent/Primary Care Treatable 0 Self Pay Medi Cal Commercial Medicare Non emergent Emergent/Primary Care Treatable Source: OSHPD ED Data, 2010 & NYU ED Algorithm Note: Data represent all discharges from Santa Clara County EDs. Discharges can include residents and non residents of the county. When the data are stratified by payer mix (see Figure 13), Medi Cal patients have the highest percentage of visits that are classified as not needing ED care (49.6 percent); however, commercial payers have the highest number of visits classified as not needing ED care (55,201 visits). Figure Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 34 of 157

35 Over the last five years, the percentage of ED visits in Santa Clara County that resulted in a hospital admission has declined slightly; this follows the statewide downward trend of hospital admissions from the ED (see Figure 14). In Santa Clara County, Stanford Hospital had the highest ED admission rate in 2011 of 20.4 percent. Percentage of ED Visits that Resulted in Admission 18% 16% 14% Santa Clara County California Stanford Hospital Good Samaritan Hospital San Jose Statewide Average Kaiser Permanente Santa Clara El Camino Hospital Regional Medical of San Jose County Average Santa Clara Valley Medical Center Kaiser Permanente San Jose O'Connor Hospital St. Louise Regional Hospital El Camino Hospital Los Gatos 20.4% 17.6% 15.9% 15.6% 15.4% 15.2% 14.7% 13.9% 12.7% 11.8% 10.1% 9.3% 0% 5% 10% 15% 20% 25% 2011 ED Admission Rate Source: OSHPD Hospital Annual Utilization and Good Samaritan Hospital data, Figure 14 ED Visit Projections Projections for growth in ED demand were developed using a linear projection model using Santa Clara County Projected ED Visits data to establish a baseline for projections to 700, (see Figure 15). The ED projection model assumes that the trend of growth 600,000 experienced in the county will continue 500,000 through This assumption was based on 400,000 the findings of Chen et al., who concluded 300,000 that the Massachusetts health reform of 2006 did not impact (positively or negatively) ED 200,000 utilization. 10 However, this may not be the 100,000 case after Health Reform in California in Some have argued that Source: The Abaris Group, 2012 Note: Projections based off of historical ED volume Figure Chen C, Scheffler G, Chandra A. Massachusetts Health Care Reform and Emergency Department Utilization. New England Journal of Medicine. 2011: Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 35 of 157

36 ED visits will decline as a result of better access to primary care. 11 Others believe that ED use will increase due to lack of access in other settings. 12 ED Treatment Station Projections There were a total of 248 ED treatment stations treating 456,131 ED visits in Santa Clara County in 2011, which equates to 1,839 ED visits per station. This is above the national benchmark of 1,500 visits per station. If no stations are added, ED visits per station is projected to rise to 2,481 (see Figure 16). To reduce the number of ED visits per station to the national benchmark, Santa Clara County would need an additional 162 stations by 2020 to make up for current shortages and keep with rising ED demand (see Figure 17). ED Visits per Sation Projections, ED Visits/Station 2,750 2,500 2,250 2,000 1,750 1,500 1,250 1, ,481 2,342 2,203 2,064 1, ED Vists/Station National Benchmark Source: OSHPD Annual Utilization data files, Figure 16 Additional ED Stations Needed to Equal National Benchmark, Source: OSHPD Annual Utilization data files, Figure 17 Note: The number of ED treatment stations shown does not show other treatment space that may be used by hospitals outside the licensed treatment space identified by POSHPD. ED volume projections are based off of historical ED volume. VA Hospital Palo Alto does not submit ED visit or treatment station data to OSHPD. 11 Smulowitz PB, Lipton R, Wharam JF, et al. Emergency Department Utilization after the Implementation of Massachusetts Health Reform. Annals of Emergency Medicine. 2011;58(3): e1. 12 Goodman J. What Will Happen To Emergency Room Traffic? Health Affairs Blog. July 12, will happen to emergency room traffic/ 14 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 36 of 157

37 ED Payer Mix Projections Projections for payer mix were developed using ED utilization data from OSHPD as well as projected changes in the Santa Clara County payer mix due to implementation of the PPACA (see Figure 18). The largest growth in payer mix will be in the commercial payer group, which is expected to grow from 163,100 to 269,000 by The other largest growth in payer mix will occur in the Medi Cal group, which is expected to grow from 97,100 to 157,500 by The self pay (uninsured) group is expected to decline from 52,300 to 18,700 by 2022, or to about 6 percent of the total ED population. Santa Clara County Projected ED Visit Volume (in Thousands) by Payer, Commercial Medicare Medi Cal Self Pay Other Thousands Note: Payer projections includes both ED discharges and ED admissions. Other includes county indigent, other government, and other indigent programs. ED volume projections based off of historical ED volume. Source: The Abaris Group estimate based upon ED data obtained from OSHPD and ACA impact projections from Insure the Uninsured Project. Figure Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 37 of 157

38 EMS Payer Mix Projections Projections for EMS transports in Santa Clara County by payer mix were developed using transport data obtained from the County Ambulance provider and Palo Alto Fire Department as well as projected changes in the Santa Clara County payer mix due to implementation of the PPACA (see Figure 19). The commercial payer group is expected to grow from 25,100 transports to 41,100 by 2022, or to 47.7% of all transports. Medi Cal is also expected to grow from 9,100 to 16,800 by 2022, or to 19.2 percent of all transports. The number of self pay (uninsured) transports is expected to decline heavily with implementation of the PPACA from 16,400 to just 1,000 by Santa Clara County EMS Projected Transport Volume (in Thousands) by Payer, Commercial Medicare Medi Cal Self Pay Other Thousands Note: Payer projections includes both ED discharges and ED admissions. Source: The Abaris Group estimate based upon data obtained from Rural Metro and Palo Alto. ACA impact projections from Insure the Uninsured Project. Figure Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 38 of 157

39 Ambulance Diversion In 2011, Santa Clara County had its lowest ambulance diversion hours in the last five years, with 1,154 diversion hours or an average of 105 hours per hospital per year (see Figure 20). Heavily contributing to this improvement was the reduction of diversion hours at Santa Clara Valley Medical Center, who reduced diversion from 951 hours in 2010 (31 st highest in California) to 424 hours in 2011 (a 55 percent improvement). Statewide, ambulance diversion has also declined considerably. Total diversion was down from 144,694 hours in 2008 to 89,452 hours in Diversion also appears to be down in 2011 based on initial data; however, the finalized OSHPD report has yet to be released. Ambulance Diversion Hours Ambulance Diversion Hours 2,500 2,000 1,500 1, Source: OSHPD Hospital Annual Utilization Data, Ambulance Off load Delays Santa Clara County In Santa Clara County, the issue of wall time, or the time it takes to off load a patient so that the patient can be the responsibility of the hospital, is a concern to the County Ambulance, interfacility ambulance providers, as well as to other system stakeholder agencies. Data provided by County Ambulance is limited but does describe the number of transports that were offloaded within 15 minutes or exceeding 15 minutes. 13 Ambulance Diversion Hours 180, , , , ,000 Figure 21 With off loads times greater than 15 minutes constituting 25 percent (see Figure 21), or 1 out of every 4 transports, thus does appear to be an issue in Santa Clara County, the data does not provide any detail as to whether the extended offloads were a minute, an hour, or more beyond the 15 minutes; therefore, it cannot be quantified further beyond the 15 minute time period. 80,000 60,000 40,000 20,000 0 California Figure Collecting data for evaluating off load times at EDs is problematic as there is no standardized agreement on who and when there is a sign off of the patient at the ED and thus the end of wall time for that patient. However, data provided by the County Ambulance contractor suggests that a problem does exist. 17 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 39 of 157

40 Long offload times contribute to reduced availability of EMS units that are able to respond to the community and increases costs to the County Ambulance, who continues to be held to the response time requirements as delineated in the contract. These lost unit hours contribute substantial costs to the system, which must be recovered through additional EMS unit hours and patient charges to offset these new costs. While the percentage of crew time spent awaiting offload in Santa Clara County has not been quantified as a percentage of crew time, it clearly identifies the County Ambulance "Wall Time" Evaluation potential impact to the County Ambulance (and the Total Transports Percent community) of these extended offload times. Effects on the provider include lost unit hours and increased Month Apr 12 Transports 4,994 >15 offload 2,480 >15 offload 49.7% May 12 5,097 1, % cost, and the impact on the system overall can Jun 12 5,468 1, % include extended response times when inadequate Jul 12 5,296 1, % units are available to respond into the community. Total 20,855 6, % Source: Rural/Metro Figure 22 Figure 22 demonstrates that there are a significant number of transports with extended wall times. Figure 23 displays the unit hours lost to wall time for the month of July 2012 based on data from County Ambulance. Using a conservative estimate of $150/unit hour, the County Ambulance lost $85,000 in unit hour productivity in one month; annualized, this exceeds $1 million. County Ambulance Lost Unit Hours, July 2012 Offload Times (in minutes) Total >15 Total Transports <10 <15 <20 <25 <30 <45 <60 <90 <120 Minutes Hours Lost Lost Unit Hours 5,213 2,678 1, , Source: Rural/Metro Figure 23 National Perspective The issue of increasing ambulance off load times is not new. Crews and ambulance providers have been raising this issue since the mid to late 1990s. It has, however, increased in both frequency and duration over the past several years and the causes are multiple and daunting. The Abaris Group defines wall time as the time from when the ambulance arrives at the hospital until the patient care has been transferred to hospital staff and the patient is no longer on the ambulance gurney. The issue of EMS off load times is not only a national but an international issue. The Niagara EMS Region, located in Ontario, Canada, reported that their system has extended offload hours which have increased from 1 percent of on duty crew time in 2005, to 21 percent in Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 40 of 157

41 With hospital closures and increases in ED utilization, ambulance diversion became a substantive issue in the 1990s and continues to be a major challenge in many communities. Diversion of ambulance patients to other than their desired hospitals results in negative patient encounters; increased cost and time to get the patients to their desired facilities and can impact the quality of patient outcomes. 15,16,17 To address these issues, many EMS systems began to severely limit diversion hours or, in some cases, eliminate diversion entirely. While that eases the issue of ambulance diversion, one of the unintended consequences has been an increasing level of wall time or ambulance parking. The issue reached a peak in the mid 2000s with the level of complaints reaching the attention of the Centers for Medicare and Medicaid Services (CMS). In their review of the ambulance parking issue, CMS said, in part, CMS recognizes the enormous strain and crowding many hospital emergency departments face every day. However, this practice is not a solution. Parking patients in hospitals and refusing to release EMS equipment or personnel jeopardizes patient health and impacts the ability of the EMS personnel to provide emergency services to the rest of the community. They have clearly stated that this practice can constitute both an EMTALA violation as well as a violation of 42 CFR , the Conditions of Participation for Hospitals for Emergency Services. 18 In follow up on this issue, CMS stated: Furthermore, such a practice of parking individuals arriving via EMS, refusing to release EMS personnel or equipment, can potentially jeopardize the health and safety of the transferred individual and other individuals in the community who may need EMS services at that time. On the other hand, this does not mean that a hospital will necessarily have violated EMTALA and/or the hospital conditions of participation, if it does not, in every instance, immediately assume from the EMS provider all responsibility for the individual, regardless of any other circumstances in the hospital. So, if the EMS provider brought an individual to the dedicated ED at a time when ED staff was occupied dealing with multiple major trauma cases, it could under those circumstances be reasonable for the hospital to ask the EMS provider to stay with the individual until such time as there were ED staff available to provide care to that individual. However, even if a hospital cannot immediately complete an appropriate MSE, it must still assess the individual s condition upon arrival to ensure that the individual is appropriately prioritized, based on his/her presenting signs and symptoms, to be seen by a physician or other QMP for 15 Schull MJ, Morrison LJ, Vermeulen M, Redelmeier DA. Emergency department gridlock and out of hospital delays for cardiac patients. Acad Emerg Med. 2003;10(7): Schull MJ, Morrison LJ, Vermeulen M, Redelmeier DA. Emergency department overcrowding and ambulance transport delays for patients with chest pain. CMAJ. 2003;168(3): Begley CE, Chang Y, Wood RC, Weltge A. Emergency department diversion and trauma mortality: evidence from Houston, Texas. J Trauma. 2004;57(6): Opinion by the Centers for Medicaid and State Operations/Survey and Certification Group; Ref: S&C dated July 13, Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 41 of 157

42 completion of the MSE. The hospital should also assess whether the EMS provider can appropriately monitor the individual s condition. In his review of these seemingly contradictory remarks, Steve Frew, esq. (medlaw.com) stated the following: Cutting through the layer speak, CMS looks at the circumstances of each case to determine whether the delay is justified in terms of the circumstances at the time and whether or not the hospital is facing an unexpected overload or has failed to staff to meet community need by providing enough staff and equipment to handle foreseeable ED presentations. At the least, CMS expects that the hospital, in periods of high ED EMS demand, will promptly triage patients upon presentation to determine the patient s condition. In cases of unusual high utilization levels, the hospital would be required to determine whether EMS personnel would be appropriate to care for the patient for the anticipated delay times, and, if appropriate, to request EMS personnel to remain with the patient. If it is not an unusual level of demand, hospitals will not be able to rely on EMS personnel as surrogate staff for ED operations. Hospital Data Inpatient OSHPD data was reviewed for the 10 acute care hospitals that also have an ED. As such, the inpatient data presented does not include admissions from the following facilities: Children s Recovery Center of Northern California Crestwood San Jose Psychiatric Health Facility Kaiser Permanente Behavioral Health Center Santa Clara Lucile Salter Packard Children s Hospital at Stanford Mission Oaks Hospital Santa Clara County General Acute Care Inpatient Services ,000 General Acute Care Discharges & Beds 4,000 70% Occupancy Rates Discharges 140, , ,000 80,000 60,000 40,000 3,500 3,000 2,500 2,000 1,500 1,000 Inpatient Beds Occupancy Rates 65% 60% 55% 20, Discharges General Acute Care Beds Source: OSHPD Hospital Annual Utilization Data, Note: Discharges from general acute care licensed beds only % County Occupancy Rate State Occupancy Rate Figure Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 42 of 157

43 The number of acute care inpatients in Santa Clara County hospitals has remained steady from 2007 to 2011 (see Figure 24). There was a drop in the total number of licensed beds in 2008 when Kaiser Permanente Santa Clara Medical Center changed their licensed beds from 613 licensed beds to 327. Bed occupancy rates were very close to the state average from 2007 to Occupancy rates have declined slightly after increasing in 2008 (note: licensed bed occupancy rates may overestimate available capacity as not all licensed beds are staffed or available to treat patients). Five hospitals in Santa Clara County have bed occupancy rates above the statewide average (see Figure 25). In 2011, bed occupancy rate ranged from 75.0 percent at Kaiser Permanente Santa Clara Medical Center to 26.4 percent at El Camino Hospital Los Gatos. The statewide and county average occupancy rates were almost identical in Licensed Bed Occupancy Rates 2011 Kaiser Permanente Santa Clara Regional Medical Center of San Jose Stanford Hospital Good Samaritan Hospital San Jose Santa Clara Valley Medical Center Statewide Average County Average Kaiser Permanente San Jose St. Louise Regional Hospital El Camino Hospital O'Connor Hospital El Camino Hospital Los Gatos 75.0% 68.8% 61.3% 60.0% 56.1% 55.6% 55.0% 51.8% 51.0% 43.6% 35.5% 26.4% 0% 25% 50% 75% 100% Source: OSHPD Hospital Annual Utilization Data, Note: Discharges from general acute care licensed beds only Figure 25 Staffed bed occupancy rates provide a more realistic capacity of the hospital bed capacity. OSHPD data shows that most hospitals in Santa Clara County operate above the statewide and county capacity averages. Six hospitals are operating at above 90 percent of their staffed beds (see Figure 26). Staffed Bed Occupancy Rates Regional Medical Center of San Jose Kaiser Permanente San Jose Good Samaritan Hospital San Jose St. Louise Regional Hospital O'Connor Hospital San Jose El Camino Hospital Kaiser Permanente Santa Clara County Average Statewide Average Stanford Hospital Santa Clara Valley Medical Center 61.1% 99.7% 99.1% 98.4% 97.8% 93.1% 90.9% 86.7% 82.8% 79.2% 79.0% Source: OSHPD Hospital Annual Financial Data, % 25% 50% 75% 100% Figure Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 43 of 157

44 Psychiatric Care During 2011, the following six facilities in Santa Clara County provided inpatient psychiatric care: Crestwood Center San Jose 16 beds El Camino Hospital 25 beds Kaiser Permanente Behavioral Health Center Santa Clara 24 beds Mission Oaks Hospital 21 beds Santa Clara Valley Medical Center 50 beds Stanford Hospital 30 beds Capacity to treat psychiatric patients in Santa Clara County expanded in 2010 with the addition of 24 beds (see Figure 27). Expansion continued in 2011 with the opening of a 16 bed psychiatric health facility (Crestwood Center San Jose). Despite this expansion in capacity, the countywide psychiatric bed occupancy rate remains relatively unchanged and is still considerably higher than the statewide average. This can be partially explained by the 41 percent growth of hospital psychiatric discharges from 3,958 to 5,566 between 2010 and Santa Clara County Psychiatric Inpatient Services Psychiatric Discharges & Beds 6, % Occupancy Rates Discharges 5,000 4,000 3,000 2,000 1, Psychiatric Beds Occupancy Rates 80% 70% 60% Discharges Psychiatric Beds Source: OSHPD Hospital Annual Utilization Data, Note: Discharges from general acute care licensed beds only 0 50% County Occupancy Rate State Occupancy Rate Figure 27 There were a total of 14,264 psychiatric patients who visited an ED in Santa Clara County in 2010 but were not admitted to an inpatient facility. Overall, the majority of these patients were residents of Santa Clara County (see Figure 28). Residency of Psychiatric Patients Discharged from Santa Clara County EDs 2010 Santa Clara County, 88.6% Other, 11.4% 1.5% 1.7% 1.0% 0.5% 0.5% 3.8% 2.3% Other Counties: Unspecified San Mateo Santa Cruz Alameda San Francisco (N=14,264) Source: OSHPD 2010 Emergency Department Data & NYU ED Algorithm San Benito Other counties Figure Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 44 of 157

45 County Demographics Overview Population of Bay Area Counties Average County Percent Change Annual Change Santa Clara 1,682,585 1,781, % 0.6% Alameda 1,443,741 1,510, % 0.5% Contra Costa 948,816 1,049, % 1.1% San Francisco 776, , % 0.4% San Mateo 707, , % 0.2% Sonoma 458, , % 0.6% Solano 394, , % 0.5% Marin 247, , % 0.2% Napa 124, , % 1.0% Bay Area Total 6,783,760 7,150, % 0.5% California 33,871,648 37,253, % 1.0% Source: U.S. Census Data 2000, U.S. Census Data 2010 Figure 29 Santa Clara County, home of the Silicon Valley, is the largest county in the San Francisco Bay Area (Bay Area) with a population of 1.8 million people and a daytime total population just exceeding 2.1 million. This influx of 330,000 daytime commuters adds to the overall impact of the population to be served. Figure 29 demonstrates that between the 2000 and 2010 census, the population of Santa Clara County grew by 5.9 percent, or 0.6 percent annually. This rate is slower than California, which averaged 1.0 percent per year. The fastest growing county in the Bay Area is Contra Costa at 1.1 percent, followed by Napa at 1.0 percent with Santa Clara County following third. Santa Clara County is composed of 15 cities, 14 of which grew in population since the 2000 census. As shown in Figure 31, the fastest growing city is Gilroy, which increased 17.7 percent, an average of 1.8 percent per year. Cupertino was second with a 15.3 percent increase. San Jose remains the largest city in Santa Clara County with a total population of 945,942 in 2010 and average growth compared to other cities within the Palo Alto Mountain View Sunnyvale Los Altos Hills Los Altos Santa Clara State Hwy 9 Cupertino Saratoga Campbell Monte Sereno Los Gatos Milpitas San Jose Total Population by City City Boundaries 3,341-7,922 7,923-48,821 48,822-74,066 74, , , ,942 County Boundary Major Roads Source: Assoc. of Bay Area Governments I- 280 Capitol Expy State Hwy 85 Hwy 101 Morgan Hill State Hwy 130 Gilroy Pacheco Pass Hwy Figure 30 Population Santa Clara County Cities Average City Percent Change Annual Change Gilroy 41,464 48, % 1.8% Cupertino 50,546 58, % 1.5% Santa Clara 102, , % 1.4% Morgan Hill 33,556 37, % 1.3% Palo Alto 58,598 64, % 1.0% Milpitas 62,698 66, % 0.7% Sunnyvale 131, , % 0.6% San Jose 894, , % 0.6% Mountain View 70,708 74, % 0.5% Los Altos 27,693 28, % 0.5% Campbell 38,138 39, % 0.3% Los Gatos 28,592 29, % 0.3% Saratoga 29,843 29, % 0.0% Los Altos Hills 7,902 7, % 0.0% Monte Sereno 3,483 3, % 0.4% Source: Association of Bay Area Governments Figure 31 county. Figure 30 shows total population by city. The darkest blue represents the most populated city, San Jose, while the lightest blue signifies the 23 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 45 of 157

46 least populated community, Monte Sereno. A full size map of this population density map may be seen in Appendix C. Santa Clara County Race Percent of Race Total 2010 White 905, , % Black/African American 47,182 46, % American Indian and Alaska Native 11,350 12, % Asian 430, , % Native Hawaiian and Other Pacific Islander 5,773 7, % Some Other Race 204, , % Two or more races 78,437 87, % Total Population 1,682,585 1,781, % Source: U.S. Census Data 2010 As depicted in Figure 32, the largest population in terms of race in Santa Clara County in 2010 was White, comprising 47 percent of the population, followed by Asian at 32 percent. Figure 33 demonstrates the race breakdown of Santa Clara County compared to both California and the United States in The percentage of Asian population in the county is more than double that of the state and about six times greater than the country. At the same time, the White population, while the largest group in the county, is less than the state by roughly 16 percent and less than the country by almost 20 percent. Sex and Age 2010 Sex Santa Clara County California United States Male 50.2% 49.7% 49.2% Female 49.8% 50.3% 50.8% Age < 5 years 6.9% 6.7% 6.5% 5 18 years 23.9% 24.6% 23.7% years 57.9% 57.0% 56.5% > 65 years 11.3% 11.7% 13.3% Source: U.S. Census Bureau 2010 Figure % 12.4% 0.4% 32.0% 0.7% Santa Clara County Race % 47.0% White Black/African American American Indian and Alaska Native Asian Native Hawaiian and Other Pacific Islander Some Other Race Two or more races Figure 32 Race Breakdown 2011 Race Santa Clara County California United States White 58.4% 74.0% 78.1% Black/African American 3.0% 6.6% 13.1% American Indian and Alaska Native 1.4% 1.7% 1.2% Asian 32.9% 13.6% 5.0% Native Hawaiian and Other Pacific Islander 0.5% 0.5% 0.2% Some Other Race 3.9% 3.6% 2.3% Total Population 100.0% 100.0% 100.0% Source: U.S. Census Data Figure 33 Unlike California and the United States, the male population in Santa Clara County is greater than the female population based on 2010 census data. Figure 34 identifies the male population at 50.2 percent in the county, while females comprised 49.8 percent. The largest age group is between 18 and 65 years at almost 58 percent of the population. 24 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 46 of 157

47 Household Income 2010 Median County Income Marin $89,268 Santa Clara $86,850 San Mateo $85,648 Contra Costa $78,385 San Francisco $71,304 Alameda $69,384 Solano $68,409 Napa $67,389 Sonoma $63,274 California $60,883 United States $51,914 Source: U.S. Census Data 2010 Figure 35 Santa Clara County s median household income is the second highest in the Bay Area at $86,850 just behind Marin County. However, Santa Clara County is still significantly above the median for California and the United States, as shown in Figure 35. Major employers in the county include Adobe Systems, Apple, Hewlett Packard Co, NASA, Lockheed Martin Corp, and San Jose State University among many others. 19 According to the State of California Employment Development Department (EDD) the annual job growth in Santa Clara County is expected to average 0.9 percent per year through 2016, while California s annual job growth is expected to be 1.6 percent (see Figure 36 Figure 36). 20 At the same time, the job growth rate in the country is expected to be similar to Santa Clara County at 0.8 percent annually. 21 A recent study confirmed that, The Bay Area posted its second straight month of strong job gains in September and accounted for more than half the jobs added in all of California, according to a report released Friday by state officials. Jobless rates also fell, with the state's dropping to 10.2 percent from 10.6 percent and unemployment rates for the South Bay, East Bay and San Francisco San Mateo Marin region also falling. The South Bay's tech industry continued to drive much of the region's job growth in September. 22 Santa Clara County Population Projections Average Change Annual Change Total Population 1,822,000 1,945,300 2,063, % 1.3% Households 614, , , % 1.3% Mean Household Income 108, , , % 1.1% Employed Residents 815, , , % 2.1% Source: Association of Bay Area Governments, 2009 Figure 37 Santa Clara County s population projections show that the county is expected to grow by 1.3 percent annually until Figure 37 also demonstrates that the employed population is also projected to increase by 20.8 percent in ten years, or 2.1 percent annually. 19 CA EDD, 20 CA EDD Occupational Employment Projections to East Bay's boom helps Bay Area account for more than half of state's job growth again, Contra Costa Times, 19 October area adds jobs east bay 25 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 47 of 157

48 Figure 38 shows the expected population growth by jurisdictional boundary and the unincorporated area. There are four incorporated cities in Santa Clara County that are projected to grow faster than the county as a whole: Milpitas (1.9 percent), Gilroy (1.8 percent), San Jose (1.6 percent), and Palo Alto (1.4 percent). Santa Clara County Population Projections for Jurisdictional Boundaries City Percent Change Average Annual Percent Change Milpitas 69,000 74,700 82, % 1.9% Gilroy 49,800 55,000 58, % 1.8% San Jose 981,000 1,063,600 1,137, % 1.6% Palo Alto 61,600 66,200 70, % 1.4% Santa Clara 114, , , % 1.2% Mountain View 72,100 76,100 80, % 1.1% Morgan Hill 38,200 40,200 42, % 1.0% Sunnyvale 135, , , % 0.9% Campbell 40,500 41,800 44, % 0.9% Unincorporated 103, , , % 0.9% Monte Sereno 3,400 3,500 3, % 0.6% Los Altos 28,400 28,700 29, % 0.4% Cupertino 55,200 55,800 56, % 0.2% Los Gatos 29,600 29,900 30, % 0.1% Los Altos Hills 8,800 8,800 8, % 0.0% Saratoga 31,400 31,400 31, % 0.0% Santa Clara County 1,822,000 1,945,300 2,063, % 1.3% Source: Association of Bay Area Governments, 2009 Figure 38 In addition to residents and the daytime influx of people, there are a number of existing major event venues and more are planned. Existing sites include the Stanford Stadium (50,000 seating capacity), Spartan Stadium (30,000), Shoreline Amphitheatre (22,000), and HP Pavilion (20,000). Within the next couple years, the Santa Clara (San Francisco 49ers) Stadium (75,000) and Earthquakes Soccer Stadium (18,000) will be completed, creating more day time and venue population in Santa Clara County. In addition, there are several smaller venues with a combined seating capacity of almost 32,000 seats. These venues impact the emergency medical services (EMS) system by creating the potential for more EMS calls in a confined area as well as increasing traffic conditions in and around the sites. They also pose a large potential target for terrorist activities. 26 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 48 of 157

49 Health Insurance Coverage Eighty eight percent of the general population of Santa Clara County and 95 percent of its children have health insurance in Santa Clara County higher than statewide rates (see Figure 39). Data from the 2009 California health interview survey found that the majority of the county population with health insurance is covered by employers and fewer people are uninsured or have Medicaid/Healthy Families coverage compared to the state as a whole (see Figure 40). Figure 39 Figure Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 49 of 157

50 The Insure The Uninsured Project group conducted an impact analysis of Health Reform on all counties in California. In Santa Clara County, the percentage of people who are uninsured is expected to drop from 12.0 to 2.7 percent by 2018 (see Figure 41). Approximately two thirds of those who will obtain health insurance in Santa Clara County will purchase insurance in health insurance exchanges with subsidies. Impact of Affordable Care Act in Santa Clara County Before Reform (2006) Full Implementation ( ) Total Population (Ages 0 64) 1,549,377 1,735,302 Uninsured Eligible for Medicaid Expansion N/A 47,794 Uninsured and Private Individually Insured Eligible for Subsidies to Purchase Insurance N/A 91,429 Estimated Uninsured (Ages 0 64) 185,925 46,701 Estimated Percent Uninsured (Ages 0 64) 12.0% 2.7% Source: Insure the Uninsured Project Analysis, 2012 Figure Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 50 of 157

51 Emergency Medical Services System Overview The Santa Clara County emergency medical services (EMS) system is a public private partnership of resources focused on delivering optimal care in the prehospital environment. Fire departments send first responders to medical calls with a private ambulance providing transportation to the hospital. The only exception is the City of Palo Alto whose fire department also provides ambulance transportation. Periodically, the County Service Area exclusive operating area (EOA), which is the entire county outside the city limits of Palo Alto for ambulance service, is set for competitive bid. This last occurred in 2011 and Rural/Metro of California was awarded the contract which had been held by American Medical Response or its predecessors for a number of years. The current EOA for the Contract Ambulance contract is five years with the potential for two, three year extensions. There are a total of 10 hospitals receiving ambulance transports in Santa Clara County. The Santa Clara County EMS Agency (SCCEMSA) has designated specific hospitals for the specialty care of trauma, stroke, or cardiac patients or has developed specific destination policies for centers that are recognized by other national bodies (i.e., burn center, psychiatric centers). The SCCEMSA policies require the ambulance providers to transport patients with any of these specialty injuries or illnesses to the closest, designated specialty care hospital. The entire county EMS system is managed through oversight by the SCCEMSA. EMS Agency The local EMS system in Santa Clara County is overseen by the SCCEMSA, which is part of the Santa Clara County Public Health Department. The SCCEMSA is the lead agency for the EMS system in the county. The SCCEMSA and its medical director provide clinical oversight through medical and operational protocols and the quality improvement process. SCCEMSA s medical director is responsible for the medical direction and management for medical control of the local EMS system. Specifically, the medical director establishes written medical policies and procedures for the local advanced life support (ALS) and basic life support (BLS) systems. SCCEMSA s core responsibilities are to plan, implement, monitor, and evaluate the local EMS system. Its tasks include planning the finances for system operation and collecting, analyzing, and disseminating EMS related data. (Health & Safety Code, Division 2.5, Chapter 4) The SCCEMSA is also responsible for: Establishing policies and procedures for EMS system operations (using state minimum standards). Developing and submitting a plan to the EMS Authority for its EMS system and, if desired, its trauma care system. Designating and/or contracting with EMS base hospitals and specialty care centers. 29 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 51 of 157

52 Developing guidelines, standards, and protocols for the triage, prehospital treatment, and transfer of emergency patients. Authorizing and implementing a prehospital advanced life support program, if desired. Certifying and accrediting prehospital medical care personnel and approving EMS personnel training programs. Other duties and responsibilities as defined by Title 22 of the California Code of Regulations. The SCCEMSA is divided into five sections response services, compliance and enforcement, system coordination, clinical quality/performance improvement/data analysis, and administration. The first three sections are managed by the EMS Section Chief and the agency EMS Director is responsible for the remaining two as well as the overall performance of the SCCEMSA and delivery system. The SCCEMSA is a progressive EMS agency in that it provides substantial system oversight through partnerships with local ambulance and fire first response entities. It is the only EMS agency in the state with contracts with all key providers of the EMS delivery system (i.e., 9 1 1, interfacility transport, fire first response, ED and specialty centers). Key to the oversight and readiness capability of the local EMS delivery system is the use of field Duty Chiefs which in their more progressive role is unique to Santa Clara County. This role was conceptualized in 2001 to bridge the gap of a perceived lack of operational, field leadership in the past and to provide more extensive readiness assessment and planning for major emergency events. This need led the SCCEMSA to begin to standardize incident command system (ICS) training, credentialing and site readiness especially for those sites that have scheduled large events. In order to ensure proper field supervision, two full time employees with specific field responsibilities were dedicated to the SCCEMSA Duty Chief role starting in April 2011, just prior to the new provider commencing services. There is an EMS Duty Chief available 24 hours a day, 7 days a week. The position is in the field during the day and on call at night. The EMS Duty Chief has the authority to materially change the EMS system as needed and handles all non routine events that exceed the scope of the ambulance provider s daily contracted activities. A typical day was described as 60 percent customer service, 30 percent training field providers, and 10 percent running calls. This level of field operational capability is not seen in other EMS systems. The SCCEMSA recently began offering Six Sigma training to not only its staff, but system stakeholders as well which is a first for EMS agencies in the state. These classes are designed to teach staff how to problem solve following a proven process approach. It is an excellent methodology for quality improvement to reduce service failure rates in the EMS system to a negligible level. This level of investment is critical to preparing the community for the future of health care including anticipating and planning for the impact of Health Reform. 30 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 52 of 157

53 Prehospital Providers First Responders There are nine fire departments within Santa Clara County who provide first response EMS within their respective jurisdictions (see Figure 42, note: volunteer and industrial fire departments were not included in this report). Most first responder agencies have firefighter paramedics staffing ALS fire engines, squads, or trucks who respond to medical calls; the only exception is Sunnyvale. The City of Sunnyvale is unique in that the first response EMS is provided by the Department of Public Safety (DPS) with personnel that are cross trained as police officers and firefighters. All of the personnel are trained to the emergency medical technician (EMT) level and BLS services are provided from both fire apparatus and police units. Depending on the type of EMS call, both police and fire will respond. The remaining eight fire departments provide ALS care and have signed EMS provider agreements in place with the SCCEMSA. Each agreement specifies First Responder Agency Service EMS Volume Gilroy Fire Department ALS 2,720 Milpitas Fire Department ALS 2,860 Mountain View Fire Department ALS 3,892 Palo Alto Fire Department ALS 4,671 San Jose Fire Department ALS 49,320 Santa Clara Fire Department ALS 6,864 Santa Clara County Fire Department ALS 13,344 South Santa Clara County Fire District* ALS 1,468 Sunnyvale Department of Public Safety BLS 5,804 Source: Individual fire department, 2011 data, updated SJFD data is pending Note: *Contracted with the California Department of Forestry & Fire Protection (CAL FIRE) for department administration and personnel services Figure 42 the scope of services to be provided, including the use of paramedics to deliver prehospital care services as part of an integrated countywide EMS system. The agreements also include two annexes one address the use of fire department backup ambulances and the other describes the allocation of firstresponder funding provided by the contracted County Ambulance provider. The County Ambulance provider is required to provide five million dollars annually with potential increases annually as provided in their ambulance agreement with Santa Clara County. Funding for first responder services requires adherence to the EMS provider agreements. The SCCEMSA written contracts with the fire departments provides for communities that provide ALS first response to meet an emergency response time requirement of 7:59 minutes (12:59 for non emergency) in the urban areas. In general, the fire departments first responders are meeting the requirement in excess of 90 percent of the time. 23 Due to the lack of ALS first response in the City of Sunnyvale, ambulance response times for the County Ambulance provider are more stringent at 7:59 minutes for this urban area. Through the interview process, the EMS chiefs representing the different fire departments stated that the EMS system is working well overall and the SCCEMSA has made significant improvements to the countywide EMS system. They also reported that their ability for the department to meet the needs or 23 City of San Jose has missed the 90 percent target response time standard in the first two months of Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 53 of 157

54 requests from the SCCEMSA is challenging because of the demands on their time based on additional workloads and other assigned duties outside of EMS. They often are not able to attend the many SCCEMSA committee meetings or send the appropriate representatives. As a group, they stated that they do not always have input into decisions that may impact their organizations and would like to see a more collaborative approach to EMS system decision making. The EMS chiefs admit that they have slowed down the implementation of certain EMS policies or procedures, especially if there is a budgetary impact. The SCCEMSA allows up to 18 months for the implementation of certain EMS policies, procedures or additional equipment Ambulance Providers The primary ambulance provider is the County Ambulance currently under contract with Rural/Metro of California. This company was awarded the Santa Clara County EOA ambulance contract through a competitive bid process and began operations in July The response time standards are based on population density as specified by the SCCEMSA and broken into five zones. The urban service area standard is 11:59 minutes at least 90 percent of the time for emergency calls (16:59 minutes for nonemergency calls). Due to the lack of ALS first response in the City of Sunnyvale, ambulance response times are more stringent at 7:59 minutes for the same urban area. This is a common practice and the response time standards are comparable with those established by other California EMS agencies. When the County Ambulance does not meet the response time standards on a particular call, it is assessed a penalty for non compliance. These liquidated damages are collected in an EMS trust fund, which funds EMS related activities such as training, education, capital improvements, and EMS system preparedness for catastrophic events. The estimate annual payments to the trust fund are $2.1 to $2.2 million. During low system levels, the County Ambulance has the ability to request mutual aid from the other private ALS ambulance providers through an automated SCCEMSA procedure, which is monitored by the EMS Duty Chief. Each request carries a $1,000 penalty and the County Ambulance is also responsible for guaranteeing payment to the other ambulance provider. With the exception of one zone in the first month, the County Ambulance provider has been meeting or exceeding the response time standards specified within the EMS contract for each zone. SCCEMSA staff commented that the County Ambulance is not meeting the more stringent response times (due to the lack of ALS first responders) in Sunnyvale; however, this city is only a portion of a larger zone and the County Ambulance is meeting the response time standards set for the zone overall. Palo Alto Fire Department has retained its 201 legislative rights and is the exclusive ambulance service within its jurisdiction. In addition to seven ALS fire engines providing first response to medical calls, the city staffs three ambulances, two full time ALS and one part time BLS. Should Palo Alto need additional ambulances, it can request mutual aid from the County Ambulance. During fiscal year 2012, there were 607 mutual aid requests according to reports provided by SCCEMSA. Of the 5,500 EMS responses annually, roughly 4,200 (76 percent) are transported by ambulance to the hospital. Three of the fire departments have ambulances at their stations San Jose has five ambulances, there are three in Santa Clara, and one in Gilroy. The SCCEMSA policy allows these units to transport if the patient s condition is immediately life threatening or the ambulance provider response has not 32 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 54 of 157

55 arrived within 18 minutes and the patient requires emergency transport to the hospital. However, this transport option is significantly under utilized there was one transport during fiscal year Air Ambulance Providers There are two primary EMS helicopter providers serving Santa Clara County CALSTAR, based at St. Louise Hospital in Gilroy, and Stanford Life Flight, based at Stanford University Hospital. There are other providers based in surrounding counties who transport within Santa Clara County less often, Air Ambulance EMS Volume Year Responses Transports % Transported 57.3% 59.8% 60.3% 55.2% Source: SCCEMSA annual reports Figure 43 including REACH Air Medical Services. Figure 43 provides the volume of EMS responses and transports performed by all providers from For rural areas, an EMS helicopter is simultaneously dispatched with ground resources for significant calls, such as a traumatic injury or stroke; this is the standard in most EMS operations in order to expedite the patient s arrival at a trauma center or other appropriate specialty care hospital. Similar to other counties, the SCCEMSA performs retrospective quality improvement (QI) on all transports to ensure proper utilization of air resources. Advanced Life Support Interfacility Ambulance Providers A total of four non emergency ambulance providers offer ALS ambulance transports between healthcare facilities WestMed, ProTransport, Silicon Valley, and Rural/Metro. Some of these transports are coming from urgent care centers and one provider stated they are actively marketing ALS interfacility transports to these facilities instead of the system; a patient complaining of chest pain is an example of this marketing focus. Non emergency providers are also using ALS ambulances for BLS transport requests from skilled nursing facilities to EDs. Once on scene, the paramedics are upgrading some of these originally BLS requests to an ALS level of care. The volume of ALS interfacility transports not originating from a hospital is unclear, but two providers stated it was the majority of the ALS calls. There is a significant concern when patients with emergent issues are treated and transported outside of the system. These patients receive no immediate care from first responders, are not guaranteed the contracted ambulance response times, and are not subject to the same clinical review. Further, the contracted ambulance provider could claim that the ALS interfacility providers are performing transports that are within the contract. If the volume is significant, it could be negatively impacting the number of ambulances within the EMS system. Critical Care Transportation Interfacility Ambulance Providers There are seven interfacility ambulance providers offering nurse critical care transportation (CCT). Providers utilize either a dedicated CCT ambulance with a nurse and EMT or a BLS ambulance with a nurse who meets the ambulance at the sending hospital with the CCT supplies and equipment. Due to the widespread use of ALS interfacility in this community, the use of CCT is significantly less than other Bay Area counties. Two hospitals mentioned response time challenges when requesting CCT for emergency cases, such as a stroke patient needing a higher level of care. 33 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 55 of 157

56 Similar to ALS interfacility, the CCT volume is not being tracked and the true system demand is unknown. It would appear that there are enough providers, since the number of Bay Area CCT ambulances has increased steadily over the last 20 years (i.e., American Medical Response was the only CCT provider in 1992). If the issue is isolated to a couple hospitals, there may be a need to require response time standards in existing contracts or include contract language that allows hospitals to call other CCT providers when the contracted provider is unavailable to meet the required response time. Santa Clara County recently awarded an ambulance contract for its healthcare facility needs that is performance based with response time standards. If the lack of CCT services is more prevalent and affecting all of the hospitals, the SCCEMSA may want to consider franchising CCT services through a competitive process that requires defined response times and carries penalties when they are not met, similar to the ambulance service. Specialty Care The SCCEMSA has identified three areas of specialty care that are recognized by the SCCEMSA trauma, stroke, and cardiac care (see Figure 44). Through its policies, the SCCEMSA designates specialty receiving Analysis of Adjacent County Trauma Volume Current Santa Clara County trauma volume 6,666 Current trauma volume from Monterey, Santa Cruz, and San Benito counties Adult 495 Pediatric 57 Santa Clara County trauma volume without 6,114 adjacent counties Estimated change in trauma volume 8.3% Source: SCCEMSA report, data period: Jan 1 Oct 15, 2012 Figure 45 Hospital Specialty Center Volume Year Stroke Centers 2,642 2,221 2,528 3,072 Trauma Centers 7,619 7,300 7,461 7,329 STEMI Centers n/a Source: SCCEMSA annual reports Figure 44 hospitals and requires ambulance providers to transport patients only to these specialty centers when applicable. Each specialty has its own EMS QI committee that meets on a bimonthly or quarterly basis. In addition to the designated specialty care, there is a burn treatment center at the Santa Clara Valley Medical Center. There are three trauma centers in Santa Clara County Regional Medical Center of San Jose (Level II), Santa Clara Valley Medical Center (Level I), and Stanford University Hospital (Level I). The Level I trauma centers have been in place for over 25 years and the Level II trauma center was moved from San Jose Medical Center when it closed in 2005 to Regional Medical Center. All three centers have considerable experience and provide an excellent level of injury treatment. Monterey and Santa Cruz counties currently send trauma patients to these facilities, but are in the process of designating their own Level II and Level III centers, respectively. The SCCEMSA has calculated the current volume of trauma patients received from the counties to the south in order to assess the potential impact on the Santa Clara County trauma centers (see Figure 45). Based on The Abaris Group s experience, the impact will be less due to some of the pediatric trauma cases continuing to be transported to Santa Clara County s pediatric trauma center and some of the Santa Cruz County adult trauma patients needing a higher level of care than available at the proposed Level III trauma center in that county. 34 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 56 of 157

57 The stroke program formally began in Nine hospitals have achieved stroke center designation from the SCCEMSA. As a whole, the stroke specialty care program is meeting and exceeding the goal set by the American Heart Association to deliver thrombolytic within 60 minutes of hospital arrival at least 50 percent of the time. The stroke QI committee is continuing to investigate ways to provide definitive care even faster through best practice research and system improvements. The cardiac care committee is currently focused on ST elevated myocardial infarction (STEMI) patients. Started in 2008, eight hospitals have become designated receiving centers for STEMI patients. They are typically identified by the 12 lead EKG interpretation performed by the prehospital staff s heart monitor. Currently, paramedics are not able to activate the STEMI protocol manually. There are concerns about false activations, both by prehospital staff as well as incorrect interpretations by the heart monitors. One prehospital provider is sharing hospital disposition information to crews on 100 percent of its STEMI patients. Currently, the cardiac care committee only addresses STEMI patients and does not manage cardiac arrest cases, including the prehospital and hospital use of therapeutic hypothermia treatment. However, at the most recent cardiac care meeting, the committee discussed expanding its scope to include cardiac arrests and there was general consensus to do so. Public Education Beginning in 2013, SCCEMSA will launch a monthly, countywide community education program that is coordinated with County Ambulance, first responders, other ambulance providers, hospitals, and county public health staff. For example, drowning will be one of the monthly topics during EMS providers will receive continuing education first followed by coordinated public outreach by ambulance providers, fire departments, hospitals, and public health. Another potential program could be CPR training. Other communities, such as Seattle (WA) and Boston (MA), have implemented community bystander CPR programs that have increased out of hospital cardiac arrest survival rates to 40 percent or better. The SCCEMSA and designated hospital stroke centers developed a shared stroke awareness campaign called, Strokebusters. A subcommittee of the stroke care system quality improvement committee created the program and markets it as a unified message during stroke awareness month and other opportunities during the year. There are system committees for trauma and cardiac care, but there is no agreed upon specialty care educational campaign. Designated trauma centers and cardiac care hospitals each identify opportunities, develop educational programs, and implement with no coordination or synergies between facilities. Disaster Preparedness Through state and federal grant funding, Santa Clara County has purchased a significant number of resources, including 13 disaster trailers (9 field treatment site/multi casualty incident (MCI), 1 special operations, 1 cabana/command, 1 cabana tender, and 1 personal protective equipment/medical volunteer disaster response (MVDR)), 2 disaster medical support units (DMSU), and an equipment and 35 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 57 of 157

58 supply truck provided by the County Ambulance. The county EMS and Public Health staff has established a number of disaster preparedness and public health plans. The MVDR (known as medical reserve corps in most counties) program has a part time coordinator who manages over 500 active members with roughly 100 immediately available based on prior exercise activations. This level of response is significantly greater than most MRC programs. A second, part time coordinator works exclusively with allied healthcare facilities to develop their ability to be self sustaining during a disaster. It is understood that other EMS agencies in the Bay Area consider Santa Clara County one of the more prepared counties in the region. Representatives from fire departments, ambulance services, and county staff attend a quarterly EMS command and control quality improvement committee meeting, which offers continuing education hours based on incident reviews. The SCCEMSA is also in the process of updating its medical response system field operations guide with input from the system stakeholders. This guide provides direction to EMS leadership on day to day and disaster management of the EMS system. The EMS system has also established a process to mobilize an ambulance strike team (i.e., five ambulances and a supervisor) within eight minutes for local needs or mutual aid requests. A second, planned need strike team can be assembled within 60 minutes. The DMSU can be deployed within 12 minutes as well. An example of when some of these resources are activated is an Alert II L response for aircrafts enroute to San Jose Airport and in distress. The Abaris Group is not aware of any other California EMS system that has the capacity to mobilize resources so quickly. The next stage of development for the disaster preparedness capabilities is the continued training, testing, and exercising of the different plans with stakeholders including Public Health. Initial focus should be on the most likely disasters as identified by a Hazard Vulnerability Analysis (HVA) for Santa Clara County (healthcare facilities are required to complete an HVA annually and may be useful for Public Health disaster planning). However, training should not be limited to just the top three to five hazards; less likely disaster scenarios should be included as well. Through the exercising of plans, staff will better understand assignments, gaps will be identified, and current planning will improve. Santa Clara County has significant disaster resources; continued exercising will test if there are mechanisms in place to mobilize them as needed and how to do so most effectively during an event. All of the disaster supplies, equipment, and vehicles were purchased through a number of different grants, each with its own priorities and requirements. Grant funding should be utilized to support a predetermined, cohesive vision for the overall county disaster planning strategy. In addition, the long term sustainability of grant purchases, such as maintenance, storage, and replacement, should be considered as part of the overall strategy when requesting items through grants. The command and control committee meeting is well attended by emergency and non emergency ambulance providers, ambulance supervisors, and SCCEMSA staff. Typically, the first responders staff the position of medical group supervisor during an MCI, one of the most critical EMS roles in ICS. Their involvement with the committee is crucial for effective MCI planning. 36 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 58 of 157

59 Data Management Project Overview One of the critical components of a high performance EMS system is a comprehensive, integrated data management system. A well designed data system should provide the platform for the following functions, at a minimum: Electronic patient care reporting, from dispatch to hospital discharge Patient billing through electronic integration with various payer sources, i.e. Medicare, Medicaid, third party payers Data integration between multiple providers with often disparate systems Data extraction/data mining for routine performance reports as well as continuous quality improvement (CQI) related activities, trending CQI activities should, in turn, drive education and training, policy and procedural revision/development, and related system improvements Recognizing the need for an assessment of its current data system capabilities and future improvements, the SCCEMSA retained webreach (January, 2009) to assist in the assessment of the then current data system and provide a comprehensive set of recommendations for system development and improvement. 24 Figure 46 identifies the system requirements analysis process conducted as part of this project. 25 Figure 46 A Data Project Steering Committee was established, made up of key county, service provider, and webreach staff, to provide project oversight and vetting of specific recommendations. A comprehensive system assessment was conducted with all system participants to inventory the hardware, software, and operating systems of the various provider agencies and organizations. An important element of the inventory assessment was to determine to what extent current data systems in Santa Clara County could be leveraged to improve upon data collection, storage, exchange, and reporting of data. From this inventory and the proposed system design activities, a set of five broad recommendations for new system architecture and operations were put forward for the county s consideration: Development of a SCCEMSA central data repository Ensure that all provider organizations have access to a web based advanced analytics/business intelligence to allow for querying, data extractions/mining, reporting, etc. Include a data integration bridge component to the architecture design Implement a countywide epcr system 24 For a detailed report of the project activities and recommendations, see the Final Report for the SCCEMS System Data Assessment Project 25 From the Final Report for the SCCEMS System Data Assessment Project 37 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 59 of 157

60 Establish industry standard security & system administration In addition to the structural recommendations, above, the project team also made several recommendations regarding policy and implementation strategies: Establish a data committee to review all National Emergency Medical Services Information System (NEMSIS) inclusive data elements and policies to address potential data needs and adaptations of business partners and stakeholders Establish, review, and update a countywide data dictionary (i.e., data elements) based on NEMSIS+ (includes NEMSIS, California EMS information system, and Santa Clara County data elements), that ensures ongoing data dictionary change management and communication of changes. Develop policy to establish that EMS provider and business partner data systems comply with current county EMS data dictionary (NEMSIS+) Develop policy to establish minimum data exchange rules for all disparate applications/data systems describing how, when, and where to export NEMSIS+ data into county EMS system data repository Establish (electronic) mechanism for timely notifications by SCCEMSA to keep EMS providers and business partners apprised of data policy changes and compliance requirements Develop a policy for all disparate systems to maintain NEMSIS+ versioning compliance with current NEMSIS revisions and vendor testing The current status of the EMSA data project is as follows: Development of a SCCEMSA central data repository: A request for proposals (RFP) for an application service provider (ASP) solution is currently in draft form. The project must be cleared by SCC information technology governance and then move forward to procurement. The SCCEMSA projects the RFP release by 4 th quarter Ensure that all provider organizations have access to a web based advanced analytics/business intelligence to allow for querying, data extractions/mining, reporting, etc: This element has been incorporated into the above referenced RFP. The provider agencies will all have access to their data including a report generating tool with analytic capabilities. Include a data integration bridge component to the architecture design: As in Figure 47, below, the data integration bridge has been included as a required element of the aforementioned RFP. Implement a countywide epcr system: Currently the all of the fire agencies are being brought up on ImageTrend epcr system. The other private agencies will have a choice to either go with the free epcr solution provided in the data RFP, or provide data integration, through the bridge, to get their data to the county EMS data warehouse. Several fire agencies are currently online with the epcr program (e.g., San Jose, County Fire, Milpitas, and Mountain View). Sunnyvale is in process of implementation. Establish industry standard security & system administration: The ASP solution will meet security standards as set forth by federal and state privacy laws, ensuring HIPAA compliance and overall system security. There still prevails a predominant sentiment of EMS system stakeholders on access to global EMS data for special studies. In particular, the specialty group committees (i.e., trauma, stroke and STEMI) indicated a strong desire to see global specialty data for the county for special studies and potential 38 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 60 of 157

61 research projects. It is expected that the SCCEMSA may be able to improve access to this data with this new data project. Figure 47 is a graphic representation of the anticipated architecture and process for the new Santa Clara EMS data system. As noted, it was updated by the SCCEMSA in July Figure Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 61 of 157

62 Communications System Overview Santa Clara County Communications (SCCC) is an independent, multi disciplined public safety answering point (PSAP) providing call taking and radio dispatching for the county and several cities within the county. The SCCC provides law enforcement, fire, and emergency medical services (EMS) communication services, including ambulance dispatching services for the County Ambulance. The center received 135,579 calls through the system in The SCCC building was constructed in The approximate annual budget is $19 million funded by the Santa Clara County general fund, $1.5 million from the County Ambulance contract that includes an annual cost of living adjustment, and some grants. A funding formula is used to allocate costs back to the users of the SCCC. This formula consists of a combination of activity levels and types of events that are rated on a scale of 1 to 12 with 12 being the top rated event. Fifty percent of the budget is provided by the Santa Clara County Fire Department. The SCCC has 112 full time employee positions but only 107 full time positions are currently funded. The employees are represented by three separate bargaining groups. There are five scheduled shifts based on ten hour work days that overlap. Dispatchers are trained in all disciplines law enforcement, fire, and EMS. There are three levels of dispatchers Level I, II, and III; Level II and III dispatchers are emergency medical dispatch (EMD) certified. Staffing for dispatch operations consists of six positions primary call taker, law enforcement dispatcher, fire dispatcher and three EMS dispatchers. The dispatchers are interchangeable and provide backup to each position based on call volume needs. There is a County Ambulance employee that is assigned to the SCCC as a System Status Coordinator (SSC) who primarily provides assistance and coordination of ambulance personnel. Oversight of the SCCC is the responsibility of the County Communications Director with assistance from the Assistant Communications Director. The Communications Director reports to a deputy county executive. There are three primary divisions administration, dispatch operations, and engineering and technical services. The Computer Aided Dispatch (CAD) system for SCCC is an in house designed system with technical support provided by SCCC s Engineering and Technical Service Division. This division also provides support for the system s radio system which includes VHF, UHF, and 800 MHz radio channels. The National Academies of Emergency Dispatch (NAED) has officially recognized SCCC since January 2002 as an Accredited Center of Excellence in Emergency Medical Dispatching. They were the first county in California to receive the NAED Center of Excellence designation and 11 th county to receive this 40 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 62 of 157

63 designation nationally. The San Jose Fire Department Dispatch Center is also an Accredited Center of Excellence as designated by the NAED /Public Safety Answering Points In addition to the Santa Clara County PSAP, there are 11 other primary PSAPs within the Santa Clara County. The SCCC serves as a secondary PSAP for most of these primary PSAPs. Figure 48 provides an overview of the primary and secondary PSAPs in Santa Clara County. Location Primary PSAP Secondary PSAP Ambulance Dispatch EMD Services Campbell Campbell PD SCCC SCCC SCCC Cupertino SCCC SCCC SCCC SCCC Gilroy Gilroy PD Gilroy FD SCCC SCCC Los Altos Los Altos PD SCCC SCCC SCCC Los Altos Hills SCCC SCCC SCCC SCCC Los Gatos* Los Gatos PD SCCC SCCC SCCC Milpitas Milpitas PD Milpitas FD SCCC SCCC Monte Sereno* Los Gatos PD SCCC SCCC SCCC Morgan Hill Morgan Hill PD SCCC SCCC SCCC Mountain View Mountain View PD Mountain View FD SCCC Mountain View FD Palo Alto Palo Alto PD Palo Alto FD Palo Alto FD Palo Alto FD San Jose** San Jose PD San Jose FD SCCC SJFD/SCCC 30/70% Santa Clara Santa Clara PD Santa Clara FD SCCC Santa Clara FD Saratoga SCCC SCCC SCCC SCCC Sunnyvale Sunnyvale DPS Sunnyvale DPS SCCC Sunnyvale DPS Notes: *Combined communication centers, ** SJFD provides approximately 30% and SCCC 70 % of EMD Source: SCCC Figure 48 Coordination between the PSAPs and requests for ambulances are primarily through phone lines with the exception of the City of San Jose and California Department of Forestry and Fire Protection (CAL FIRE) that have a two way electronic interface with the SCCC CAD and the City of Sunnyvale that has a one way interface where they can send information to the SCCC CAD. The inability for data sharing between the communication centers results in the need for telephone contact between the dispatchers and re entry of incident data. In some cases, this increases response times because of call processing. Through the Silicon Valley Regional Interoperability Authority, there is a countywide, CAD to CAD project underway to link the CAD systems in Santa Clara County together. Call data will be shared electronically and decrease the current processing time necessary to dispatch an ambulance. The CADto CAD project will provide connectivity between disparate CAD systems by utilizing a data broker concept. This project is scheduled for 2012 implementation and will use EComm for data transport. The core data broker tool will serve as a platform for other future data sharing initiatives. This project has 41 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 63 of 157

64 evolved to include other data that can be shared as well as a standardized records management component. Computer Aided Dispatch System The current CAD system used by the SCCC is an in house system designed by SCCC engineers and technicians. The CAD system has been in use for many years and is upgraded as needed by in house staff. The advantages over a vendor provided CAD system are upgrades and changes to the CAD programs can be made in a timely manner and at less cost than through an outside vendor. Many CAD vendors will not make program changes unless they are requested by a majority of its users and there will be additional costs involved. The CAD system is comparable to other systems available in the communications industry. The primary limitation of the current CAD system is that the geographical system used by the CAD system is based on cross streets and not a comprehensive geographical information system (GIS) which uses longitude and latitude coordinates. In addition, the mobile area routing and vehicle location information system (MARVLIS) used by the County Ambulance is integrated with the CAD system and recommends the closest ambulances to the dispatcher. Because the CAD system uses cross street instead of longitude and latitude, there is some inaccuracy in the response time estimates provided by MARVLIS. The SCCC will be interfacing a GIS program with the CAD system in the future which will enhance this feature in MARVLIS. While there is general consensus that the current CAD is functional, Santa Clara County EMS Agency (SCCEMSA) and County Ambulance staff expressed concerns that the CAD uses an older operating system and there is difficulty integrating new technologies. There is SCCC staff interest in exploring the possibility of a vendor CAD that may meet the system s current needs better. There is also specific information related to lost unit hours that the County Ambulance contractor cannot access from the reports provided by the current CAD. Radio System There are four different radio bands and frequencies used by fire departments in Santa Clara County. The SCCC and County Ambulance utilize an 800 MHz radio system for communication. Figure 49 provides an overview of four different bands and frequencies used by the fire departments in Santa Clara County. While the ability to communicate between firefighters and County Ambulance crews exists under the current radio system, they may only utilize tactical or mutual aid channels, which are typically used during major events, not day to day operations. Only field supervisors and EMS Duty Chiefs are permitted to communicate with the firefighters on dispatch or control channels. The Silicon Valley Regional Communications System (SVRCS) is planning to replace existing public safety radio systems with a countywide digital radio infrastructure in the newly allocated 700MHz band. Using 42 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 64 of 157

65 EComm for connecting dispatch centers with radio sites, SVRCS will be designed to provide radio coverage as good as or better than that provided by the current mosaic of radio systems along with new features such as global positioning system (GPS) location and unit status. SVRCS is a major project with an estimated cost of $100 million. While the roll out of the complete system waits adequate funding, an effort to implement the first stage of the system which would serve two cities is being investigated. The SCCEMSA staff commented during the interview process that it was not part of the communications system development process. As one of the primary users of the radio system, it would be typical to include SCCEMSA as a stakeholder in the process. Band and Frequency Fire Department VHF: MHz Santa Clara County FD; Gilroy FD; Palo Alto FD; Mountain View FD; San Jose FD UHF: MHz Milpitas FD UHF (T Band): MHz Sunnyvale Department of Public Safety 800 MHz Santa Clara FD Source: SCCC Figure 49 Medical Priority Dispatch System The SCCC uses the medical priority dispatch system (MPDS) software for pre arrival medical instructions, to determine the appropriate response mode (e.g., lights and siren) and the amount of resources to send. The SCCC is upgrading the software to ProQA Paramount, the latest version of the MPDS software, which was provided by the SCCEMSA. The SCCC adheres to the NAED standards, code of conduct, and code of ethics. There is a quality assurance (QA) program to ensure that dispatchers are accurately following the EMD protocols. One of the staff members is designated as the EMD Coordinator and reviews a percentage of EMD calls and scores them according to the QA guidelines provided by the NAED. The Aqua QA software is used to assist in the quality improvement process. In addition to the in house QA program, there are two committees that meet on a quarterly basis. There is a medical dispatch review committee and a medical dispatch steering committee; both have representation from the County Ambulance as well as the EMS Medical Director. The field feedback program is not used. There is an informal program for first responder and ambulance personnel to observe the dispatch process. The SCCC provides EMD services through a contract with ten cities; the other five cities provide EMD internally (see Figure 48 on page 41). There is some local minor variation in the dispatch determinants used by the various organizations but all of them are in compliance with the Santa Clara County EMS policy addressing the provision of EMD. Because of the time to process EMS calls with the MPDS, the fire departments of San Jose, Santa Clara County, Mountain View, CAL Fire, Palo Alto and Sunnyvale have implemented a policy that dispatches the closest first responder vehicle to an EMS incident with redlights and siren and, if the call is determined to not require an emergency response, the dispatcher will notify the responding agency to discontinue the use of lights and siren. The SCCC does not use the MPDS 43 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 65 of 157

66 Omega protocol which identifies calls needing basic life support (BLS) response only. It was also observed that the San Jose Fire Department Dispatch Center did not utilize the MPDS screening process on a number of calls for a variety of reasons, including the incident was a police matter and the caller not being transferred to the fire dispatchers and because of a significant fire or other emergency incident resulting in the fire dispatchers not having time to use the MPDS system. Further, the dispatch system currently sends first responders to calls at healthcare facilities with medical personnel on site (e.g., skilled nursing facilities, medical office buildings) regardless of the patient acuity. SCCEMSA and County Ambulance staff stated that the MPDS program at the SCCC meets the requirements of the NAED, although there are concerns regarding crew safety with the number of calls that are un triaged from San Jose Fire Department Dispatch Center. Staff also mentioned a significant number of responses are labeled as sick person. This general category does not fully capture the possible patient needs, which can impact resources dispatched and the ability to bill for advanced life support (ALS) ambulance services. Federal law allows an ambulance provider to bill for ALS service if the nature of the emergency requires ALS, even if the paramedic does not provide it. This can be the case with someone having chest pain and the paramedic determines the pain to be muscular skeletal in nature and no ALS interventions are performed. It should be noted that although each of the Communications Centers that provide MPDS have an internal quality improvement (QI) process, there is no Countywide QI process of the MPDS system. Figure 50 provides an overview of the EMD presumptive problem assignments of calls for this time period. No medical priority dispatch system (MPDS) determinants are used by the City of Palo Alto, so their dispatch data is not included. Medical Dispatch Presumptive Problem Presumptive Problem Total % of Total Delta Determinant Call 19, % Sick Person 10, % Fall Victim 8, % Difficulty Breathing 7, % Unknown 7, % Unconscious Person 6, % Chest Pains 5, % Accident With Injuries 4, % Seizure 3, % Transfer/Interfacility/Palliative Care 3, % Abdominal Pain/Problems 2, % Trauma 2, % Hemorrhage/Laceration 2, % Stroke (CVA) 1, % Not Breathing/Ineffective Breathing 1, % Diabetic Problems 1, % Person Down 1, % Heart Problems 1, % Unknown Problem 1, % Back Pain % Headache % Allergic/Sting/Med Reaction % Psych % Assault % Overdose % Bravo Determinant Call % Choking % Charlie Determinant Call % Other Problem 3, % Total 101, % Source: Rural/Metro, July 2011 June 2012 Figure Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 66 of 157

67 Medical Priority Dispatch System Original Codes New "Clinical Model" Codes Code Severity Resources Response Letter Severity Resources Response Non Life Alpha Basic Life Support Non Emergency Threatening Immediatly Life Advanced Life Red 1 Emergency Possibly Life Threatening Support Bravo Basic Life Support Emergency Threatening Advanced Life Possibly Life Advanced Life Charlie Life Threatening Emergency Red 2 Emergency Support Threatening Support Delta Echo Omega Serious Life Threat Life Status Questionable Public Assist Only Advanced Life Support Emergency Green 1 Serious but NOT Life Threatening Closest Available Serious but (Multiple Resources Emergency Green 2 NOT Life Sent) Threatening Basic Life Support Non Emergency Green 3 Source: NAED Planned Clinical Telephone Assessment Face to face clinical assessment within 30 minutes Emergency Face to face clinical assessment within Non Emergency 30 minutes (Urgent) Planned clinical telephone assessment, call back within 10 minutes Non Emergency Figure 51 The Abaris Group identified the frequent use of determinant codes for by the dispatch system, e.g., Delta, Charlie, Bravo. While these codes are still in use in most systems, The Abaris Group is noticing a trend towards the incorporation of the new MPDS Clinical Model determinant codes (see Figure 51). These new protocols facilitate the incorporation of new and innovative dispatch and response alternatives for systems looking to include such activities as treat and release, treat and refer, alternate transport options, community paramedic activities, as well as referrals to doctor or clinic appointments. Mobile Area Routing and Vehicle Location Information System MARVLIS is a recent addition to the SCCC and is a result of the new ambulance agreement with the County Ambulance. This GIS based system uses GPS satellite technology that identifies the location of emergency response resources on a separate computer monitor in the SCCC. The MARVLIS software can also be used to predict demand and has several features that can enhance resource deployment to incidents. There are two issues with MARVLIS, first the recommended units feature is not as accurate as it could be because of the CAD systems use of cross street instead of longitude and latitude and, secondly, there are two versions of the software currently in use. The newest version is displayed on two large monitors near the dispatch consoles and the older version is in each EMS dispatcher s work station monitor. According to the SCCC administration, the issue is based on licensing of the software. They expressed the need for one version of the software and that additional software licenses are needed. SCCEMSA and County Ambulance representatives stated that the MARVLIS newer version uses ARC GIS technology and the cost per license is significantly higher. SCCEMSA staff shared that 10 new licenses are being ordered following a new county system that promotes purchasing through the agency or company that can buy items at the lowest cost, regardless of who is actually paying for them. There are additional benefits through the newer version of MARVLIS but, because the current CAD system is not using longitude and latitude geographical coordinates, these features are not available. The mobile computer 45 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 67 of 157

68 terminals in the ambulances also have access to MARVLIS as well as the field supervisors and SCCEMSA. MARVLIS can also provide ambulances post recommendations, but it still requires input from the dispatcher or SSC because of certain deployment rules related to 12 or 24 hour ambulance crew shifts. System Status Coordinator County Ambulance recently created the SCC position to ensure that its deployment plan is effectively implemented at the SCCC as well as ensure that the County Ambulance provider s business practices and rules are followed. In addition to optimizing the deployment plan, the SSC takes phone calls from ambulance crews related to meal breaks, ensures crews get relieved on time, and manages special requests. This information is relayed to the dispatchers as needed. The SSC also recommends the movement of ambulance crews to specific posts for optimal coverage. The SSC does not have access to the CAD system and looks at one of the dispatcher s monitors or ask for information related to specific calls. The SSC can offer ambulance response suggestions but the dispatcher makes the final decision. The SCCC dispatchers can consult the SSC when there are questions regarding which ambulance to dispatch. In addition, the SCC is in communications with ambulance crew members via cell phone and is able to address special needs or concerns without the ambulance crews tying up dispatch phone lines or radio channels for non emergency communications. The position has been well received by the dispatch staff and has reduced some of the dispatch workload related to ambulance deployment and nonemergency communications from ambulance personnel. The responsibilities and duties of the SSC are still being defined by the County Ambulance contractor management team. Staffing and Personnel The staffing in the SCCC at times is reduced because of vacant positions and the inability to require mandatory overtime of staff when the dispatch center is understaffed. During an observation period, The Abaris Group noticed that only two of the three EMS dispatch positions were filled. Concerns were raised by SCCEMSA staff regarding the requirement for dispatchers to be proficient in all three disciplines, possibly negatively impacting the dispatchers proficiency in each role. One of the challenges to hiring staff is that new dispatch employees are subject to a law enforcement background check that may limit the number of potential employees that could be hired as EMDs. In addition, changing from a police dispatcher to a fire/ems dispatcher requires personnel to receive specific training for each discipline. Although there are no national standards for minimum staffing levels in emergency communications centers, there have been several articles and research papers related to the impact of understaffed communications centers. One of the biggest concerns is the potential for dispatcher burnout and morale problems related to higher workloads and overtime. The SCCC has an in house training program for new dispatch employees that is police officer standard training (POST) certified and a POST certified continuing education program. In addition, the use of the NAED curriculum for MPDS initial certification and recertification is followed. Representatives from the 46 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 68 of 157

69 SCCC stated that training is also provided on SCEMSA policies and procedures as well as the policies and procedures of the County Ambulance provider. EMS Agency Coordination The SCCC and SCCEMSA have each assigned a primary contact as liaisons. Because of additional job duties the SCCC dispatch supervisor has not been as active in the role of liaison to the SCCEMSA as desired. In general, the administration of the SCCC has a stable working relationship with the SCCEMSA and communication between the two agencies is good. The SCCC administration complimented the SCCEMSA for always looking towards the future with the goal of enhancing and improving the EMS system as well as the associated impact on the SCCC. The SCCC appreciates being included proactively on planned system improvements, especially when they involve dispatch. The SCCC EMS dispatch center is working well but could improve with the updating of CAD software, with appropriate use of currently available technology, MARVLIS, and EMResource. The EMS dispatch component is currently understaffed and, on occasion, there are only two dispatchers on duty instead of the three typically scheduled. The employees are appropriately trained, follow the MPDS system and appear to be highly competent. EMS Consolidated Dispatch There are 12 different portals for a public member to enter the system due to the number of decentralized communications centers in Santa Clara County. These 12 centers will transfer the caller to one of another eight centers for fire department first responder dispatch. Lastly, most of the fire department dispatch centers manually call the ambulance dispatch center and verbally relay the call information previously captured. In addition, there are six separate dispatch centers that provide EMD pre arrival instructions following different protocols and policies. A consolidated center would decrease response times, provide simultaneous dispatch of first responder and ambulance resources, and allow for better quality control and staff training. Many of these findings were supported by the Santa Clara County Grand Jury Report of The 2011 Santa Clara County Civil Grand Jury expressed concerns in the manner that emergency personnel and equipment were being dispatched after a call. The Grand Jury found that basic dispatching functions were being duplicated among different agencies, wasting resources. The Grand Jury became concerned the duplication of dispatching may cause delayed or inadequate response. They also found that in areas where 911 calls first go to a local dispatch before being transferred to SCCC, delays response anywhere from 20 seconds to 3 minutes or more, depending on the state of the local agency s communications equipment. It was also discovered that regional radio communications equipment was not in place; meaning local jurisdictions cannot easily communicate with each other, 26 May 19, 2011 Santa Clara County Civil Grand Jury Report Can You Hear Me Now Emergency Dispatch in Santa Clara County 47 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 69 of 157

70 local agents cannot communicate with their home area when the agent is out of range, and the entire network of county emergency responders cannot easily communicate in the event of a regional need. The Grand Jury found that SCCC was already responsible for more fire dispatching than any other dispatch center, and was responsible for all ambulance dispatching, so they asked interviewees the question: Given that there is duplication in the dispatching function, why maintain a local center? The Grand Jury found that municipalities were clinging to local control which the Grand Jury believes the system cannot afford, especially when SCCC could offer a capable and more technologically advanced alternative compared to the outdated equipment used in some municipalities. The key Grand Jury findings were: Finding 1: Dispatch consolidation would result in more cost effective and efficient emergency response and should be implemented throughout Santa Clara County. Finding 2: Radio equipment has not been standardized and impedes effective countywide communication and emergency dispatch. The 2011 Santa Clara Grand Jury Report on EMS dispatch mimics the observations and concerns raised by The Abaris Group s own findings on EMS dispatch in the county. 48 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 70 of 157

71 Clinical Care and Continuous Quality Improvement Clinical Care Specialty Care Within Santa Clara County, there are three types of specialty care designated by Santa Clara County EMS Agency (SCCEMSA) trauma, stroke, and ST elevated myocardial infarction (STEMI). All three programs are well seasoned, provide excellent care, and often exceed national benchmark standards in their respective care arenas. The SCCEMSA has established protocols and contracts to identify designated receiving centers for each specialty. Each receiving center shares outcome data that is blinded by the county and distributed during committee meetings. This information is reviewed and committee members discuss ways to further improve patient outcomes. There are further specialty care opportunities that could benefit emergency medical services (EMS) patients. Examples include reviewing the incorrect activation/triage of patients, conducting research with the blinded data, publishing and sharing outcomes with other systems, and collaborating on joint prevention programs and community outreach messages. There is another opportunity to develop a cardiac arrest program separately or in conjunction with an existing specialty care committee to review therapeutic hypothermia and other protocols recently put in place. Protocols and Innovation The current clinical protocols are overseen by the SCCEMSA Medical Director, which is a part time position staffed by an emergency medicine physician. Protocols are updated once a year and the last significant overhaul was in The SCCEMSA is currently in a two year process of developing algorithm based protocols to be released in Paramedics have access to the protocols through a smartphone application developed by a local paramedic. This level of access is a best practice and this application has been expanded for use by other EMS systems and private providers to ensure field providers always have the latest protocols. During the review process, it was mentioned that protocols are not being updated as continually as other EMS systems. The 2010 American Heart Association guidelines for cardiac care have yet to be implemented and hypothermic resuscitation is still within the implementation period. Other EMS systems are testing and/or implementing behavioral health medications for the prehospital providers. Interviewees had unwavering support for the current medical director and identified him as an innovator who is truly committed to EMS, but it was unclear why protocol development and clinical system changes were not occurring at a faster rate. There also does not appear to be any research or clinical trial projects occurring in the county. With the high caliber of innovation and education available locally, there may be excellent opportunities to improve patient care. 49 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 71 of 157

72 Clinical Data and Trending County Ambulance uses ImageTrend software to manage electronic PCR data review and flag certain high risk or infrequently used skills (e.g., intubation, drowning, cardiac arrest, trauma, stroke, STEMI). It also tracks 226 different validation points; County Ambulance paramedics have attained a high rate of compliance. These electronic PCRs are reviewed by the clinical coordinators and follow up is provided by the field supervisors as quickly as possible; typically, this is 25 percent during the same shift. Calls requiring remediation or other steps are referred to the clinical manager, clinical medical advisor, or other managers as necessary. The ImageTrend platform is being offered to first responders and existing non emergency ambulance companies; however, providers have the option of using their own epcr systems as long as they will interface with the county s database. ImageTrend offers the ability to identify individual calls for quality assurance review. The real time approach to quality improvement (QI) is considered a best practice, even if the provider is only achieving 25 percent currently. Completing the electronic PCR before leaving the hospital could significantly increase this success rate. However, the software fails to provide any trending or other mechanism to quantify success rates for procedures, medication compliance, and other clinical performance indicators. This information is invaluable for proactively identifying system wide training, educational opportunities, and QI. The software also does not offer conditional fields to ensure specific questions are answered for specialty care, such as the onset time for stroke symptoms or Glasgow coma scale for traumatic head injuries. With the current migration of other system stakeholders to ImageTrend, the problem will only expand to include first responders and other transport providers. EMS Committees The Santa Clara County EMS system maintains nine committees which are staffed by a combination of system participants, SCCEMSA staff, and public representatives, where appropriate. This is a large array of committees requiring considerable County resources and staff to maintain. There is also much overlap between these committees and the potential for missing communication between these committees. Most of these committees are either directly or indirectly involved in some aspect of EMS system review and related quality assurance/qi activities. The structure for the different SCCEMSA committee includes: 27 Emergency Medical Services Committee The Emergency Medical Services Committee is comprised of a diverse cadre of representation, from all provider levels, to afford the SCCEMSA and the Health Advisory Commission with community and stakeholder based input that fosters enhancement of the EMS system. Medical Control Advisory Committee The Medical Control Advisory Committee serves as an advisory body to the SCCEMSA Medical Director. This stakeholder group is comprised of provider medical advisors, ED physicians and nurses, field providers, administrative officers, emergency medical techinicans (EMTs), paramedics, and other physicians and nurses Meetings.aspx 50 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 72 of 157

73 Prehospital Providers Advisory Committee Designed for all stakeholders to provide input in the area of EMS field operations, policy review, education, and multi patient management operations. Cardiac Care System Quality Improvement Committee This is a multidisciplinary committee comprised of various system stakeholders. Major responsibilities include cardiac system performance review and providing recommendations to the SCCEMSA. Stroke Care System Quality Improvement Committee This committee is a multidisciplinary committee comprised of various system stakeholders. Major responsibilities include stroke system performance review and providing recommendations to the SCCEMSA. Trauma Care System Quality Improvement Committee This committee is a multidisciplinary committee comprised of various system stakeholders. Major responsibilities include trauma system performance review and providing recommendations to the SCCEMSA. Prehospital Care System Quality Improvement Committee This multidisciplinary committee is comprised of various system stakeholders. Major responsibilities include prehospital performance improvement review and providing recommendations to the SCCEMSA. EMS Air Resource Utilization Quality Improvement Committee Designed to review the operational aspects of EMS air resources use. Clinical issues and review are routed to appropriate committees. EMS Command and Control Quality Improvement Committee Designed for EMS field managers and supervisors. This quality improvement review addresses the operational aspects of EMS response including incident review, planning for events, emergency preparedness/disaster medical services, and provider agency operational reports. Continuous Quality Improvement Background The concept of continuous quality improvement (CQI) traces its roots back to W. Edwards Deming, considered by most as the father of CQI. His substantial work in Japan with the auto industry following World War II is legendary. Unfortunately, most of the activities in CQI has been focused on the manufacturing of products, not the delivery of services. Only in the last years has there been a concerted effort to move the products based CQI process into the service delivery arena. Nonetheless, healthcare has fully imbraced the concept of CQI and proving the value of an organization s services is a cornerstone of Health Reform. Opportunities for Santa Clara County One model CQI program that embraces all elements of a contemporary system wide CQI process in the program in Contra Costa County. Its key elements include: Establish CQI committee While there exists an extensive network of committees reviewing and reporting on the quality of care being provided at various phases of the patient care experience within the system, there is no overarching body responsible for putting all of this information together in a comprehensive picture of the patient experience. The SCCEMSA should establish a CQI committee with responsibility for oversight and coordination of all CQI activities within the system. It should be chaired by the SCCEMSA Medical Director and staffed by the SCCEMSA QI Coordinator. 51 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 73 of 157

74 This method leads to a formalized CQI process for any EMS issue with trending, quantifying, and identification of concerns for training opportunities (e.g., under/over trauma triage, false STEMI activations, medication errors). A coordinated approach may also improve participation of EMS system stakeholders. For example, there is minimal EMS provider involvement at specialty care and prehospital care system meetings and a lack of first responders at the command and control meetings. Identify an SCCEMSA CQI champion The SCCEMSA must establish a quality champion within the agency structure. This individual should be qualified by education and experience in the CQI principles, practice, and processes as well as not being burdened with additional job responsibilities that conflict with the CQI role. This individual must be a facilitator, coaxing and encouraging the EMS system participants through leadership and enthusiasm, not through mandates. To ensure a clear, consistent message and direction for the program, this position should be a direct report to the SCCEMSA Director and coordinate activities with the SCCEMSA Medical Director. Develop CQI data integration Critical to the future success of the CQI program is the data management project currently underway. As described previously, quality data is the cornerstone of any CQI program. The SCCEMSA should focus particular attention to the data integration bridge component of the application service provider solution that is selected through the upcoming request for proposals process. The ability to link all of the patient s encounters into a complete record of that patient s experience will help ensure that the Santa Clara County CQI Program is a true best practice in quality care. Consider a Just Culture approach to quality review initiatives The National Association of EMTs has announced that they are encouraging all EMS agencies to adopt a just culture approach to system quality improvement. 28 The term just culture refers to a value system of shared responsibilityin which health care organizations are accountable for responding to their staff performance in a fair and just manner. The staff are likewise them responsible for their choices and for reporting both their errors and system vulnerabilities. Thus a system where blame is not the first reaction to an error but rather these events are likely breakdowns to a system failure. The just cause environoment breaks behavours down to three types of errors: human error at risk behaviour reckless behavior These categories help create a framework for consistency among evaluators and instills a sense of confidence and accoutability for the invididuals involved /Board_Adopts_New_Position_Statement_on_Just_Culture_in_EMS.aspx?ReturnURL=%2Fdefault.aspx Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 74 of 157

75 Summary of Current QI The SCCEMSA has an established QI plan, as required by California Code of Regulations, Title 22, Chapter 12, et seq. It defines the system participants, expectations, policies and procedures of the SCCEMSA and key performance indicators. The plan describes what the providers will be expected to submit to the SCCEMSA, the frequency of that collection, and the SCCEMSA staff reviewing those submissions. The plan also describes the feedback that will be provided back to the system participants. Some of the committees offer continuing education credits for prehospital and hospital providers as an inducement to attend these QI meetings. 53 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 75 of 157

76 Industry Trends and Best Practices Overview The Abaris Group researched current industry trends and best practices in emergency medical services (EMS) in support of the upcoming strategic planning process for Santa Clara County EMS system. Research consisted of searches for best practices and trends, reviewing current EMS magazine and journal articles, as well as interviewing EMS providers and public agencies. Four categories of best practices and trends in EMS were identified in the EMS systems listed in Figure 52. The EMS trends and best practices identified in this report may be of interest to the county as part of the future strategic planning sessions. Location/Program Dispatch Triage & Awareness Alternate Transportation & Destination High System User Diversion Primary & Mobile Healthcare Alameda County, California 1 Fort Worth, Texas Houston, Texas Lake County, Florida Las Vegas, Nevada Liberty County, Texas Mesa, Arizona Richmond, Virginia 2 San Antonio, Texas San Diego, California San Francisco, California San Mateo County, California Santa Barbara County, California 2 Seattle, Washington Spokane, Washington Toronto (Ontario), Canada Tucson, Arizona Western Eagle County, Colorado Notes: 1 Expected Fall Program discontinued Figure Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 76 of 157

77 9 1 1 Dispatch Triage and Awareness Tele Triage Services As the demand for EMS increases, EMS systems struggle to keep up with the demand for EMS resources. Nurse tele triaging has been used effectively in Canada and England for several years. In the United States, nurse tele triage has been used as an effective tool to reduce EMS demand in the cities of Seattle (WA) since 2000, Richmond (VA) since 2006, and Houston (TX) since A 2009 Philadelphia City Auditor Report entitled, Tele Nursing: Lifting the Burden on Emergency Medical Services, studied all three of these systems in an attempt to encourage the Philadelphia Fire Department to implement this type of program. 30 In that report, the three studied cities diverted approximately 2,500 ambulance responses overall and experienced a combined savings of approximately $660,000 per year. 31 Applying diversion rates from these systems to the Santa County County s demographics, it is possible to estimate $250,000 in potential savings to the EMS system (see Figure 53). Several Canadian studies have shown the effectiveness of nurse tele triage systems and that appropriate advice is being provided with a tendency to err on the side of caution and send an ambulance City by City Comparison of Tele nursing Programs Location Houston Seattle Richmond Toronto Santa Clara 1 Population (2011) 2,145, , ,533 2,615,060 1,809,378 Responses/year 2 300, ,000 40, , ,100 Diversion rate 1.83% 0.51% 8.04% 1.42% 1.79% Diversions/year 5, ,285 3,398 1,813 Send back rate 75% 9% 83% 18% 58% Final diversions/year 1, , Final diversion rate 0.46% 0.47% 1.34% 1.16% 0.74% Net savings $328,562 $240,324 $30,660 $1,560,362 $252,797 Sources: Notes: 1 Santa Clara estimated Diversion & Send back rates are weighted averages of other cities. 2 Responses/year are from 2006, except Toronto (2011) and Santa Clara (Jul 12 annualized). Figure 53 if there is any doubt. These tele triage programs vary widely in their cost and implementation. Seattle uses an outsourced program to identify specific types of EMS calls to receive only a basic life support (BLS) fire engine initially; once assessed, that crew determines whether an advanced life support (ALS) or BLS ambulance is needed or if another transportation solution is more appropriate. Mesa Fire Department (AZ) staffs four transitional response vehicles (TRV) during peak times to handle calls identified by dispatch triage protocols as non emergency in lieu of a traditional fire engine and ambulance response. If the TRV evaluates the patient and determines an ambulance is warranted, the TRV crew can request an ambulance from the contracted provider. In Houston, the tele triage program was outsourced for nurse triage; however, it has recently been brought in house and Houston Fire Department emergency medical techinicans (EMTs) follow internal protocols for calls identified as low acuity. The Richmond program used an in house program until 2011 when it discontinued its teletriage program citing not enough call volume identified as needing nurse triage to sustain the program. Tele triage system software is available through several vendors, including Odyssey (used primarily in Europe) and Clinical Solutions Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 77 of 157

78 Starting in 2009, Fort Worth (TX) implemented nurse tele triage in conjunction with its community health paramedics (CHP) program to respond to non emergency calls. Currently, there is a nurse in the dispatch center weekdays during business hours; this position is jointly paid by three area hospitals in an effort to decrease uncompensated ED care, reduce ED saturation, and improve patient satisfaction scores. Starting in November 2012, the public hospital will fund 24 hour a day, 7 day a week nurse tele triage accessible through dispatch as well as a non emergency number distributed to patients who utilize the public hospital as their primary care center. The public hospital s objectives are to manage patient navigation, avoid ED use, and provide round the clock nurse advice to its patients. Based on the significant EMS demand, Santa Clara County may consider the implementation of a nurse tele triage system in collaboration with the contracted ambulance provider and hospital systems. EMS systems have shown a reduction in ambulance transports of 15 percent or greater with the implementation of a nurse tele triage system. 32 There are numerous articles written on the effectiveness, as well as several studies conducted, which validate that appropriate advice is being provided and no increase in liability has been associated with not sending an ambulance Awareness Campaigns The issue of misuse for EMS calls has existed for decades and the theme of Make the Right Call was promoted by the National Highway Traffic Safety Administration and the American College of Emergency Physicians during the National EMS Week in May misuse is an international problem and, in response, the London Ambulance Service initiated a Use Them, Don t Abuse Them public education program for when to use (9 9 9 in England) which includes a series of videos that can be viewed on YouTube. 34 Programs also are in place in the US. 35 In 2007, Lake EMS in Lake County (FL) implemented an effective public awareness campaign to reduce needless EMS calls. The campaign titled, When to Call 9 1 1, has been duplicated throughout Florida as well as in New Jersey, Virginia, and Colorado. The When to Call website has had hits from all over the world, including Germany, Brazil, and Dubai. 36 The initial campaign cost approximately $30,000 for billboards, flyers, posters, and the launch of the website. The website not only stresses the importance of when to call, but also explains what happens when a call is received and what to do while waiting for an ambulance to arrive. Although no data is available regarding the potential decrease in calls, the reduction has been described by the program as significant and the campaign has been duplicated in other communities Prehospital Emergency Care, 2002 Oct Dec; 6(4): Meer A, Gwerder T, Duembgen L, Zumbrunnen N, Zimmermann H. Emerg Med J. 2012;29: template.asp?articleid=1875&zoneid=39 56 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 78 of 157

79 Alternate Transportation and Destination Mental Health Transportation The counties of San Mateo (CA) and Santa Barbara (CA) established specific programs to reduce the need for ambulances to transport patients on a 72 hour mental health hold (i.e., 5150 ). In San Mateo County, local law enforcement can request the San Mateo County mental health assessment and referral team (SMART) unit to respond to any mental health call that is non emergent. All of the police officers receive Crisis Intervention Training to provide education on the mental health options available beyond a 72 hour hold, which had become the default choice in the community and the most expensive option. The San Mateo County paramedics who staff the SMART unit receive 120 hours of additional behavioral health education including the ability to place someone on a 72 hour hold and transport to a mental health facility. However, most patients are convinced by the SMART unit paramedic to accept transport and treatment voluntarily. Other options include immediate clinic appointments, transportation to shelters, and referrals to adult, drug/alcohol, and other services. The SMART paramedics are part of the mental health crisis team a multidisciplinary group including shelter managers, alcohol and drug agency representatives, police officers, and mental health providers to ensure a working relationship with the different resources available to the SMART program. Due to funding issues, the SMART unit staffing was reduced from 24 to 12 hours per day. The program responds to an average of five patients per day. In discussions with the provider, there may be opportunities to better optimize the SMART paramedic position by including other responsibilities, such as community paramedicine or high system user diversion, which may lead to a higher level of efficiency for the position and other funding sources. Santa Barbara County began its alternate transport program in 1989 by training the local ambulance provider s paramedic supervisors to respond to mental health calls, assess the medical and mental health status, and consult with a psychiatrist to determine the best course of action. If the person needs to be transported, the supervisor has a transport capable vehicle. In addition, the medical screening has already been completed allowing direct transport to a psychiatric facility, avoiding an ED visit. This approach reduced ambulance mental health transports to EDs by 80 percent. The program was funded through the local Medi Cal provider, mental health agency, hospitals, police departments, and the local ambulance provider. In 2008, the program was discontinued due to a number of challenges including funding and training paramedics effectively to serve as mental health workers. The transport of patients on a 5150 hold is typically covered by most insurance providers, including Medicare and MediCal. In order to ensure prompt payment, a copy of the hold is needed. The hold directive can be written by a mental health worker or law enforcement officer, who can transport themselves or request an ambulance to do so. Only ambulance transportation is covered; police or other transport methods cannot bill insurance. Alternate transport units, such as the programs in San Mateo and Santa Barbara, are/were funded through grants, local health services, public safety agencies, and hospitals. Local policies, such as those written by a county manager, mental health director, or health officer, typically drive who can legally transport patients on a hold as well as whether they can go directly to a psychiatric facility or require a medical screening first by an ED. In San Mateo County, 57 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 79 of 157

80 patients are sent directly to the emergency psychiatric facility, which performs an initial medical assessment and decides if a more thorough medical screening in needed. It is important to note that the best practice goal of alternate transport/destination programs for mental health patients is to not place them on holds, which enables other options to meet patients needs such as other mental health facilities and resources. Sobering Centers Several EMS systems have partnered with resources in their community to minimize the impact of responses for intoxicated individuals. Often times, an inebriated person is transported by ambulance to an ED due to lack of other transportation and destination options. San Francisco (CA) established a 12 bed sobering center in It offers comprehensive case management services including mental health support, homeless shelter admission, and coordination of outreach services through a working relationship with the Partnership of Community Awareness & Treatment Services and San Francisco Department of Public Health. This center is unique as it has the capability to accept people with medical issues, whereas similar programs in San Diego (CA) and Las Vegas (NV) are only able to accept healthy people, limiting their success as a destination for people who activate the EMS system. The San Francisco Sobering Center admits are assessed by registered nurses and medical assistants upon intake. The co located Medical Respite program has nurse practitioners and physician assistants for further medical assessment if needed. The San Francisco program operates a San Francisco Encounters by Referring Parties Ambulance 1, % 1, % 1, % Mobile Assistance Patrol (MAP) 1, % 1, % 1, % Police % % % ED Transfer (via MAP) % % % Referred by Other % % % Total Referrals 5, % 3, % 2, % Source: San Francisco Coordinated Case Management System Note: The number of EMS calls referred to MAP is not tracked currently Figure 54 Mobile Assistance Patrol (MAP) van that can respond to EMS and police requests for transports to the sobering center as well as homeless shelters, outreach services, and urgent care centers. The MAP van will also pick up intoxicated individuals being discharged from local EDs and transport them to shelters or the sobering center as appropriate. Figure 54 demonstrates the number of sobering center referrals during the last three years and it is growing steadily. Over 150 patients/month are transported via ambulance to the sobering center and more are transported by the MAP van following an EMS request (currently, the number of EMS referrals is not tracked). Hospitals are discharging an increasing number of patients to the sobering center from less than 10/month in 2010 to over 50/month in One of the longest running and more effective programs is located in Spokane (WA). The Emergency Services Patrol (ESP) program has been in existence for over 12 years and is based on a contractual partnership between the City of Spokane and Community Detox Services of Spokane (CDSS). The annual operating costs for the ESP are $103,800 with the city of Spokane providing $82,800 and CDSS the remainder. The City provides a van and CDSS staffs the van with EMT drivers; CDSS is responsible for the van s operating costs. The ESP is available Monday Friday, from 8:00 am to midnight, Saturday and Sunday from 4:00 pm to midnight. The van is required to make a sweep of the downtown core every four hours as well as respond to requests from the Spokane Police and Fire Departments, merchants, 58 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 80 of 157

81 and private citizens. The drivers have a radio to communicate with both law enforcement and first responders. The radio and EMS equipment are provided by the City. The van will transport intoxicated individuals to the CDSS sobering unit and can also Spokane Diversions to Sobering Center by Referring Parties Referral Source 2012* Fire Department % % % Police Department % % % Merchants/Private Citizens % % % Total Referrals 1, % 1, % 1, % Note: * Projected using Jan Jun 2012 data Figure 55 make referrals to other resources in the community as needed. CDSS produces monthly statistical data on client demographics, referral source, and which long term treatment facility was selected. The Spokane County Community Mental Health coordinates its resources with CDSS staff as well. Figure 55 demonstrates the number of ambulance transports diverted from the system since Taxi Cab Vouchers A number of EMS systems are using taxi cab vouchers for EMS patients who do not need to be transported to a medical facility by ambulance. Two metropolitan cities that have implemented an alternative transport program using cab vouchers are San Antonio (TX) 38 and Houston. The Abaris Group cautions that any such program should be developed with strict medical control and be protocol driven. High System User Diversion Some EMS systems have identified that there is a small number of patients generating a disproportionate share of the emergency calls for service. The Fort Worth EMS system (TX) identified 21 people who accounted for more than 1 percent (>1,000 calls) of the total call volume as they were calling as often as twice a week or more. 39 Programs have been adopted in San Diego (CA), Tucson (AZ), as well as Fort Worth to address the needs of these frequent EMS users. Most use a multidisciplinary approach to coordinate care from multiple public agencies to proactively address needs before they become acute and require or ED services. The City of San Diego established the Resource Access Program (RAP) in 2008 after determining that 933 individuals accounted for 3,347 (11 percent) of the nearly 85,000 annual transports and most likely a disproportionate share of ED visits and hospital admissions. RAP is a paramedic based surveillance and case management system that intercepts these high EMS users. RAP seeks to reduce dependence on EMS and acute care services by linking individuals with appropriate resources for their underlying medical, mental health, and social needs. The program is coordinated by the contracted ambulance provider and overseen by the EMS Medical Director. Over the initial 30 month period, the program reduced EMS encounters by 37.6 percent. 40 To further reduce the EMS and ED needs in San Diego, the EMS system is coordinating RAP with its Serial Inebriate Program (SIP) as an intervention program to slow down the revolving door syndrome of chronic alcoholics going in and out of ambulances, EDs, paramedics seek to prevent emergencies too.html?_r=2 40 Prehospital Emergency Care, October/December 2012, #4 59 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 81 of 157

82 and jail. Once identified as a serial inebriate, individuals have the option of participating in this program, typically in lieu of jail time. A multi disciplinary approach is used to coordinate a number of services and agencies to benefit patients until they are ready to be discharged from the program. As a result, arrests were reduced by 58 percent and EMS runs and ED visits by 54 percent for this population. 41 Based on a report in the Annals of Emergency Medicine, the average EMS and hospital charges for the care of this targeted population is $4,436,821 annually at a collection rate of 18.6 percent. 42 The San Diego SIP program has reduced healthcare system charges by almost $2.4 million a year. Fort Worth chose to approach the issue differently. Starting in 2009, Fort Worth created the community health program (CHP) to focus on a number of issues, including high volume EMS users. Instead of waiting for these users to call 9 1 1, the CHP proactively contacts, meets, and coordinates primary care to avoid acute issues. In the 12 months following enrollment in the program, Fort Worth reduced use by 86.2 percent in the targeted population, saving $1.6 million in EMS charges and an estimated $7.4 million in ED charges. 43 The program is funded by the cost savings of fewer ambulance unit hours as a result of approximately 200 less transports per month. Primary and Mobile Healthcare Community Paramedicine Programs Several models for a Community Paramedic program exist with varying applicability for EMS systems. The premise is the lack of primary care and transportation results in poor care coordination and follow up care. This leads to a declining health condition and the increase use of EMS (and ED) resources (see Figure 56). Many of these programs are focused in rural areas (e.g., Western Eagle County (CO), Liberty County (TX)) with geographic or transportation isolation access issues; however, their concept of operations may be applicable to urban areas focused on high EMS system users or as referred by partner healthcare organizations. Such is the case in Fort Worth (TX), where the CHP began by reducing the call volume of heavy system users enough to produce cost savings that pays for the community paramedics who staff the CHP program (see Figure 57). The program also provides out of hospital monitoring services to avoid hospital admissions and readmissions. The local hospitals, hospice agencies, Decreased Health Status Poor Follow-up Care Increased EMS Use Lack of Primary Care Poor Care Coordination Lack of Transportation Source: MedStar, Fort Worth, TX MedStar Community Paramedic Program 12 month Retrospective Review Figure 56 Number of Patients: 20 Jul10 Jun11 Jul11 Jun12 Change Transports % Related Costs EMS $ 188,928 $ 37,632 $ 151,296 ED $ 209,592 $ 41,748 $ 167,844 ED Bed hours 2, ,364 Source: MedStar, Fort Worth, TX, 12 Month Look, 6/30/12 Figure health program 60 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 82 of 157

83 and even physicians groups have identified these services as valuable and agreed to compensate the CHP program to provide them. Patients can be discharged from the ED into the CHP s observation admission avoidance program, where the CHP staff will monitor and manage the patient at home instead of being admitted to the hospital for observation. The patient receives a number to reach CHP staff at any time, regular check ins from the paramedic, in home visits as needed, and even transportation to follow up appointments. Two cardiologist groups have agreed to compensate the CHP program to provide medical management of their congestive heart failure patients to avoid hospital readmissions. The CHP staff regularly visit, assess, and treat these patients, including the use of point ofcare testing and in home diuresis as needed. The third fee for service program offered by CHP is highrisk (i.e., high probability of calling 9 1 1) home hospice patient care coordination. The CHP team conducts an initial home visit with the patient, family, and hospice representative to ensure everyone understands the patient s end of life plan, provides follow up as needed, and instructs dispatch to send CHP and hospice staff to any call at the address. Since the hospice program initiation, plan revocation has dropped from 70 to 1 percent. Mesa Fire Department has announced a new partnership with a local medical center to staff an additional TRV unit with a physician assistant or nurse practitioner. This unit will be assigned nonemergent calls that most likely will not require ambulance transportation. The medical center will bill for the mid level provider s care and treatment. The applicability for community paramedic programs for the county should be driven by an identified need for additional out of hospital healthcare access and would be best facilitated in a collaborative effort between the county agencies, local healthcare organizations, insurance providers, public health, and the contracted ambulance provider. Community Fire Station Healthcare Portals Alameda County (CA) is in the process of establishing community clinics or healthcare portals colocated with fire stations in underserved community areas. The program is called Fire Access Portals and is a unique model in partnership with its Public Health Department that will focus on providing services to: Respond to sub acute calls under the Medical Priority Dispatch System (approximately 30,000 calls annually), which triages response to non life threatening calls, Provide discharge follow up for residents in a defined area within 48 hours of discharge from emergency department care, and Take direct referrals from the call center for medical advice or consultation. This new model for expanding access to Alameda s underserved population is an innovative solution that Santa Clara County may wish to follow for applicability to its population. The Alameda County Board of Supervisors has provided $5 million in initial funding for this project. The Fire Access Portals are expected to open in the Fall of Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 83 of 157

84 Health Care Innovation Grant Awards The Health Care Innovation Awards are funding up to $1 billion in grants to applicants who will implement the most compelling new ideas to deliver better health, improved care and lower costs to people enrolled in Medicare, Medicaid and Children's Health Insurance Program, particularly those with the highest health care needs. 44 The majority includes programs that will decrease ED visits and hospitalizations; four grants have been awarded that are specifically related to EMS. Each award will accomplish one or more of the following improvements through community paramedicine, community health workers, or increased training of the existing EMS workforce: Reduce unnecessary ambulance responses Reduce ED visits Reduce hospital admissions and readmissions Increase access to primary and preventative care Increase in home patient care follow up in medically underserved areas While all of these system advancements would benefit Santa Clara County, the programs were awarded Summer 2012 and the actual results are unknown. The true benefits will become more evident as the programs mature during the three year project period. For the Santa Clara County EMS system to consider one or more of these projects, it would first need to identify funding sources to support the implementation. If the project involved an expanded scope of practice for paramedics, such as a community paramedicine program, this would require either scope of practice changes to be approved at the state level. Regional Emergency Medical Services Project Title: "REMSA Community Health Early Intervention Team" Geographic Reach: Nevada Funding Amount: $9,872,988 Estimated 3 Year Savings: $10,500,000 Summary: The Regional EMS Authority (REMSA) of Reno (NV), a non profit provider of ground and air ambulance services, in partnership with Renown Medical Group, the University of Nevada Reno School of Community Health Sciences, the Washoe County Health District, and the State of Nevada Office of EMS, is receiving an award to create a community health early intervention team (CHIT) to respond to lower acuity and chronic disease situations in urban, suburban, and rural areas of Washoe County, Nevada. CHIT is designed to reduce unnecessary ambulance responses, as well as hospital admissions and readmissions, while improving the patients healthcare. A central component to the success of CHIT is the adoption of a new non emergency phone number to provide an alternative pathway to care for patients with lower acuity problems. Goals of this initiative include reductions in non urgent ED visits, unreimbursed ED costs, hospital admissions, and hospital readmissions, as well as decreased hospital stays, fewer ambulance transports, and improved overall healthcare and continuity of care Awards/index.html 62 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 84 of 157

85 Prosser Public Hospital District Project Title: Prosser Washington Community Paramedics Program Geographic Reach: Washington Funding Amount: $1,470,017 Estimated 3 Year Savings: $1,855,400 Summary: Prosser Public Hospital District (WA), serving a large, rural area, is receiving an award for a program through which physicians can send a community paramedic (CP) to visit a patient of concern, providing in home medical monitoring, follow ups, basic lab work, and patient education. The area has high rates of obesity, high cholesterol, diabetes, heart attacks/coronary disease, and angina/stroke. ED visits and readmissions are high and preventive care is limited with poor follow up care for chronic illnesses and frequent missed appointments. By expanding the role of EMS, CPs can increase access to primary and preventive care, provide wellness interventions, decrease ED utilization, and improve outcomes. University Emergency Medical Services Project Title: Better health through social and health care linkages beyond the emergency department Geographic Reach: New York Funding Amount: $2,570,749 Estimated 3 Year Savings: $6.1 million Summary: University EMS, a practice plan affiliated with the Department of Emergency Medicine at the University at Buffalo (NY) is receiving an award to deploy community health workers in EDs to identify high risk patients and link them to primary care, social and health services, education, and health coaching. The program targets 2,300 Medicare and Medicaid beneficiaries who have had two or more ED visits over 12 months at two EDs in urban Buffalo. These patients account for 29 percent of all ED patients; further, 85 and 54 percent of all hospital inpatients are admitted through each hospital s ED. Health coaching and improved access to primary care is expected to result in lower ED utilization, reduced hospital admissions, and improved health with estimated savings of approximately $6.1 million. Upper San Juan Health Service District Project Title: Southwest Colorado cardiac and stroke care Geographic Reach: Colorado Funding Amount: $1,724,581 Estimated 3 Year Savings: $8.1 million Summary: The Upper San Juan Health Service District (CO) is receiving an award to expand access to specialists and improve the quality of acute care in rural and remote areas of southwestern Colorado. Their care delivery model will offer cardiovascular early detection and wellness programs, implement a telemedicine acute stroke care program, use telemedicine and remote diagnostics for cardiologist consultations, and upgrade and retrain its EMS Division to manage urgent care transports and in home follow up patient care for over 3,400 patients in medically underserved areas. The program will provide access to cardiologists and neurologists and is expected to reduce cardiovascular risk, improve patient outcomes, create healthier communities, and reduce health care costs with estimated savings of approximately $8.1 million. 63 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 85 of 157

86 Beacon Community Program San Diego The U.S. Department of Health & Human Services awarded San Diego $15 million to develop an electronic health record and health information exchange (HIE) system. Out of the 17 awards, San Diego was the only community to incorporate EMS providers. The Beacon HIE design automatically shares healthcare information through a centralized data server in near real time following privacy and security rules (see Figure 58). 45 This includes dispatch data, ambulance electronic PCRs, ED and hospital records, including discharge diagnosis, and public health data. It may change the way prehospital and hospital staff view their involvement and responsibilities with each other and the involved patients. Figure 58 The bi directional flow of information will improve prehospital clinical care. In practical terms, San Diego EMS is already seeing results. The Beacon HIE allows EMS to function as a public health surveillance tool to track, monitor, and alert on high system users. These users receive individual, targeted care plans through existing community programs to reduce their impact on EMS, hospitals, and law enforcement. The Beacon HIE surveillance enables real time identification of these individuals and notification to assigned case managers if a high system user contacts the EMS system. As the project continues, expected additional benefits include: Pushing EMS information: electronic PCRs will be sent in real time bursts to the receiving hospitals, including ST elevated myocardial infarction (STEMI) patient ECGs, trauma activations, and stroke alerts. The benefit will be better resource management and preparation of the hospital ED for when the patient arrives. 2. Better prehospital care: Critical patient information will be available to the ambulance crews, such as EMS and hospital medical histories, medications, and allergies and result in data driven, medical care decisions in the field. 3. Faster turnaround times: Ambulance crews will have a majority of their reports auto populated from the Beacon HIE, providing faster and higher quality documentation. 4. Better Continuous Quality Improvement: A significant benefit will be the ability to close the loop and share ED diagnosis and patient outcome information with EMS providers. This information will provide key performance indicators of the system and drive future training needs. 5. Reduced hospital utilization: ED staff will have access to a patient s healthcare information regardless of where it was provided in San Diego. Having a complete medical history will reduce the number of ED tests and procedures required and lead to fewer hospital admissions diego beacon project delivers real t 46 IBID 64 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 86 of 157

87 6. Improved surveillance: The real time sharing of information will enable better syndromic surveillance. This is the case with the current use of the Beacon HIE to identify high system users in near real time. The success of the San Diego Beacon project will lead to improved healthcare in other communities and Santa Clara County may be one of them. There are a number of similarities between the two communities large urban settings, over one million people, an existing (or pending) centralized data project with stakeholder acceptance, and subject to the same state laws and regulations. The county should monitor the results of the San Diego Beacon project for incorporation locally. The county may also want to review the current EMS data project for design needs that could lead to synergies with the Beacon HIE design in a future phase. 65 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 87 of 157

88 Key Study Take Aways County Demographic and Payer Projections 1) Population is growing slowly 2) Demographics demonstrate a large and complex population 3) The County s economy is growing 4) The uninsured rate will drop to approximately 3 percent with Health Reform EMS Capacity & Demand 1) ED demand will rise approximately 33% by ) EMS utilization will rise approximately 16.5% by ) Capacity of EDs has not kept pace with demand and is not likely to in the future without additional ED expansion 4) The number of ED treatment stations will need to grow by at least 162 new ED beds by ) EMS will need to add at a minimum of 3 new 24 hour units by ) ED and EMS payer mix will likely improve 7) There will be a substantial reduction in Medicare payments during that same period EMS System Performance 1) The EMS system is performing well 2) Most of the EMS & emergency providers are contracted based on performance and/or capabilities 3) This exceeds the performance of many other EMS systems in the state 4) Ambulance off load times need to be addressed through a community collaborative Hospital Capacity 5) Most hospitals in the county operate above the theoretical full capacity of 80% with greater than half above 90% capacity 66 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 88 of 157

89 6) While much of health care is moving towards outpatient services the current capacity needs in SCCO will likely need to be addressed 7) Inpatient psychiatric beds are improving in the county but the impact has yet to be felt Emergency Care Providers 1) The county has full coverage of performing fire/public safety first response and ambulance providers 2) The county is also blessed with an abundance of specialty hospital providers operating at a very high level 3) There are some developing needs for CCT ambulance capacity that may be addressed in the future EMS Dispatch 1) Comprehensive capability 2) Considerable PSAP & EMD fragmentation 3) Many opportunities to upgrade SCCC. Capabilities (i.e., updated CAD, MARVLIS compatibility, etc.) 4) County operability group (SVRIA) should assist with improving the fragmentation 5) County wide EMS dispatch consolidation should be considered EMS Data Project 1) Significant and innovative move 2) Will provide a platform for managing and planning into the future 3) Strong message of collaboration amongst all emergency care providers 4) Will be a substantial tool to integrating CQI into the future EMS Best & Promising Practices 1) There are a significant number of best & promising practices that could be models for SCC 67 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 89 of 157

90 2) Many of these programs focus on EMS system overutilization and abuse which will be hallmarks for survival in the future 3) Should be used as frames for the this Strategic Planning Process 68 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 90 of 157

91 Observations/Considerations Establish county wide coordinated continuous quality improvement (CQI) program While there exists an extensive network of committees reviewing and reporting on the quality of care being provided at various phases of the patient care experience within the system, there is no overarching body responsible for putting all of this information together in a comprehensive picture of the patient experience. The Santa Clara County EMS Agency (SCCEMSA) should establish a CQI committee with responsibility for oversight and coordination of all CQI activities within the system. It should be chaired by the SCCEMSA Medical Director and staffed by the SCCEMSA quality Figure 59 improvement (QI) coordinator. Figure 59 graphically represents the Contra Costa County Emergency Medical Services (EMS) Agency CQI relationships, and the interaction between the various QI groups within that system. 47 This method leads to a formalized CQI process for any EMS issue with trending, quantifying, and identification of concerns for training opportunities (e.g., under/over trauma triage, false STEMI activations, medication errors). A coordinated approach may also improve participation of EMS system stakeholders. For example, there is minimal EMS provider involvement at specialty care and prehospital care system meetings and a lack of first responders at the command and control meetings. Identify an SCCEMSA CQI champion The SCCEMSA must establish a quality champion within the agency structure. This individual should be qualified by education and experience in the CQI principles, practice, and processes as well as not being burdened with additional job responsibilities that conflict with the CQI role. This individual must be a facilitator, coaxing and encouraging the EMS Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 91 of 157

92 system participants through leadership and enthusiasm, not through mandates. To ensure a clear, consistent message and direction for the program, this position should be a direct report to the SCCEMSA Director and coordinate activities with the SCCEMSA Medical Director. Develop CQI data integration Critical to the future success of the CQI program is the data management project currently underway. As described previously, quality data is the cornerstone of any CQI program. The SCCEMSA should focus particular attention to the data integration bridge component of the application service provider solution that is selected through the upcoming request for proposals process. The ability to link all of the patient s encounters into a complete record of that patient s experience will help ensure that the Santa Clara County CQI Program is a true best practice in quality care. Industry Trends and Best Practices Implement a appropriateness campaign Utilize the existing public service announcement to develop a subsequent When to Call educational campaign and website. Quantify and possibly develop a prehospital mental health program Quantify the volume of 5150 transports and determine whether an alternative response and transport program may be more appropriate. Quantify and possibly develop a program for serial inebriates Quantify the volume of serial inebriate transports and determine whether an alternative response and transport program may be more appropriate. Implement a solution to address the needs of high system EMS users Identify the heaviest users of the system and develop a multi disciplinary approach to reduce the frequency used. Research community paramedicine programs Follow community paramedic and mobile healthcare programs being developed and implemented in other EMS systems for suitability in the local environment. Compare these programs with the quantified local needs (e.g., users who are the least served by the current healthcare system) and define opportunities to partner with public and private entities to financially support a potential program. Monitor Health Care Innovation Awards These programs will mature over the three year implementation period. The SCCEMSA should monitor these projects for outcome results and consider their appropriateness and applicability to be replicated locally. 70 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 92 of 157

93 Next Steps Based upon results of this emergency medical services (EMS) system assessment phase, a three to seven year strategic plan will be created for the system. The process will heavily involve the EMS committee and other representative stakeholders. The Abaris Group will conduct stakeholder based strategic planning workshops to develop a draft strategic plan following the process provided in Figure 60. EMS system participant comments will be incorporated into the strategic plan. The desired output of this second phase will be a high level strategic plan that identifies the EMS system s mission, vision, values, goals, and objectives. The final strategic plan will be submitted to the EMS committee and the Santa Clara Valley Health and Hospital Committee for review, comment, and approval. Figure 60 The final phase of the project will be the development of a comprehensive implementation plan upon the successful completion of the EMS system strategic plan detailed above. The implementation plan will address each component of the approved plan and include guidance for implementing each project. 71 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 93 of 157

94 Appendix A: Interview List The Abaris Group Interviews Conducted First Name Last Name Title Affiliation Mark Anderson Engineering Manager SCCC Cameron Bailey Lieutenant Sunnyvale DPS Michael Baulch Operations Director Stanford Life Flight JJ Baumann, RN Stroke Clinical Nurse Specialist Stanford John Blain EMS Specialist SCCEMSA Terry Blay, MD Emergency Medicine Physician Kaiser San Jose Tony Bradshaw President Bradshaw Consulting Services Andrea Brollini ED Nurse Manager SCVMC Laurie Brown Assistant Communications Director SCCC Mike Cabano EMS Specialist SCCEMSA Jo Capro Pending Hospital Council Amy Carta Assistant Director Santa Clara Health & Hospital System Tony Casellini Supervisor Rural/Metro Marcus Chow, MD Kaiser San Jose Mike Clark EMS Specialist SCCEMSA Josh Davies Section Chief SCCEMSA Courtney Davis EMT, Medic Unit 37 Rural/Metro Charlene Donahue EMS Coordinator Sunnyvale DPS Steven Drewniany Deputy Chief Sunnyvale DPS Pam Dudley, NP Trauma Program Manager Regional Medical Center of San Jose Ross Fay Regional Director CalStar Fenstersheib, Marty MD Public Health Officer Public Health Barbara Finnegan, RN Nurse Project Coordinator Kaiser San Jose Richard Frawley Captain Milpitas FD Allied Healthcare Facilities Work Group Mark Frise Coordinator SCCEMSA Peter Fung, MD Stroke Medical Director El Camino Hospital Interventional Services Medical Matt Go, MD Director Kaiser San Jose Molly Goel, MD Chief Medical Officer SCVMC Steve Grau CEO Royal Ambulance Gary Graves CAO Office/COO CEO/COO Curtis Guy Clinical Coordinator Rural/Metro Harry Hall Chairperson EMS Committee Chad Henry Clinical Manager Rural/Metro Bert Hildebrand Communications Director SCCC Jamie Hill, RN Lead Flight Nurse Stanford Life Flight Randy Hooks President Silicon Valley Ambulance 72 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 94 of 157

95 The Abaris Group Interviews Conducted First Name Last Name Title Affiliation Eileen Hoover, RN Assistant Program Manager SCVMC Sherril Hopper, RN Stroke Program Coordinator El Camino Brian Hubbell Operations Manager Rural/Metro Natalie Humboldt Human Resources Manager Rural/Metro Mike Johnson CEO Regional Medical Center of San Jose Trudi Johnson Acting CEO SCVMC Phil King Fire Division Chief Gilroy FD Rick Kline, MD Medical Director of Trauma Services Regional Medical Center of San Jose Jeremiah Kunze Public Health Preparedness Manager Public Health Hasieb Lemar Operations Manager Royal Ambulance Jennifer Lerault Supervisor Rural/Metro Joel Levis, MD ED Medical Director Kaiser Santa Clara Jackie Lowther Acting CNO SCVMC Anne Marcotte EMS Specialty Care Programs SCCEMSA Rose Marino Dispatch Supervisor SCCC Larry Marsala CEO Golden State Ambulance Rose Martinez EMS Dispatcher SCCC Paul Maxwell Clinical Coordinator Rural/Metro Barbara McDonald, RN Clinical Coordinator Rural/Metro Howard Michaels, MD Medical Director San Jose FD John Montes EMS Specialist SCCEMSA Pena Nancy Director Mental Health Patricia Natividad Unit Manager SCCEMSA John Netto Information Technology Manager Rural/Metro Richard Newell, MD CA Emergency Physicians Wil Nguyen Paramedic, Medic Unit 37 Rural/Metro Mark Norman General Manager Rural/Metro John Owen Battalion Chief Mountain View FD Angela Pacheco, RN Assistant Director Kaiser San Jose Dan Peddycord, RN Public Health Director Public Health Mike Petrie Director SCCEMSA Jeff Plecque Captain Sunnyvale DPS Steve Ramos EMT, Medic Unit 17 Rural/Metro Aimee Reedy Division Director Programs Public Health Kim Roderick EMS Coordinator Palo Alto FD Valerie Rogers, RN Interventional Services Manager Kaiser San Jose Erik Rudnick, MD EMS Medical Director SCCEMSA Diana Sandoval Healthcare Program Analyst SCCEMSA Rene Santiago Assistant County Executive, Health SCCO Steve Schmidt MVDR Coordinator SCCEMSA Donna Schreiber Cardiovascular Quality Coordinator Good Samaritan 73 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 95 of 157

96 The Abaris Group Interviews Conducted First Name Last Name Title Affiliation Rick Seal Battalion Chief EMS Division Manager San Jose FD John Seitz Logistics Coordinator SCCEMSA Chris Seymour ALS Coordinator Westmed John Sherck, MD Medical Director of the Trauma Center SCVMC David Spain, MD Chief of Trauma Stanford Matt Streck Captain CAL Fire Heather Tagger, MD Clinical Advisor Rural/Metro Ron Vega Battalion Chief EMS Santa Clara FD Danny Vollberg Supervisor Rural/Metro Tom Wagner CEO AMR West Dr. Wang, MD Acting Medical Director SCVMC Bradley Wardle Fire Chief Mountain View FD T.C. Warford Paramedic, Medic Unit 17 Rural/Metro Jason Weed EMS Specialist SCCEMSA Augie Wiedemann Deputy Fire Chief Santa Clara FD Joe Williams EMS Specialist SCCEMSA Krissy Zamarron Administrative Assistant SCCEMSA 74 Santa Clara County Emergency Medical Services System Assessment Phase I October 2012 Page 96 of 157

97 75 Santa Clara County EMS System Assessment Phase I October 2012 Appendix B: County Ambulance Response Time Maps Code 3 responses for County Ambulance from July 2011 through June 2012 in which the response time was less than 4 minutes. As anticipated, the urban areas enjoy the vast majority of the short response times, reflecting the posting of units in the populated areas of the county. Pacheco Pass Hwy Hwy 101 State Hwy 130 State Hwy 85 I- 280 Capitol Expy State Hwy 9 San Jose Palo Alto Gilroy Milpitas Saratoga Sunnyvale Santa Clara Los Gatos Cupertino Morgan Hill Mountain View Los Altos Los Altos Hills Campbell Monte Sereno Major Roads Municipal Boundaries RT < 4min. (n=22,476) County Boundary Rural Metro Santa Clara Code 3 Responses July, 2011 thru June, 2012 Response Time < 4 min. Source: RM SCC July, June, 2012 Page 97 of 157

98 76 Santa Clara County EMS System Assessment Phase I October 2012 Code 3 responses times that were greater than 12 minutes. While many of these longer response times are in the unincorporated areas of the county, there are a substantial number within the urban areas, as well. Pacheco Pass Hwy Hwy 101 State Hwy 130 State Hwy 85 I- 280 Capitol Expy State Hwy 9 San Jose Palo Alto Gilroy Sunnyvale Milpitas Santa Clara Saratoga Cupertino Campbell Los Gatos Morgan Hill Mountain View Los Altos Hills Los Altos Monte Sereno Major Roads Municipal Boundaries RT > 12 min. (n=1,016) County Boundary Rural Metro Code 3 Responses Response Time > 12 min. July, 2011 thru June, 2012 Source: RM SCC July, June, 2012 Page 98 of 157

99 77 Santa Clara County EMS System Assessment Phase I October 2012 Code 3 responses times that were greater than 16 minutes. These extended responses reflect a similar pattern to the greater than 12 minute responses, noted in the prior map. Pacheco Pass Hwy Hwy 101 State Hwy 130 State Hwy 85 I- 280 Capitol Expy State Hwy 9 San Jose Palo Alto Gilroy Sunnyvale Milpitas Sant a Clara Saratoga Cupertino Campbell Los Gatos Morgan Hill Mountain View Los Altos Los Altos Hills Monte Sereno Major Roads Municipal Boundaries RT > 16 min. (n=260) County Boundary Rural Metro Code 3 Responses Response Time > 16 min. July, 2011 thru June, 2012 Source: RM SCC July, June, 2012 Page 99 of 157

100 Appendix C: County Population Density Map Palo Alto Milpitas Mountain View Sunnyvale Los Altos Hills Los Altos Santa Clara Cupertino San Jose I- 280 Capitol Expy State Hwy 130 Saratoga Campbell State Hwy 9 Monte Sereno Los Gatos State Hwy 85 Hwy 101 Morgan Hill Total Population by City City Boundaries 3,341-7,922 7,923-48,821 48,822-74,066 74, , , ,942 County Boundary Major Roads Source: Assoc. of Bay Area Governments Gilroy Pacheco Pass Hwy 78 Santa Clara County EMS System Assessment Phase I October 2012 Page 100 of 157

101 County of Santa Clara Emergency Medical Services System Emergency Medical Services Agency 976 Lenzen Avenue, Suite 1200 San Jose, CA voice fax Date: December 6, 2012 To: From: Subject: Santa Clara County EMS Committee Members Michael Petrie EMS Director Sobering System Planning Issue and History A preliminary EMS study, using data collected from July 1, 2011 through December 31, 2011, indicated that 7,000 7,500 patients annually presenting with alcohol-related intoxication and other injuries, drugs, illnesses or complaints, are transported via 911 ambulances annually to hospital emergency departments throughout Santa Clara County. Of these patients, approximately 2,720 annually are transported primarily for alcohol intoxication or other primarily-alcohol related effects, without drug, trauma, illness, or other confounding factors. A more detailed analysis, conducted using clinical and ICD-9 data collected from January 1, 2012 through June 30, 2012 indicated that approximately 1,120 patients annually could be transported directly from the field by a sobering van to a Sobering Center. Many of the balance of these patients could be medically screened and cleared at an Emergency Department, and then re-transported by sobering van to the Sobering Center, thus keeping the Emergency Department beds available for patients with more serious illnesses and injuries. Outline of Sobering System and Operations Paramedics would respond to a 911 call for a medical emergency. Upon arrival, paramedics would evaluate the patient, using a clinical protocol developed by the EMS Medical Director. If the paramedics determine that the patient s primary clinical impression is alcohol intoxication without other complicating clinical issues, the patient may be deemed appropriate for transport by the ambulance or a sobering van directly to the sobering center. Should other medical concerns be present, the patient would be transported, per EMS protocol, directly to a hospital emergency department. All alcohol intoxicated patients arriving at the Emergency Department both those transported by ambulance and those who self-present may be medically screened and deemed appropriate for transport from the emergency department to the Sobering Center. Patients would maintain their right of self-determination and choose their own destination. Admission to the 14 to 20-bed Sobering Center would be determined by clinical protocols developed by the EMS Medical Director, the Medical Director of the Sobering Center and participating hospital emergency department medical directors. At least initially, admissions to the Sobering Center would be directed from an EMS response, law enforcement or a patient cleared by a hospital emergency department and transported to the sobering center. Patients whose clinical status deteriorates beyond the level of care provide in the Sobering Center would be re-transported to a hospital Emergency Department. A division of the Santa Clara County Public Health Department Page 101 of 157

102 Financing The concept for financing the startup and ongoing operations for the sobering system would be similar to the model currently employed for the Medical Respite Center where all of the hospitals in the County provide supportive funding. Initial capital cost estimates are pending information from contractors who might bid to operate the sobering center. Program Status At their November 20, 2012 meeting, the Board of Supervisor s Health and Hospital Committee voted to approve the development of a Request for Information (RFI) for a vendor to operate the Sobering Center and hiring a dedicated project manager to oversee the development of the Sobering Center, for at least a 3-year pilot study. Presuming information gained in the RFI is appropriate, the Santa Clara Valley Health and Hospital System would bring a final report and recommendation to the Health and Hospital Committee (SCVHHS) n the late spring of If authorized by the Board of Supervisors, SCVHHS would anticipate the release of an RFP by the summer of 2013, with the expectation of having an operational sobering system in place by the fall of Options 1) Accept the EMS Director s report on the progress of the Santa Clara Sobering System. 2) Request additional information regarding the Santa Clara Sobering System. 3) Other actions, as determined by the EMS Committee. Recommendation 1) Accept the EMS Director s report on the progress of the Santa Clara Sobering System. Page 102 of 157

103 County of Santa Clara Emergency Medical Services System Emergency Medical Services Agency 976 Lenzen Avenue, Suite 1200 San Jose, CA voice fax Date: December 6, 2012 To: From: Subject: Santa Clara County EMS Committee Members Michael Petrie EMS Director California EMS Authority 2012 Awards History In 2008, the California EMS Authority instituted an annual program to recognize those EMS professionals, physicians and nurses, allied health personnel, and civilians who perform deeds of heroism, provide unusual leadership, or otherwise serve the public well in EMS-related capacities. The Santa Clara EMS Agency annually nominates the recipients of the Santa Clara County EMS Provider Recognitions to the California EMS Authority for consideration for an EMS Authority award. Issue This year, four stakeholders from the Santa Clara County EMS System received awards from the California EMS Authority. Those aware winners were: Name and Organization Award Circumstances Shawn Ellis, EMT-P Medal of Valor Rescuing a woman from a County Ambulance burning house on June 15, Brian Newton, EMT County Ambulance Creed Black The Right Stuff Health Clubs Dr. Joel Levis, MD Kaiser Santa Clara Meritorious Service Medal Civilian Awards Meritorious Service Medal Options 1) Accept report. 2) Other actions as recommended by the EMS Committee. Recommendation 1) Accept report Participating in the rescue of a woman from a burning house on June 15, Saving the life of a cardiac arrest victim on January 20, 2012 Service as an active emergency physician, and excellence in selfless contributions to the Santa Clara EMS System. A division of the Santa Clara County Public Health Department Page 103 of 157

104 County of Santa Clara Emergency Medical Services System Emergency Medical Services Agency 976 Lenzen Avenue, Suite 1200 San Jose, CA voice fax Date: December 6, 2012 To: From: Subject: Santa Clara County EMS Committee Members Michael Cabano EMS Specialist EMS Provider Recognition Awards Program History The EMS Providers Recognition Awards Program was developed to recognize those who have made an exceptional and sustained effort to benefit the Santa Clara County EMS System, rather than those that have been involved in a dramatic or high visibility incident. The long term benefit to the EMS System through exceptional and sustained performance often yields greater benefit to those operating or involved as an end user. Issue There is currently no established committee to assist the EMS Director in the selection of the award recipients. A formal committee would allow for an impartial and through review of all recognition program submissions. The EMS Committee, as the committee representing all stakeholder organizations would be strong, competent and impartial body that would greatly assist in reviewing the criteria for each award category. Cost There is no cost anticipated in the review by the EMS Committee or associated with the forming of a sub-committee to review recognition program submissions. Legal Issues There are no legal issues related to the review of the recognition program submissions. However, because the Brown Act regulates this committee, the findings and selections of the committee or sub-committee must be noticed appropriately. Options 1) Recommend that the EMS Committee form a Provider Recognition Award Review subcommittee, that at minimum includes the EMS Commissioner and (5) five other selected members of the committee to review all recognition program submissions and make recommendations for selection. 2) Recommend that the EMS Committee review all recognition program submissions and make recommendation for selection. 3) Other options, as determined by the EMS Committee. A division of the Santa Clara County Public Health Department Page 104 of 157

105 Recommendation 1) Recommend that EMS Committee form a sub-committee to assist in the in through and impartial review of all recognition program submissions and make recommendations for the selection of recipients for each award category. These selections will be noticed to the EMS Committee and reviewed by the EMS Director for selection notification. Page 105 of 157

106 County of Santa Clara Emergency Medical Services System Emergency Medical Services Agency 976 Lenzen Avenue, Suite 1200 San Jose, CA voice fax Date: December 6, 2012 To: From: Subject: Santa Clara County EMS Committee Members Michael Petrie EMS Director EMS System Exercises History Exercises are essential to coordinate multiagency responses, to validate policies and procedures, to improve individual and group performance, and to identify gaps in preparedness. Full scale exercises those exercises in which command and control and field activities are tested are the most valuable exercises, because they most closely approximate emergency operations under actual conditions. In fact, full scale exercises are the only sufficient way to comprehensively evaluate capabilities for low frequency/high-consequence events, such as earthquakes, terrorist attacks, and large mass casualty incidents. In October 2012, the EMS System participated in two full scale exercises: Children s Recovery Center Exercise On October 17, 2012 the Children s Recovery Center (CRC) conducted a full scale emergency exercise utilizing the patients from their facility. The CRC is a 27-bed facility that cares exclusively for pediatric patients. Every patient has a tracheostomy and seventy percent of their patients require a ventilator to breathe. The exercise consisted of a simulated fire in the kitchen (using actual smoke machines) that required the facility to shelter patients in place and then to evacuate the facility. The exercise tested their evacuation plan, patient relocation plan, internal and external communication, inter agency coordination, and use of the incident command system. This exercise was multiagency and multidisciplinary. Participants included the Santa Clara County Fire Department, Campbell Police Department, and County Ambulance, and the Santa Clara EMS Agency. Multi-Patient Management Plan Exercise On October 23 through October 25, 2012, the Santa Clara County Fire Chiefs Association and the Santa Clara County EMS Agency co-sponsored the 2012 Multi-Patient Management Plan (MPMP) Exercise. This exercise simulated approximately 50 persons at a rave becoming ill or injured, then requiring treatment, evacuation, and transport. To add realism, victims were located in an abandoned and dark theater, filled with distracting lighting, loud music, and smoke. Each day of the exercise, participants spent the morning receiving training in the multi-patient management plan, incident command system, and triage. Each afternoon, participants applied the lessons they learned in the morning in a comprehensive full scale exercise. A division of the Santa Clara County Public Health Department Page 106 of 157

107 Most EMS Systems do not have the number and quality of comprehensive exercises as Santa Clara County. It is only through unusual technical expertise, and strong working relationships that our agencies and departments work together to achieve these high levels of cooperation and preparedness. Options 1) Accept the EMS System Exercise report as presented. 2) Other actions, as determined by the EMS Committee. Recommendation 1) Accept the EMS System Exercise report as presented. Page 107 of 157

108 County of Santa Clara Emergency Medical Services System Emergency Medical Services Agency 976 Lenzen Avenue, Suite 1200 San Jose, CA voice fax Date: December 6, 2012 To: From: Santa Clara County EMS Committee Members Eric M. Rudnick, MD, FACEP, FAAEM Medical Director Santa Clara EMS Agency Subject: Medical Director Report for December 2012 Clinical Quality Improvement (CQI) is the corner stone for any EMS system to improve. To that end, the Santa Clara EMS Agency has developed Clinical Performance Indicators (CPI). These system wide initiatives were designed to measure the care delivered. For 2012 the following indicators have been developed and implemented. Suspected Cardiac Ischemia Quality Assurance Indicator Intraosseous Infusion Quality Assurance Indicator 12 Lead Electrocardiogram Clinical Performance Indicator Suspected Stroke/TIA Clinical Performance Indicator Therapeutic Hypothermia Quality Assurance Indicator Therapeutic Hypothermia Clinical Performance Indicator Tourniquet Procedure Clinical Performance Indicator It was recommended that provider agencies incorporate these indicators into their own internal EMS Quality Improvement Plan (EQIP). We will be holding a seminar for all system providers early in 2013 to ensure that these indicators still meet the needs of the EMS system. There have been some data validation and formatting issues. It is anticipated that once all the providers are on a standard Patient Care Report (PCR) system that these issues will be resolved. Action: For informational purpose only, no action required. A division of the Santa Clara County Public Health Department Page 108 of 157

109 County of Santa Clara Emergency Medical Services System Emergency Medical Services Agency 976 Lenzen Avenue, Suite 1200 San Jose, CA voice fax Date: December 6, 2012 To: From: Santa Clara County EMS Committee Members Patricia Natividad Senior Management Analyst Subject: EMS Trust Fund Liquidated Damages for Calendar Year 2012 Liquidated Damages for Response Time Non-Performance & Monthly Zone Non-Compliance January 1, 2012 August 30, 2012 Month / Year Amount January-12 $170, February-12 $256, March-12 $214, April-12 $220, May-12 $211, June-12 $231, July-12 $198, August-12 $235, September-12 $222, October-12 $297, Total for CY12 $2,257, Average Monthly Total In Period $225, A division of the Santa Clara County Public Health Department Page 109 of 157

110 County of Santa Clara Emergency Medical Services System Emergency Medical Services Agency 976 Lenzen Avenue, Suite 1200 San Jose, CA voice fax Date: December 6, 2012 To: From: Subject: Emergency Medical Services Committee Josh Davies CEM EMS Section Chief EMS Trust Fund Allocation FY13 Category C Background In the Spring of 2012, the EMS Agency released an open solicitation for EMS Trust Fund (Category C) projects from Santa Clara County EMS System Stakeholders. $250, was budgeted for distribution. Six funding requests were received. Discussion One request was received from a community college paramedic and EMT training program. The school requested funding for protective equipment for students/interns use while completing field training in Santa Clara County. The request would provide equipment to all three Santa Clara County approved training programs. After EMS Agency review, the request was able to be filled through other funding sources or existing inventories. However, the allocation of protective gear for students/interns will be provided to all Santa Clara County approved ambulance services directly. The remaining requests were related to the EMS Data Project. Requests were received from the Santa Clara County Fire Chiefs Association (SCCFCA) and the EMS Agency. The requests from the SCCFCA were consistent and supported the further implementation and development of the Santa Clara County Comprehensive EMS Patient Care Data Project with two exceptions. One request for a new electronic version of the patient care record and a request to fund a hospital data registry were not deemed to be consistent with the current data project implementation. However, both projects have value and would be better held until the data project is further implemented. A division of the Santa Clara County Public Health Department Page 110 of 157

111 Requested Actions EMS Agency staff recommends that the EMS Director allocate $250, of budgeted and Board-approved Category C Trust Funds to support the Santa Clara County Comprehensive EMS Patient Care Data Project, as described: (A) (B) (C) (D) Allocate $25, for one year of operations and maintenance of electronic linkage between each fire communications center and the County s patient care data server. In future years, the EMS Agency will not fund this expense, and encourages the fire departments to petition the Silicon Valley Interoperability Authority (SVIRA) to cover this cost expense in future years. Allocate $10, to create a broad assortment of patient care report templates for fire departments. Allocate a contingency of $10, to cover unforeseen data system implementation costs for fire departments. Allocate $205, for hardware to implement fire department bedside submission of patient care reports. This allocation will pay for device (such as laptop computer or tablet) costs only. It does not pay for operations, maintenance and licensing costs. The SCCFCA had requested $140, and $51, per-year in on-going service costs. The EMS Agency is unable to approve this request due to ongoing unbudgeted costs and because the software requested is not an approved component of the data project. However, the EMS Agency will allocate $212, of Franchise Fees this fiscal year for the same purpose and while eliminating ongoing costs. This approach will provide fire departments, except Palo Alto, which is not a contracted fire department, the ability to remotely capture patient care data. Page 111 of 157

112 County of Santa Clara Emergency Medical Services System Emergency Medical Services Agency 976 Lenzen Avenue, Suite 1200 San Jose, CA voice fax Date: December 6, 2012 To: From: Subject: EMS Committee Membership Josh Davies CEM EMS Section Chief EMS Trust Fund Guide The Emergency Medical Services Trust Fund Guide provides a comprehensive explanation of the intended use of the EMS Trust Fund, process for requesting funds, and the process for the use of the funds. A revised version of the Guide has been attached for your review. The EMS Agency requests approval from the EMS Committee at the December 6, 2012 meeting. The guide was revised to include more detailed explanations of processes, history of the fund, and to provide EMS System Stakeholders with the process that has been approved by the Santa Clara County Board of Supervisors. Thank you for your continued support of our Emergency Medical Services System. If you should have any questions, please feel free to contact me at the number provided or via at [email protected] Attachment: Emergency Medical Services Trust Fund Guide A division of the Santa Clara County Public Health Department Page 112 of 157

113 EMS Trust Fund Guide and Funding Application EMS Reference 812: Effective DRAFT Page 113 of 157

114 Purpose The purpose of the EMS Trust Fund Guide and Funding Application is to provide an explanation of the trust fund, identify how spending is authorized, how EMS System Stakeholders may access funds, and the purpose and intent of the fund. History of the EMS Trust Fund In October of 2001 the County entered into an agreement with American Medical Response for the provision of 911 emergency ambulance services in the County Exclusive Operating Area (all areas of the County with the exception of the City of Palo Alto and Stanford Lands Parcels). The agreement included the assessment of fines and penalties when the ambulance provider failed to meet standards contained in the agreement such as response times. The EMS Trust Fund was established as an independent account to separate fine and penalty revenue collected from the ambulance service from EMS Agency general operating funds. The deposit into the EMS Trust Fund served as a method to keep fine and penalty revenue collection transparent to the public and to address any concerns that the EMS Agency could predatorily penalize the ambulance services in order to increase revenue to the EMS Agency. The contract included the requirement that fines and penalties deposited to the EMS Trust fund were to be used for projects that would provide for (1) enhancements to the Santa Clara County EMS System and (2) were required to provide a countywide benefit to the Santa Clara County EMS System. The intended beneficiaries of the EMS Trust Fund were the County and those providing EMS services within the County Service Area excluding the 911 ambulance service provider from which the revenue was collected. Expenditures from the Trust Fund are authorized by the Board of Supervisors. Annually, the County Emergency Medical Services Director makes recommendations to the Board through the EMS Committee and Health and Hospital Committee. Prior to 2011, EMS Trust Fund revenue was used to off-set the budget of the EMS Agency within the Public Health Department. The new County Exclusive Operating Area Agreement which became effective in July of 2011 included a new County EOA Franchise Fee that eliminated the need to use Trust Fund revenue to off-set Public Health Department costs. Prior to the execution of the July 2011 agreement, the Board approved a revision to EMS Trust Fund process so that expenditures would be classified in various categories that would benefit the entire EMS System with the exception of times when the County may be in an extreme financial hardship. The revised process also required that a percentage of annual revenue be retained as a System Reserve should the EMS System be impacted by unforeseen financial burden. In July 2011, fire departments (except the City of Palo Alto) executed agreements with the County to become EMS System Providers. Fire departments (except the City of Palo Alto) were also provided with the opportunity to voluntarily participate in accessing available first responder funding that was acquired by the County through the County Service Area EOA agreement for meeting criteria such as response times, use of emergency medical dispatch, and participation 2 Page 114 of 157

115 in countywide EMS efforts. In 2011, total available funding to be distributed to fire departments was $5,000,000. The total available funding is expected to increase each year as the ambulance service provider receives a rate increase (0-5% annually), the fund is increased by 0-3%. Departments that chose to participate were provided annually with a maximum allocation based historical allocations and call volume; penalties and fines for performance variances are then deducted from the maximum available allocation. Liquidated Damages and Fines The revenue that is accrued in the EMS Trust Fund comes from variances in either the County Service Area EOA ambulance provider or the fire departments that participate in the voluntary first responder funding program within the County Service Area EOA. Revenue that is collected due to late response time performance is called liquidated damages. The payment of liquidated damages is a financial settlement that is intended to cover damages associated with late response times. The payment of liquidated damages does not forgive the occurrence of the variance and other censures may apply. A fine is financial censure that is applied for failing to meet a required component of an established agreement such as late reports, inappropriate use of resources, or failing to comply with an administrative provision of the agreement. The payment of a fine is a penalty and does not represent a settlement of damages. Additional censures most often apply when fines are issued including other processes identified in County Ordinance Code, Santa Clara County Prehospital Care Policy, law, or regulation. EMS Trust Fund Expense Categories The EMS Trust Fund consists of four expense categories; EMS System Reserve Investment, EMS System Support Training, Education, and Recognition, Benefit to EMS System Users, and EMS System Strategic Initiatives. Each year the EMS Agency submits a budget to the Board of Supervisors for approval that addresses each of the categories identified below. Category A: EMS System Reserve Investment The EMS Agency reserves at least 20% of annual fine/penalty revenue (received as liquidated damages) for significant strategic projects that serve the benefit of the EMS System with a longer range focus, and as approved by the Board of Supervisors. The intention of the reserve is realize modest growth over time so that these funds may be used should the Emergency Medical Services System experience an unforeseen hardship or incur an unanticipated financial burden such as failure of the ambulance service provider, extraordinary increase in cost of services or supplies, loss of revenue from patient billing related to federal Medicare/Medical changes or unforeseen changes as a result of National Healthcare reform. 3 Page 115 of 157

116 Category B: EMS System Support - Training, Education & Recognition Funding authorized in this category is used for annual training, education, exercise, and EMS provider recognition. The EMS Agency will include an allocation each year within the County Budget. Amounts budgeted may be transferred between any line item identified below should request or needs fall below the amounts allocated. The EMS Agency will authorize individual expenditures up to this amount and unused authorized funds would be retained in the EMS Trust Fund for use in future years. Expenses authorized in this category include, but are not limited to: EMS System Information to the Public Training (not funded by grants or other sources) Exercises (not funded by grants or other sources) Annual County EMS Conference EMS Provider Recognition and National EMS Week Category C: Benefit to EMS System Users In the fall of each year, the EMS Agency will determine a reasonable allocation for this category subject to Board Approval in the spring of each year. Projects in this category are generated from Santa Clara County EMS System Stakeholders, such as fire departments, County Communications, ambulance services, dispatch centers, and the EMS Agency. Requestors must have executed a current agreement with the County (EMS Provider Agreement, 911 Receiving Facility Agreement, etc.) to receive funding from the EMS Trust Fund. Projects funded in this category are generally one-time/short-term that solves a problem, fills a gap, or assists in completing a larger EMS System project that (1) enhances and/or (2) provides a countywide benefit to the Santa Clara County EMS System. Projects submitted for approval are first reviewed by EMS Agency staff. The results of the staff review, including the recommended and not-recommended project packets are then provided to the EMS Committee for review. If the EMS Committee Chair seats a subcommittee to review the project packets, the subcommittee shall include a Health Commissioner and at least four other Committee members, but less than a quorum of the EMS Committee. The County Service Area EOA ambulance provider may not a member of this subcommittee. The County Service Area EOA ambulance provider may not submit proposals or benefit from allocations in this Category unless the funded project provides funding or services for all Santa Clara County EMS System Providers. The selected County Service Area EOA ambulance service provider is expected to make investments to the Santa Clara County EOA that enhance and provide a countywide benefit through the allocation their funds, not those collected due to their performance variances. 4 Page 116 of 157

117 The process for submitting requests for Category C Funds are included in Appendix A: Funding Application. Unused authorized funds are retained in the EMS Trust Fund for use in the future years or moved to Category A in the next fiscal budget year. Category D: EMS System Strategic Initiatives Projects in this area focus on the development and fulfillment of strategic initiatives that will improve the Santa Clara County Emergency Medical Services System. Projects in this area may cross over fiscal years and may take multiple years to implement or complete. The EMS Agency includes these projects in the annual County Budget process. Disbursement of Funds The disbursement of funds is subject to the terms and conditions established in a written agreement between the County and recipient of the funds. In the event that the County is the recipient of the funds, County financial processes and polices apply. Based on the nature of expenditure, the County will be the fiscal agent for the project and is required to make purchases and disburse funds only as authorized by the County purchasing processes. This means that even though an external party has requested the purchase of equipment or a service, County standards apply. In some cases, the County will purchase equipment or services on behalf of the EMS System. These services and/or equipment may be provided to the Stakeholders for use; however the County will then retain ownership of the deliverables. Reporting The status of the EMS Trust Fund is provided quarterly to the EMS Committee and semiannually to the Board of Supervisors. The reports include revenue, expenditures, status of progress of approved projects, and future EMS Trust Fund spending recommendations. These reports are post to the EMS Agency website and are also available by request. Solicitation of Projects Each year, the EMS Agency will solicit projects from EMS System Stakeholders to be funded through allocated Category C Funds. Based on the County Budget Process, the solicitation will be released with an estimate of available funds. Once the Board of Supervisors has approved the County Budget, approved requests will be adjusted to meet the actual allocation authorized by the Board. 5 Page 117 of 157

118 Annex A: Funding Request Category C Eligibility To be eligible for funding, the organization must (1) hold a current written agreement with the County EMS Agency and the project requested must either (2) provide a countywide benefit in support of the County Service Area EOA and/or (3) enhance the County Service Area EOA. The County Service Area EOA 911 ambulance provider may not submit requests, except as identified in the EMS Trust Fund Guide. If the above criteria are satisfied, the project must then be reviewed by at least one of the following recognized EMS System Stakeholder Advisory Groups. If a project has not been reviewed by at least one of the groups identified it will not be considered for funding. The applicant must include either meeting minutes, a letter of support, or other written verification from the committee that reviewed the proposal. Designated EMS System Advisory Review Groups Non-Fire Service Providers Prehospital Providers Advisory Committee Fire Service Providers Santa Clara County Fire Chiefs Association Hospitals Emergency Department Nurse Managers / Santa Clara County Hospitals Emergency Preparedness Partnership Other Applicants within the Santa Clara County EMS System Santa Clara County EMS Agency 6 Page 118 of 157

119 Samples of Desirable Projects Programs that provide both a countywide benefit and enhancement of the County Service Area 911 System. Proposals from organizations that have experience in the provision of the services to be provided. Programs that provide an in-kind financial contribution. Programs that provide for operational and financial sustainability. Programs that support the EMS System strategic plan, initiatives, or Programs that are reproducible and/or are publicly accessible. Projects that fill gaps in systems, services, or initiatives that may have been underfunded but are supported by the EMS System. Programs that require no on-going costs, support, or maintenance. Programs that may supplant a proposer s obligation to provide such services or financing for same. Project plans and deliverables that clearly demonstrate a rapid project implementation and completion. In the event that a program is funded, the organization will be required to enter into a written agreement with the County unless the County is the purchaser of the services or products requested. The following requirements are part of the requesting organizations obligations to the County. Provide an accounting of all expenditures and including support documentation that may include, but is not limited to, receipts, invoices, balance sheets, copies of warrants, etc. Return all funds allocated to the project that cannot be completed within the established time lines by June of each year (unless the County and organization have agreed to other timelines). Under most circumstances, award notification will be made in July of each year and approved projects must be completed by May of the same fiscal year. Acknowledge the Santa Clara County EMS Trust Fund and the Santa Clara County Emergency Medical Services System in all informational, marketing, printed, or media materials. Any project modifications must be approved by the County. All purchases will be made in accordance with established County accounting and purchasing policies. The funded organization must work with the County to procure quotes, assist in request for proposals processes, and recommend appropriate vendors acceptable to the County. Participate in appropriate Santa Clara County EMS System Stakeholder Groups. Submitting a Funding Request 7 Page 119 of 157

120 A written request (Annex A) shall be submitted to the EMS Agency for review. All proposals must be received by the EMS Agency by the date identified in the EMS Trust Fund Solicitation. The EMS Agency will conduct a review that will include, but is not limited to, applicant eligibility, evaluation of proposed countywide benefits and the ability of the project to enhance the entire Emergency Medical Services System. All requests will then be reviewed by the EMS Committee or a designed subcommittee. Process The process below will be used for the solicitation, review, and announcement of Category C Trust Fund requests. A specific timeline will be included in the solicitation announced by the EMS Agency. Solicitation Announced The EMS Agency will announce an open solicitation period for Category C Trust Fund project applications. Prepare Application Packet Complete the application form provided in Annex A. Have project reviewed by appropriate Stakeholder Committee. Submit any supplemental information required such as deliverables, letters of support, budgets, etc. Submit the application by the date identified in the solicitation. Review EMS Agency Staff will review each proposal and make recommendations to the EMS Committee. The EMS Committee (or subcommittee) will review proposals and make a recommendation to the EMS Director. Proposers may be requested to make project presentations at the EMS Committee (or subcommittee) meeting. Notification and Award The EMS Director will determine which Category C projects will be funded. The EMS Agency will notify all applicants of the status of requests. Those selected for funding will enter into agreements with the County and begin project work. Project Completion Funded organizations will provide project updates to the EMS at least quarterly or as identified in a written agreement. The EMS Committee will be provided with quarterly updates as to the progression of Category C projects. A final implementation report will be provided to the EMS Committee when a project is completed. 8 Page 120 of 157

121 Date: July 20, 2012 Section I: General Information Organization Name: Santa Clara County Emergency Medical Services Chiefs Address: 1000 Villa Street, Mountain View, CA Telephone: (650) Fax: (650) Contact Person: Title: John Owen Battalion Chief, President SCC EMS Chiefs Section II: Project Summary Provide a brief summary of your request (a more detailed description should be included with this packet). Project Name: Emergency Medical Services Data Project On Going Support Project Summary: This funding request is to support the Emergency Medical Services Data Systems Project. The requested funds would be used to pay for on-going cost of the Image Trend electronic patient care reporting system, to be used specifically in the following areas: Cost of annual hosting and support - $25,000 Development of additional reports - $5,000 Enhance the system through the use from Field Bridge Express to gather data at or near patient side. - $ 100,000 Start Up, $16,000 Annually Other unforeseen cost to complete project implementation as approved by the Santa Clara County EMS Chiefs section and County EMSA - $10,000 first year, $5,000 annually Requested Funding Amount: $ 140,000 first year $ 51,000 each of the remaining years of the contract Page 121 of 157

122 Describe how this project will enhance the Santa Clara County Emergency Medical Services System. The Emergency Medical Data Systems project has made tremendous progress in the last year. With the Rural-Metro contract implementation, all county fire agencies have be provided access to Image Trend s EMS Field Bridge software to have a common platform for electronically completing and submitting their Patient Care Reports (PCRs). This is a huge step forward to tying together the patient care information from the inception of the call, dialing 911 to patient outcome at the emergency room. This implementation of this countywide patient care reporting system is currently in process, and it is anticipated that all fire agencies will be completing the integration process in the 4 th quarter of The final piece that is missing is the ability for the First Responders to initiate and transfer the initial patient care information wirelessly when patient care is transferred to County Ambulance, on scene, at the patient s side. This funding will be used in two ways. 1) For on-going support of this project to cover CAD and hosting fees that the fire agencies will incur to maintain their connections to the Image Trend system. 2) To provide Image Trend Field Bridge Express, a module of the Image Trend system that will allow the collection of patient information and treatments at patient side on a pad device such as a ipad or Android tablet and post this information so that it integrates seamlessly with the County Ambulance paramedics patient care report. This will provide complete continuum of patient care which will help insure better patient care and a more efficient EMS system overall. The EMS Chief s feel this is an important to phase in such a large and complicated implementation. With the completion of the first phase, introduction the EMS Bridge reporting system, the next step is to bring the system into the field. If the funds are granted they will be distributed based on cost that each agency incurs in support of the system. Describe how this project will provide a countywide benefit. This phase in the EMS data system integration will benefit county twofold: 1) Better Patient Care: By maintaining a contiguous Patient Care Report the overall emergency medical system is better poised to provide a better level of patient care. The information gathered by the Fire Agency First Responders would be accurately and completely transferred to the transport paramedics, who in turn transmit this information to the hospital more accurately. The current system relies on Fire Agencies First Responders hand filling out a paper first responder Page 122 of 157

123 run report and providing that information to the transport paramedic. The transport paramedic then has to transfer this information to their electronic report which both time consuming, a point to introduce errors and delay in patient care. 2) Better Data for System Planning: By having a complete picture of patient care the EMS system can be better designed and efficiencies can be built. Currently gathering complete information from time of 911 call to patient outcome is almost impossible. This has been improved in the first phase of the data project, having all first responders use the image trend system. However, this final step is important to insure that the complete EMS system performance can be evaluated. Provide a list of recognized stakeholder groups, community based organizations, Agency advisory committees, that support this request. Please include contact information, affiliation, and a letter of support from each. Each First Responder Fire Agency in Santa Clara County will benefit. Letters of Endorsement from each fire agency are attached. Section III: Finance Attach a copy of the program budget including a list of all estimated costs. Include copies of quotes from vendors (at least three) if the request is for material goods or services to be purchased by the County or organization. Please find the attached quote and information. Note that there is only one quote as this is tied to the existing Image Trend system. What in-kind contributions is your organization or partner organizations, providing to the project. If a partner organization is involved, attach a statement from that organization that identifies the inkind participation. Each department will be responsible to provide any gap funding for the hardware or software that these funds don t cover. Identify what other sources you have attempted or are attempting to access to fund this project. Provide the status of each. Page 123 of 157

124 Currently there is no other countywide effort to obtain funding. If your organization does not attain funding from the Trust Fund, how will the project be funded/implemented? Please also discuss if less than the requested amount was provided, what portions of the project could be completed. Each agency is working within their budgeting system to obtain funding, which is doubtful at best in these current economic conditions. Section IV: Sustainability/Coordination Describe how this project will be sustained after the Trust Fund monies have been used. Sustainability will be achieved in part by: 1. Each agency will be responsible maintaining their Computer Aided Dispatch (CAD) system and maintaining data accuracy. 2. Each agency will be responsible for putting into place the policies and procedures that assure proper use. Explain how your organization will integrate the Santa Clara County Emergency Medical Services Stakeholders into the project (including program delivery, accessibility, marketing, media, public relations, etc.). As the project includes EMS Agency specific implementation, all agencies will be involved. Section V: Submission Submissions not meeting the criteria established herein will not be Considered List all additional attachments (other than those required in the application) Any additional materials, beyond those requested, that support or describe the proposed project should be included. All submissions must be provided in an editable electronic format ( , CD, flash drive, etc.). Page 124 of 157

125 Materials may be submitted in person or via mail to: EMS Trust Fund Request Santa Clara County EMS Agency 976 Lenzen Avenue, Suite 1200 San Jose, California Page 125 of 157

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127 M E M O R A N D U M Fire Department (Emergency Response Services) August 5th, 2012 Santa Clara County EMS Trust Fund Review Committee Santa Clara County EMS Agency 976 Lenzen Avenue, Suite 1200 San Jose, California Dear Review Committee Member, This letter hereby serves as a letter of support for the Santa Clara Fire Chiefs Association Santa Clara County Trust Fund application dated August 1 st, 2012 soliciting County support to provide on-going support of the EMS Data Systems project with funds to for on-going cost and introduction of new technology. The project serves all EMS employees in the County, in that in strives for county wide consistency in patient care reporting and a system that uses data driven decisions to enhance and improve patient care The project also recognizes that a sustainable program is necessary in that both the First Responder Fire Agencies and the EMS Agency management responsible for building and enhancing the system. On behalf of the Milpitas Fire Department, I ask you to please consider favorably funding this application. Regards, Rick Frawley EMS Battalion Chief Milpitas Fire Department Page 127 of 157

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133 July 25, 2012 John Owen, President Santa Clara County Fire Chief s EMS Section Mountain View Fire Department 1000 Villa Street, Mt. View, CA, Re: Santa Clara County EMS Trust Fund allocation Dear Chief Owen, This memorandum is submitted as support for the request of EMS Trust Fund monies for the County s first responders. The San José Fire Department endorses the proposal of using the EMS Trust Fund monies for the acquisition of the following general items as it relates to the countywide data project: 1. Mobile tablets 2. Mobile Wi Fi connectivity hardware 3. Image Trend s software package Field Bridge Express 4. Annual fees for hosting and support of the CAD connection with Image Trend 5. Advanced programming of queries that will generate reports associated with Field Bridge by Image Trend If there any questions or concerns about this correspondence, at your convenience, please feel free to contact Richard Seal, Battalion Chief at [email protected]. Submitted by, /s/ RICHARD SEAL, Battalion Chief EMS Division Manager 1661 Senter Road, Suite 300 San José, CA (408) fax (408) Page 133 of 157

134 Ship To: John Owen Santa Clara County EMS Section Chiefs 976 Lenzen Ave, Suite 1217 Bill To: Same as Ship To San Jose, CA Approved by: Rosanna Roedder (650) Salesperson Proposal Number Todd York Budgetary Proposal Description Field Bridge Xpress Santa Clara County Wide Site License PROPOSAL Date July 24, 2012 Qty Unit Price Total Field Bridge Xpress Site License 1 $100, $100, Rural Metro negotiated 10% on all ImageTrend Licensed Producted in Santa Clara Co 1 ($10,000.00) ($10,000.00) FBX Annual Support 1 $16, $16, TOTAL Year 1 Annual Fees after Year 1 Terms of Agreement The above mentioned items will be invoiced independently upon completion with payment terms of net 30 days. The recurring annual fees will be billed annually in advance. This Site License is limited to: Operations in Santa Clara County, CA Use in conjunction the Rural Metro Santa Clara Service Bridge with Rural Metro's written permission. Exceptions: The License is moved to a new Service/Rescue/State Bridge as a whole. I.E., ALL departments must change Service/Rescue/State Bridge together. ImageTrend's license and annual support are based on 100,000 annual incidents as provided by Client. $106, $16, Departments or providers who have purchase an independent Service/Rescue Bridge. In this case, this Field Bridge Xpress Site License will extend to those Service/Rescue Bridges. ImageTrend reserves the right to reevaluate on an annual basis and potentially increase the ongoing annual fee rates for the subsequent years. The increase shall not, however, exceed inflation. This proposal is valid for 90 days. Agreed to and accepted by: ImageTrend, Inc. Santa Clara County EMS Section Chiefs Signature Date If you have any questions regarding this proposal, contact: Todd York at or [email protected] or Julie Kaufman-Boom at or [email protected] Thank you for your business! ImageTrend, Inc Kensington Blvd Lakeville, MN Page 134 of 157 Tel: Fax:

135 County of Santa Clara Emergency Medical Services System Emergency Medical Services Agency 976 Lenzen Avenue, Suite 1200 San Jose, CA voice fax Date: December 6, 2012 To: From: Subject: Santa Clara County EMS Committee Members John Blain Contract Manager County EOA Service Area Response Time Performance Report History and Issue The County has entered into agreements with private and public entities to provide emergency medical response and advanced life support ambulance transportation services. Periodic response time compliance reports have been provided to the EMS Committee for the purpose of providing public review of those entities performance and compliance with contractual response time requirements. Context Compliance is measured by several key performance indicators that include; response time requirements based on population density; designated response areas; type of response priority (red lights & siren or non-red lights & siren); total number of responses; total number of late responses; and total number of responses exempted (removed) from compliance calculations. Compliance is achieved when ninety (90%) percent or more of the responses meet the specified response time requirement in each response priority within each designated response area. Cost There is no direct cost to the EMS Committee to accept and/or not accept the report. Legal Issues There are no legal issues related to accepting and/or not accepting the report. Options 1) Recommend that the EMS Committee accepts the County EOA Service Area - Response Time Performance Report for January-September ) Recommend that the EMS Committee does not accepts the County EOA Service Area - Response Time Performance Report for January-September Recommendation 1) Recommend that the EMS Committee accepts the County EOA Service Area - Response Time Performance Report for January-September A division of the Santa Clara County Public Health Department Page 135 of 157

136 County of Santa Clara Emergency Medical Services System County EOA Service Area COUNTY EOA SERVICE AREA RESPONSE TIME PERFORMANCE REPORT 2012 January September 2012 Page 136 of 157 Page 1 of 6

137 TABLE 1 Rural/Metro 2012 EMS Response Time Performance Report Jan Feb Mar Apr May Jun Jul Aug Sep Totals Code 3 Responses 6,370 5,830 6,470 6,098 6,459 6,208 6,129 6,375 6,238 56,177 Cancel On Time ,794 Unadjusted Late Calls ,552 Unadjusted Compliance 92.36% 90.67% 91.82% 90.89% 91.14% 90.37% 91.70% 90.10% 89.52% 90.97% Adjusted Late Calls ,283 Adjusted Compliance 94.47% 92.73% 93.65% 93.28% 93.37% 93.36% 94.64% 93.21% 92.56% 93.48% Extended Minutes ,719 Code 2 Responses 2,343 2,123 2,312 2,299 2,466 2,355 2,296 2,467 2,339 21,000 Cancel On Time ,912 Unadjusted Late Calls ,268 Unadjusted Compliance 93.90% 92.45% 92.91% 93.98% 93.57% 92.05% 94.05% 91.86% 92.12% 92.99% Adjusted Late Calls Adjusted Compliance 95.51% 94.31% 94.49% 95.60% 94.99% 94.11% 96.01% 94.61% 94.38% 94.89% Extended Minutes ,525 Responses with Transports 6,037 5,435 5,982 5,614 6,013 5,738 5,582 5,803 5,726 51,930 Total Patients Transported 6,118 5,581 6,161 5,707 6,088 5,738 5,646 5,854 5,783 52,676 Page 137 of 157 Page 2 of 6

138 TABLE 2 Rural/Metro 2012 Subzone Performance Report Subzone 5 Subzone 4 Subzone 3 Subzone 2 Subzone 1 Jan Feb Mar Apr May Jun Jul Aug Sep Totals CODE 3 - Responses Late Responses Adjusted Compliance 92.66% 90.02% 91.76% 91.75% 92.68% 91.66% 92.08% 91.61% 90.49% 91.83% CODE 2 - Responses Late Responses Adjusted Compliance 95.58% 94.76% 95.53% 97.29% 95.39% 95.38% 95.34% 93.36% 94.75% 95.62% CODE 3 - Responses Late Responses Adjusted Compliance 93.84% 93.49% 93.40% 92.14% 92.83% 92.36% 94.05% 91.77% 90.48% 93.16% CODE 2 - Responses Late Responses Adjusted Compliance 95.10% 93.84% 96.15% 94.35% 96.01% 93.36% 96.30% 93.58% 93.81% 95.04% CODE 3 - Responses Late Responses Adjusted Compliance 96.04% 94.33% 95.26% 95.71% 94.76% 95.84% 96.65% 94.95% 94.81% 95.52% CODE 2 - Responses Late Responses Adjusted Compliance 97.46% 96.59% 93.48% 95.45% 96.57% 95.58% 95.83% 95.62% 96.49% 95.86% CODE 3 - Responses Late Responses Adjusted Compliance 94.42% 91.84% 93.68% 92.11% 92.29% 93.30% 94.61% 93.33% 92.10% 93.18% CODE 2 - Responses Late Responses Adjusted Compliance 93.70% 91.85% 93.01% 94.93% 92.10% 92.22% 95.90% 95.61% 92.02% 93.40% CODE 3 - Responses Late Responses Adjusted Compliance 94.74% 94.38% 92.49% 95.28% 95.44% 90.41% 94.03% 93.03% 96.59% 93.81% CODE 2 - Responses Late Responses Adjusted Compliance 98.70% 96.97% 93.88% 97.37% 96.46% 95.24% 99.03% 95.05% 96.97% 96.72% Page 138 of 157 Page 3 of 6

139 TABLE 3 Gilroy Fire Department 2012 EMS Response Time Performance Report Jan Feb Mar Apr May Jun Jul Aug Sep Totals CODE 3 - Responses ,122 Adjusted Late Calls Adjusted Compliance 95.98% 97.08% 96.70% 98.73% 99.52% 98.33% 97.45% 97.12% 97.04% 97.68% TABLE 4 Milpitas Fire Department 2012 EMS Response Time Performance Report Jan Feb Mar Apr May Jun Jul Aug Sep Totals CODE 3 - Responses ,054 Adjusted Late Calls Adjusted Compliance 98.90% 99.34% 96.17% 98.41% 96.57% 96.55% 99.20% 98.72% 95.73% 97.63% TABLE 5 Mountain View Fire Department 2012 EMS Response Time Performance Report Jan Feb Mar Apr May Jun Jul Aug Sep Totals CODE 3 - Responses ,851 Adjusted Late Calls Adjusted Compliance 96.97% 95.56% 95.92% 98.71% 98.22% 98.03% 99.37% 98.12% 98.05% 97.30% CODE 2 - Responses Adjusted Late Calls Adjusted Compliance % % % % % % % % % % Page 139 of 157 Page 4 of 6

140 TABLE 6 San Jose Fire Department 2012 EMS Response Time Performance Report Jan Feb Mar Apr May Jun Jul Aug Sep Totals CODE 3 - Responses 3,906 3,569 3,882 3,781 4,029 3,754 3,793 3,927 3,889 22,921 Adjusted Late Calls ,209 Adjusted Compliance 91.63% 89.27% 90.91% 89.63% 90.47% 90.14% 90.11% 91.67% 88.71% 90.36% CODE 2 - Responses ,404 Adjusted Late Calls Adjusted Compliance 99.23% 96.60% 97.30% 96.43% 96.33% 94.33% 93.14% 94.80% 94.85% 96.73% TABLE 7 Santa Clara City Fire Department 2012 EMS Response Time Performance Report Jan Feb Mar Apr May Jun Jul Aug Sep Totals CODE 3 - Responses ,157 Adjusted Late Calls Adjusted Compliance 97.83% 97.55% 95.11% 95.69% 95.76% 98.46% 95.39% 95.24% 95.02% 96.75% CODE 2 - Responses Adjusted Late Calls Adjusted Compliance 97.04% 97.87% 96.55% 97.26% 96.77% 96.82% 97.66% 97.32% 96.88% 97.03% Page 140 of 157 Page 5 of 6

141 TABLE 8 Santa Clara County Central Fire District 2012 EMS Response Time Performance Report Jan Feb Mar Apr May Jun Jul Aug Sep Totals CODE 3 - Responses 1,110 1, ,806 Adjusted Late Calls Adjusted Compliance 96.94% 97.08% 96.00% 95.77% 96.04% 96.67% 96.56% 96.14% 95.48% 96.45% CODE 2 - Responses ,095 Adjusted Late Calls Adjusted Compliance 99.00% 99.38% % % 98.33% % % 98.51% 97.87% 99.45% TABLE 9 South Santa Clara County Fire Protection District [CAL FIRE] 2012 EMS Response Time Performance Report Jan Feb Mar Apr May Jun Jul Aug Sep Totals CODE 3 - Responses Adjusted Late Calls Adjusted Compliance % 98.90% 98.15% 97.14% 99.13% 97.17% 97.39% 98.36% 96.58% 98.36% CODE 2 - Responses Adjusted Late Calls Adjusted Compliance % % % % % % % % % % TABLE 10 Sunnyvale Department of Public Safety 2012 EMS Response Time Performance Report Jan Feb Mar Apr May Jun Jul Aug Sep Totals CODE 3 - Responses ,897 Adjusted Late Calls Adjusted Compliance 98.78% 97.89% 98.22% 97.96% 98.55% 97.44% 99.55% 98.76% 98.28% 98.14% Page 141 of 157 Page 6 of 6

142 County of Santa Clara Emergency Medical Services System Emergency Medical Services Agency 976 Lenzen Avenue, Suite 1200 San Jose, CA voice fax Date: December 6, 2012 To: From: Subject: Santa Clara County EMS Committee Members Diana Sandoval Data Analyst Hospital Destination, Diversion and Advisory Status Reports Issue The EMS Agency monitors and reports on the destination of ambulance patients, the amount of time each hospital is on ambulance diversion status, and the amount of time hospitals have declared service advisories. The attached reports demonstrate: The volume and distribution of ambulance transports to Santa Clara County hospitals is consistent with previous years. Santa Clara Valley Medical Center and San Jose Regional Medical Center continue to receive more ambulance patients than other hospitals. Veterans Hospital diversion levels continue to be well above the allowable 39 hours per month. The overall amount of diversions hours have continuously decreased throughout most of the Santa Clara County hospitals. Good Samaritan Hospital has shown a significant increase in stoke diversion hours during the past 3 months, due to the unavailability of ICU beds. Options 1) Accept the Hospital Destination, Diversion and Advisory Status Reports as presented. 2) Do not accept the Hospital Destination, Diversion and Advisory Status Reports, as presented. 3) Other options, as determined by the EMS Committee Recommendation 1) Accept the Hospital Destination, Diversion and Advisory Status Report as presented. A division of the Santa Clara County Public Health Department Page 142 of 157

143 TABLE 8 Santa Clara County Central Fire District 2012 EMS Response Time Performance Report County of Santa Clara Emergency Medical Services System Monthly Hospital Destination, Diversion and Advisory Status Report Monthly Hospital Destination, Diversion and Advisory Status Report May October 2012 Page 143 of 157

144 County of Santa Clara Emergency Medical Services System Monthly Hospital Destination, Diversion and Advisory Status Report Report for Time Period: May 2012 Table 1: Number of Patients Transported to Hospital ED from System* Hospital Dec -11 Jan - 12 Feb - 12 Mar - 12 Apr - 12 May - 12 Total El Camino - Los Gatos El Camino - Mt. View ,986 Good Samaritan ,379 Kaiser - San Jose ,481 Kaiser - Santa Clara ,850 O'Connor ,383 Regional - San Jose 952 1, , ,060 6,093 Saint Louise ,340 Stanford ,524 VA - Palo Alto VMC 1,280 1,323 1,166 1,286 1,299 1,399 7,753 Total 6,053 6,277 5,786 6,399 5,885 6,276 36,676 Source: Santa Clara County Communications & Palo Alto Fire Department Table 2: Daily Average of Patients Transported By Hospital* Hospital Dec-11 Jan - 12 Feb - 12 Mar - 12 Apr - 12 May - 12 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 Source: Santa Clara County Communications & Palo Alto Fire Department *Notes for Tables 1 and 2: These numbers only reflect patients that originated in Santa Clara County and were transported by the County's EOA Ambulance Provider and Palo Alto Fire Department. Data for Stanford does not include patients from San Mateo County. The data includes but, does not differentiate specialty center status (TRAUMA, STROKE, STEMI, BURN) Santa Clara County EMS l 976 Lenzen Avenue, Suite 1200 l San Jose, CA l Page 1 of 2 Page 144 of 157

145 Table 3: Total Monthly Hours of "AMBULANCE DIVERSION" Status Hospital Dec -11 Jan - 12 Feb - 12 Mar - 12 Apr - 12 May - 12 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 Color Legend Above 37hrs Above 30hrs Below 30hrs Table 4: Total Monthly Hours of "STROKE / CT DOWN" Status* Hospital Dec -11 Jan - 12 Feb - 12 Mar - 12 Apr - 12 May - 12 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 Table 5: Total Monthly Hours of "STEMI" Service Advisory Status* Hospital Dec -11 Jan - 12 Feb - 12 Mar - 12 Apr - 12 May - 12 Total El Camino - Mt. View Good Samaritan Kaiser - San Jose Kaiser - Santa Clara O'Connor Regional - San Jose Stanford VMC Total Table 6: Total Monthly Hours of Trauma Center "BYPASS" Status Hospital Dec -11 Jan - 12 Feb - 12 Mar - 12 Apr - 12 May - 12 Total Regional - San Jose Stanford VMC Total Santa Clara County EMS l 976 Lenzen Avenue, Suite 1200 l San Jose, CA l Page 2 of 2 Page 145 of 157

146 County of Santa Clara Emergency Medical Services System Monthly Hospital Destination, Diversion and Advisory Status Report Report for Time Period: June 2012 Table 1: Number of Patients Transported to Hospital ED from System* Hospital Jan - 12 Feb - 12 Mar - 12 Apr - 12 May - 12 June - 12 Total El Camino - Los Gatos El Camino - Mt. View ,968 Good Samaritan ,349 Kaiser - San Jose ,436 Kaiser - Santa Clara ,788 O'Connor ,401 Regional - San Jose 1, , ,060 1,024 6,165 Saint Louise ,372 Stanford ,547 VA - Palo Alto VMC 1,323 1,166 1,286 1,299 1,399 1,309 7,782 Total 6,277 5,786 6,399 5,885 6,276 6,050 36,673 Source: Santa Clara County Communications & Palo Alto Fire Department Table 2: Daily Average of Patients Transported By Hospital* Hospital Jan - 12 Feb - 12 Mar - 12 Apr - 12 May - 12 June - 12 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 Source: Santa Clara County Communications & Palo Alto Fire Department *Notes for Tables 1 and 2: These numbers only reflect patients that originated in Santa Clara County and were transported by the County's EOA Ambulance Provider and Palo Alto Fire Department. Data for Stanford does not include patients from San Mateo County. The data includes but, does not differentiate specialty center status (TRAUMA, STROKE, STEMI, BURN) Santa Clara County EMS l 976 Lenzen Avenue, Suite 1200 l San Jose, CA l Page 1 of 2 Page 146 of 157

147 Table 3: Total Monthly Hours of "AMBULANCE DIVERSION" Status Hospital Jan - 12 Feb - 12 Mar - 12 Apr - 12 May - 12 June - 12 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 Color Legend Above 37hrs Above 30hrs Below 30hrs Table 4: Total Monthly Hours of "STROKE / CT DOWN" Status* Hospital Jan - 12 Feb - 12 Mar - 12 Apr - 12 May - 12 June - 12 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 Table 5: Total Monthly Hours of "STEMI" Service Advisory Status* Hospital Jan - 12 Feb - 12 Mar - 12 Apr - 12 May - 12 June - 12 Total El Camino - Mt. View Good Samaritan Kaiser - San Jose Kaiser - Santa Clara O'Connor Regional - San Jose Stanford VMC Total Table 6: Total Monthly Hours of Trauma Center "BYPASS" Status Hospital Jan - 12 Feb - 12 Mar - 12 Apr - 12 May - 12 June - 12 Total Regional - San Jose Stanford VMC Total Santa Clara County EMS l 976 Lenzen Avenue, Suite 1200 l San Jose, CA l Page 2 of 2 Page 147 of 157

148 County of Santa Clara Emergency Medical Services System Monthly Hospital Destination, Diversion and Advisory Status Report Monthly Hospital Destination, Diversion and Advisory Status Report Monthly Hospital Destination, Diversion and Advisory Status Report Report for Time Period: July 2012 Table 1: Number of Patients Transported to Hospital ED from System* Hospital Feb - 12 Mar - 12 Apr - 12 May - 12 June - 12 July - 12 Total El Camino - Los Gatos El Camino - Mt. View ,837 Good Samaritan ,314 Kaiser - San Jose ,394 Kaiser - Santa Clara ,699 O'Connor ,304 Regional - San Jose 999 1, ,060 1, ,089 Saint Louise ,389 Stanford ,570 VA - Palo Alto VMC 1,166 1,286 1,299 1,399 1,309 1,318 7,777 Total 5,786 6,399 5,885 6,276 6,050 5,818 36,214 Source: Santa Clara County Communications & Palo Alto Fire Department Table 2: Daily Average of Patients Transported By Hospital* Hospital Feb - 12 Mar - 12 Apr - 12 May - 12 June - 12 July - 12 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 Source: Santa Clara County Communications & Palo Alto Fire Department *Notes for Tables 1 and 2: These numbers only reflect patients that originated in Santa Clara County and were transported by the County's EOA Ambulance Provider and Palo Alto Fire Department. Data for Stanford does not include patients from San Mateo County. The data includes but, does not differentiate specialty center status (TRAUMA, STROKE, STEMI, BURN) Santa Clara County EMS l 976 Lenzen Avenue, Suite 1200 l San Jose, CA l Page 1 of 2 Page 148 of 157

149 Table 3: Total Monthly Hours of "AMBULANCE DIVERSION" Status Hospital Feb - 12 Mar - 12 Apr - 12 May - 12 June - 12 July - 12 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 Color Legend Above 37hrs Above 30hrs Below 30hrs Table 4: Total Monthly Hours of "STROKE / CT DOWN" Status* Hospital Feb - 12 Mar - 12 Apr - 12 May - 12 June - 12 July - 12 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 Table 5: Total Monthly Hours of "STEMI" Service Advisory Status* Hospital Feb - 12 Mar - 12 Apr - 12 May - 12 June - 12 July - 12 Total El Camino - Mt. View Good Samaritan Kaiser - San Jose Kaiser - Santa Clara O'Connor Regional - San Jose Stanford VMC Total Table 6: Total Monthly Hours of Trauma Center "BYPASS" Status Hospital Feb - 12 Mar - 12 Apr - 12 May - 12 June - 12 July - 12 Total Regional - San Jose Stanford VMC Total Santa Clara County EMS l 976 Lenzen Avenue, Suite 1200 l San Jose, CA l Page 2 of 2 Page 149 of 157

150 Page 150 of 157

151 County of Santa Clara Emergency Medical Services System Monthly Hospital Destination, Diversion and Advisory Status Report Report for Time Period: August 2012 Table 1: Number of Patients Transported to Hospital ED from System* Hospital Mar - 12 Apr - 12 May - 12 June - 12 July - 12 Aug - 12 Total El Camino - Los Gatos El Camino - Mt. View ,793 Good Samaritan ,323 Kaiser - San Jose ,403 Kaiser - Santa Clara ,691 O'Connor ,286 Regional - San Jose 1, ,060 1, ,063 6,153 Saint Louise ,411 Stanford ,570 VA - Palo Alto VMC 1,286 1,299 1,399 1,309 1,318 1,369 7,980 Total 6,399 5,885 6,276 6,050 5,818 6,045 36,473 Source: Santa Clara County Communications & Palo Alto Fire Department Table 2: Daily Average of Patients Transported By Hospital* Hospital Mar - 12 Apr - 12 May - 12 June - 12 July - 12 Aug - 12 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 Source: Santa Clara County Communications & Palo Alto Fire Department *Notes for Tables 1 and 2: These numbers only reflect patients that originated in Santa Clara County and were transported by the County's EOA Ambulance Provider and Palo Alto Fire Department. Data for Stanford does not include patients from San Mateo County. The data includes but, does not differentiate specialty center status (TRAUMA, STROKE, STEMI, BURN) Santa Clara County EMS l 976 Lenzen Avenue, Suite 1200 l San Jose, CA l Page 1 of 2 Page 151 of 157

152 Table 3: Total Monthly Hours of "AMBULANCE DIVERSION" Status Hospital Mar - 12 Apr - 12 May - 12 June - 12 July - 12 Aug - 12 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 Color Legend Above 37hrs Above 30hrs Below 30hrs Table 4: Total Monthly Hours of "STROKE / CT DOWN" Status* Hospital Mar - 12 Apr - 12 May - 12 June - 12 July - 12 Aug - 12 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 Table 5: Total Monthly Hours of "STEMI" Service Advisory Status* Hospital Mar - 12 Apr - 12 May - 12 June - 12 July - 12 Aug - 12 Total El Camino - Mt. View Good Samaritan Kaiser - San Jose Kaiser - Santa Clara O'Connor Regional - San Jose Stanford VMC Total Table 6: Total Monthly Hours of Trauma Center "BYPASS" Status Hospital Mar - 12 Apr - 12 May - 12 June - 12 July - 12 Aug - 12 Total Regional - San Jose Stanford VMC Total Santa Clara County EMS l 976 Lenzen Avenue, Suite 1200 l San Jose, CA l Page 2 of 2 Page 152 of 157

153 County of Santa Clara Emergency Medical Services System Monthly Hospital Destination, Diversion and Advisory Status Report Report for Time Period: September 2012 Table 1: Number of Patients Transported to Hospital ED from System* Hospital Apr - 12 May - 12 June - 12 July - 12 Aug - 12 Sep - 12 Total El Camino - Los Gatos El Camino - Mt. View ,730 Good Samaritan ,230 Kaiser - San Jose ,334 Kaiser - Santa Clara ,589 O'Connor ,233 Regional - San Jose 976 1,060 1, ,063 1,091 6,197 Saint Louise ,383 Stanford ,532 VA - Palo Alto VMC 1,299 1,399 1,309 1,318 1,369 1,281 7,975 Total 5,885 6,276 6,050 5,818 6,045 5,982 36,056 Source: Santa Clara County Communications & Palo Alto Fire Department Table 2: Daily Average of Patients Transported By Hospital* Hospital Apr - 12 May - 12 June - 12 July - 12 Aug - 12 Sep - 12 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 Source: Santa Clara County Communications & Palo Alto Fire Department *Notes for Tables 1 and 2: These numbers only reflect patients that originated in Santa Clara County and were transported by the County's EOA Ambulance Provider and Palo Alto Fire Department. Data for Stanford does not include patients from San Mateo County. The data includes but, does not differentiate specialty center status (TRAUMA, STROKE, STEMI, BURN) Santa Clara County EMS l 976 Lenzen Avenue, Suite 1200 l San Jose, CA l Page 1 of 2 Page 153 of 157

154 Table 3: Total Monthly Hours of "AMBULANCE DIVERSION" Status Hospital Apr - 12 May - 12 June - 12 July - 12 Aug - 12 Sep - 12 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 Color Legend Above 37hrs Above 30hrs Below 30hrs Table 4: Total Monthly Hours of "STROKE / CT DOWN" Status* Hospital Apr - 12 May - 12 June - 12 July - 12 Aug - 12 Sep - 12 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 Table 5: Total Monthly Hours of "STEMI" Service Advisory Status* Hospital Apr - 12 May - 12 June - 12 July - 12 Aug - 12 Sep - 12 Total El Camino - Mt. View Good Samaritan Kaiser - San Jose Kaiser - Santa Clara O'Connor Regional - San Jose Stanford VMC Total Table 6: Total Monthly Hours of Trauma Center "BYPASS" Status Hospital Apr - 12 May - 12 June - 12 July - 12 Aug - 12 Sep - 12 Total Regional - San Jose Stanford VMC Total Santa Clara County EMS l 976 Lenzen Avenue, Suite 1200 l San Jose, CA l Page 154 of 157

155 Santa Clara County EMS l 976 Lenzen Avenue, Suite 1200 l San Jose, CA l Page 2 of 2 Page 155 of 157

156 County of Santa Clara Emergency Medical Services System Monthly Hospital Destination, Diversion and Advisory Status Report Report for Time Period: October 2012 Table 1: Number of Patients Transported to Hospital ED from System* Hospital May - 12 June - 12 July - 12 Aug - 12 Sep - 12 Oct - 12 Total El Camino - Los Gatos El Camino - Mt. View ,769 Good Samaritan ,248 Kaiser - San Jose ,323 Kaiser - Santa Clara ,611 O'Connor ,275 Regional - San Jose 1,060 1, ,063 1,091 1,120 6,341 Saint Louise ,419 Stanford ,586 VA - Palo Alto VMC 1,399 1,309 1,318 1,369 1,281 1,364 8,040 Total 6,276 6,050 5,818 6,045 5,982 6,264 36,435 Source: Santa Clara County Communications & Palo Alto Fire Department Table 2: Daily Average of Patients Transported By Hospital* Hospital May - 12 June - 12 July - 12 Aug - 12 Sep - 12 Oct - 12 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 Source: Santa Clara County Communications & Palo Alto Fire Department *Notes for Tables 1 and 2: These numbers only reflect patients that originated in Santa Clara County and were transported by the County's EOA Ambulance Provider and Palo Alto Fire Department. Data for Stanford does not include patients from San Mateo County. The data includes but, does not differentiate specialty center status (TRAUMA, STROKE, STEMI, BURN) Santa Clara County EMS l 976 Lenzen Avenue, Suite 1200 l San Jose, CA l Page 1 of 2 Page 156 of 157

157 Table 3: Total Monthly Hours of "AMBULANCE DIVERSION" Status Hospital May - 12 June - 12 July - 12 Aug - 12 Sep - 12 Oct - 12 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 Color Legend Above 37hrs Above 30hrs Below 30hrs Table 4: Total Monthly Hours of "STROKE / CT DOWN" Status* Hospital May - 12 June - 12 July - 12 Aug - 12 Sep - 12 Oct - 12 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 Table 5: Total Monthly Hours of "STEMI" Service Advisory Status* Hospital May - 12 June - 12 July - 12 Aug - 12 Sep - 12 Oct - 12 Total El Camino - Mt. View Good Samaritan Kaiser - San Jose Kaiser - Santa Clara O'Connor Regional - San Jose Stanford VMC Total Table 6: Total Monthly Hours of Trauma Center "BYPASS" Status Hospital May - 12 June - 12 July - 12 Aug - 12 Sep - 12 Oct - 12 Total Regional - San Jose Stanford VMC Total Santa Clara County EMS l 976 Lenzen Avenue, Suite 1200 l San Jose, CA l Page 2 of 2 Page 157 of 157