BOARD OF SUPERVISORS HEALTH COMMITTEE PRESENTATION · 28/1/2013 · BOARD OF SUPERVISORS HEALTH...

ALAMEDA COUNTY EMS

BOARD OF SUPERVISORS HEALTH COMMITTEE PRESENTATION


January 28, 2013

ALAMEDA COUNTY EMS


OVERVIEW EMS SYSTEM

ALAMEDA COUNTY EMS


EMS SYSTEM OVERVIEW

• Response system consists of dispatch, first responder agencies, transporting ambulance providers, and hospitals

• Coordinated system began in 1973 with new position of Coordinator of EMS and Disaster Planning – Ben Mathews was first Coordinator

• EMS District formed in 1984 – assessment measure passed with over 80% to fund countywide paramedic service

• Reaffirmed in 1997 with 81.3% majority for “Measure C” • Current assessment is $27.68 per unit

ALAMEDA COUNTY EMS


EMS MISSION STATEMENT Alameda County EMS ensures the provision of quality

emergency medical services and prevention programs to improve health and safety in Alameda County.

Vision Statement Alameda County EMS will explore new frontiers while creating

an environment where collaboration and consensus building thrive among staff and stakeholders.

ALAMEDA COUNTY EMS


LOCAL EMS AGENCY (LEMSA)

• Alameda County EMS is a division of the Health Care Services Agency • EMS Director responsible for system oversight • Agency is designated to plan, implement, and

evaluate local EMS system • Charged by state with implementing statutes,

regulations, and local policies • Latest EMS System Plan approved by state EMS

Authority in June, 2011

ALAMEDA COUNTY EMS


LEMSA RESPONSIBILITIES

• Procurement of emergency ambulance services for countywide Exclusive Operating Area (EOA)

• Monitoring of contract compliance • Also contracts with Fire Department first responder

agencies for Advanced Life Support services (FRALS) • Additonal contracts with three Trauma Centers and

County Dispatch Center (ACRECC)

ALAMEDA COUNTY EMS


RFP & TRANSITION EMS SYSTEM

ALAMEDA COUNTY EMS


RFP AND TRANSITION

• Countywide paramedic service began in 1986 • American Medical Response (AMR) provided ambulance

service in EOA for 21 years – started with RFP process in 1990 • Early 2010 RFP competitive process opened for qualified

companies to bid on contract for largest EOA • Following rigorous review process, Paramedics Plus LLC (based

in Texas) chosen • Four cities excluded from EOA since they provide their own

ambulance transport – Alameda, Berkeley, Albany, and Piedmont

ALAMEDA COUNTY EMS


TRANSITION (CONTINUED)

• Paramedics Plus had over a year to plan for implementation of new system – AMR was a good partner during planning phase

• New provider began service at midnight on November 1st 2011

• Many AMR EMTs and Paramedics were hired – stipulation in contract

• System experienced only minor issues considering complexity of transition on 11/1/11

ALAMEDA COUNTY EMS



• Lucas Device for better CPR • Lifepak 15 monitor/defibrillators • Common radio frequency between fire and

ambulance • New ambulances (modular design) • New System Status Plan (“Marvlis” system) • Hydraulic stretchers

ALAMEDA COUNTY EMS



• New dispatch system also implemented with new contract – Medical Priority Dispatch System (MPDS)

• MPDS provides more robust call screening and pre-arrival instructions (national standard)

• New electronic patient care reporting system also implemented – gathers data from first responder and transport agencies

ALAMEDA COUNTY EMS


911 AMBULANCE PROVIDER CONTRACT

EMS SYSTEM

ALAMEDA COUNTY EMS


OVERVIEW AND SUMMARY OF CONTRACT

• Contract is a “high performance” contract between county and provider agency (one of the most strict in the country)

• Contractor (Paramedics Plus) agrees to provide all services in accordance with applicable state code (Health & Safety Code – Division 2.5) and regulations (Title 22, Division 9)

• Contractor must supply all resources necessary to meet response time standards and numerous other required performance measures

• Contractor must increase resources at its own expense to meet increased demand for services

ALAMEDA COUNTY EMS


• Paramedics Plus ambulances are dispatched by ACRECC – support is provided to dispatch center for system upgrades, workstations, computer aided dispatch (CAD) components

• Each ambulance and supervisor vehicle has necessary radio equipment for system-wide communications

• Vehicles have mobile computers also

CONTRACT (CONTINUED)

ALAMEDA COUNTY EMS



Contract maintains strict response time standards for urban, suburban/rural, and wilderness areas

Calls are categorized based on severity (Alpha, Bravo, Charlie, Delta, Echo)

Fines are assessed for non-compliance with response time standards

MPDS Dispatch Category METRO/URBAN SUBURBAN/RURAL WILDERNESS

Echo 08:30 min. 14:00 min. 18:00 min. Delta 10:30 min. 16:00 min. 22:00 min.

Charlie 15:00 min. 25:00 min. 28:00 min. Bravo 15:00 min. 25:00 min. 28:00 min. Alpha 30:00 min. 40:00 min. 40:00 min

ALAMEDA COUNTY EMS



Additional sections of contract include:

• Staffing (one EMT and one paramedic) for more serious calls • Transport destination – up to patient unless specific policies

apply (i.e. trauma activation, STEMI, CVA) • Mutual aid during disasters • Vehicle/equipment requirements • Electronic PCR system – data submission for use in quality

improvement efforts • Also includes unique partnership with hiring of EMS Corps

graduates

ALAMEDA COUNTY EMS


DISPATCH & FIRST RESPONSE EMS SYSTEM

ALAMEDA COUNTY EMS


DISPATCH AND FIRST RESPONSE

• 18 Public Safety Answering Points (PSAPs) in county that receive 9-1-1 calls

• Two centers are nationally accredited Emergency Medical Dispatch (EMD)/MPDS centers – Oakland Fire and ACRECC

• EMD centers provide pre-arrival instructions on topics such as CPR, choking, bleeding control, and childbirth

• Begins care before responders arrive on scene • Calls are reviewed for appropriateness – much like

review of clinical care provided to patient

ALAMEDA COUNTY EMS


DISPATCH AND FIRST RESPONSE (CONT.)

• Following fire departments provide ambulance transportation: City of Alameda, Albany, Berkeley, Piedmont

• Following fire departments provide First Responder Advanced Life Support (FRALS): Alameda County Fire, Fremont, Hayward, Livermore/Pleasanton and Oakland – these departments all have contracts with EMS and are financially compensated with pass-through funds from contract provider

ALAMEDA COUNTY EMS


DISPATCH AND FIRST RESPONSE (CONT.)

• First response agencies provide initial assessment and treatment on scene

• Provide report to arriving ambulance crew • Assist with moving of patient to ambulance • Provide extrication and other specialized rescue

services as needed • FR personnel ride-in with ambulance to help with

seriously ill or injured patients

ALAMEDA COUNTY EMS


PERFORMANCE AND CLINICAL QUALITY

EMS SYSTEM

ALAMEDA COUNTY EMS


Ambulance Zones

77.0%

78.0%

79.0%

80.0%

81.0%

82.0%

83.0%

84.0%

85.0%

86.0%

87.0%

88.0%

89.0%

90.0%

91.0%

92.0%

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%

Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12

Com

plia

nce

%

Alpha Level Calls Nov 2011 - Nov 2012 Zone 2 Alpha Zone 3 Alpha Zone 4 Alpha Zone 5 Alpha

77.0%

78.0%

79.0%

80.0%

81.0%

82.0%

83.0%

84.0%

85.0%

86.0%

87.0%

88.0%

89.0%

90.0%

91.0%

92.0%

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%


Com

plia

nce

%

Bravo Level Calls Nov 2011 - Nov 2012 Zone 2 Bravo Zone 3 Bravo Zone 4 Bravo Zone 5 Bravo

77.0%

78.0%

79.0%

80.0%

81.0%

82.0%

83.0%

84.0%

85.0%

86.0%

87.0%

88.0%

89.0%

90.0%

91.0%

92.0%

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%


Com

plia

nce

%

Charlie Level Calls Nov 2011 - Nov 2012 Zone 2 Charlie Zone 3 Charlie Zone 4 Charlie Zone 5 Charlie

77.0%

78.0%

79.0%

80.0%

81.0%

82.0%

83.0%

84.0%

85.0%

86.0%

87.0%

88.0%

89.0%

90.0%

91.0%

92.0%

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%


Com

plia

nce

%

Delta Level Calls Nov 2011 - Nov 2012 Zone 2 Delta Zone 3 Delta Zone 4 Delta Zone 5 Delta

77.0%

78.0%

79.0%

80.0%

81.0%

82.0%

83.0%

84.0%

85.0%

86.0%

87.0%

88.0%

89.0%

90.0%

91.0%

92.0%

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%


Com

plia

nce

%

Echo Level Calls Nov 2011 - Nov 2012 Zone 2 Echo Zone 3 Echo Zone 4 Echo Zone 5 Echo

ALAMEDA COUNTY EMS


STATISTICAL SIGNIFICANCE (COMPLIANCE)

0

200

400

600

800

1000

1200

1400

1600

ALPHA BRAVO CHARLIE DELTA ECHO

Zone 2 Zone 3 Zone 4 Zone 5

AVERAGE CALLS PER MONTH

77.0%

78.0%

79.0%

80.0%

81.0%

82.0%

83.0%

84.0%

85.0%

86.0%

87.0%

88.0%

89.0%

90.0%

91.0%

92.0%

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%


Com

plia

nce

%

Echo Level Calls Nov 2011 - Nov 2012 Zone 2 Echo Zone 3 Echo Zone 4 Echo Zone 5 Echo

77.0%

78.0%

79.0%

80.0%

81.0%

82.0%

83.0%

84.0%

85.0%

86.0%

87.0%

88.0%

89.0%

90.0%

91.0%

92.0%

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%

Com

plia

nce

%

Echo Nov 2011 - Nov 2012 (Adjusted) Zone 2 Zone 3 Zone 4 Zone 5

ALAMEDA COUNTY EMS


Performance and Clinical Quality

EMS SYSTEM

ALAMEDA COUNTY EMS


Increase the percentage of SCA victims who receive effective bystander CPR

– AHA’s CPR Anytime for Family &

Friends – CPR7-all 7th graders/families in

Alameda County trained in CPR

– ~10,000 7th graders trained each school year (2010-12)

PERFORMANCE AND CLINICAL QUALITY (CONT.)

NEW 2012 Custom CPR7 Box

ALAMEDA COUNTY EMS


COUNTYWIDE YIELD

45,000 Community members exposed to

the skill set of CPR annually!

ALAMEDA COUNTY EMS


PERFORMANCE AND CLINICAL QUALITY

BYSTANDER CPR

Year # VF/VT # Bystander CPR % of Bystander CPR

2007 196 77 39.29%

2008 129 48 37.21%

2009 157 66 42.04%

2010 163 86 52.76%

2011 172 76 44.18%

Total 1183 499 42.18% Table 4: Number and Percent of Bystander CPR (2007 – 2011)

ALAMEDA COUNTY EMS


CROWD SOURCING FOR OHCA

ALAMEDA COUNTY EMS


PERFORMANCE AND CLINICAL QUALITY (CONT.) Automatic External Defibrillator (AED) Program

• EMS Agency has been assisting with placing AEDs throughout

county for several years – certain requirements such as training and medical direction apply

• Start of 2012 – 1154 AEDs throughout county (that we are aware of – some are placed without going through us)

• 203 were placed last year - for total of 1357 in county • Paramedics Plus contributes ten per year per contract • Approximately 30 citizen uses per year – 5 to 10 survive to

hospital discharge

10%

16% 13%

28% 28% 32%

0%

10%

20%

30%

40%

% S

urvi

val

Cardiac Arrest Survival


SYSTEMS APPROACH TO CARDIAC ARREST

2005 2006 2007 2008 2009 2010

ACLS Updates: (2005 AHA)

Changes to Drug, Defibrillation and

CPR. One MPDS Center

AEDs required in health clubs. Changes to intubation

procedures

Intensive airway and enhanced

CPR training by Dr. Levitan.

CPR in the schools pilot project.

Res-Q-Pod CPR device added.

Re-emphasis on CPR technique. CPR7 program implemented.

Two MPDS Centers Mechanical CPR

trial

Induced hypothermia. Introduction of cardiac arrest

centers.

Ventricular Fibrillation / Pulseless Ventricular Tachycardia

Enhancements for Prehospital Cardiac Arrest Resuscitation

2012

ALAMEDA COUNTY EMS


Survival to Discharge, SCA and Received ACLS

Survival to Discharge, V Fib 0

10

20

30

40

REGIONAL VARIATION IN SURVIVAL


ALAMEDA COUNTY EMS



• STEMI: Treatment for STEMI is time sensitive: For patients that meet inclusion criteria (60%) of EMS activations, International guidelines as well as the American Heart Association recommend hospital door to intervention time is less than 90 minutes.

• ALCO STEMI Receiving Centers average time: 54 minutes.

• ALCO EMS 911 median dispatch to hospital time: 35 minutes.

2012 Countywide 911 to intervention time:

89 minutes

ALAMEDA COUNTY EMS



• STROKE: Treatment for acute ischemic/occlusive stroke is time sensitive: For patients that meet inclusuon criteria (20%) of EMS activations, International guidelines as well as the American Heart Association and American Stroke Association recommend IV fibrinolytic intervention started within 60 minutes of hospital arrival.

• ALCO STROKE Receiving Centers average time: 66 minutes. • ALCO EMS 911 median dispatch to hospital time: 34 minutes.

2012 Countywide 911 to intervention time:

100 minutes

ALAMEDA COUNTY EMS



Sepsis Alert Program • Sepsis is potentially life-threatening infection • High mortality rate – 20 to 50% • New program started December 1st 2010 • Screening Tool designed to identify potential sepsis patients -

“sepsis alert” is called into receiving hospital • Goal is to begin therapy in ED as quickly as possible

(antibiotics) – study with two hospitals

ALAMEDA COUNTY EMS


SYSTEMS BASED APPROACH

STEMI & CARDIAC ARREST

6 Centers

TRAUMA 3

Centers

STROKE 8 Centers

SEPSIS All 13

Hospitals

ALAMEDA COUNTY EMS


YEAR ONE LESSONS EMS SYSTEM

ALAMEDA COUNTY EMS


YEAR ONE LESSONS

• Paramedics Plus did a good job of setting up their system – were ready to go when the “switch was flipped”

• Transition took good collaboration between P+, EMS Agency, Fire Departments, ACRECC, and other stakeholders

• New dispatch system and patient care reporting system also worked well from outset – ACRECC running at approximately 99% compliance

ALAMEDA COUNTY EMS


YEAR ONE LESSONS

• Some challenges were identified during first several months of contract however:

- some confusion as to workforce representation (eventually resolved)

- workforce engagement issues - equipment issues (lack of familiarity) - scheduling and overtime issues

ALAMEDA COUNTY EMS


YEAR ONE LESSONS

• Survey was done by EMS Agency five months after transition to gauge workplace attitudes/issues

• Changes were made in some provider policies and procedures (including scheduling)

• Committees established with workforce to work on issues identified (equipment for example)

• Operational changes occurred

ALAMEDA COUNTY EMS


YEAR ONE LESSONS

• Electronic PCR system took time to fully implement in all fire departments

• Issues were identified with PCR system – various interfaces, access to data, ease of use

• Contract with vendor for system maintenance expired in December after one year – need identified for continued support from vendor

• New contract being developed with input from various stakeholders – goal is to have system that provides good record-keeping and useful data for quality improvement purposes

ALAMEDA COUNTY EMS


RECOMMENDATIONS

Future Contract Changes • Clean up language about upgrade and

downgrade of calls • Minimum number of calls in subcategory

(“bucket”) before fines are calculated • Rate analysis

ALAMEDA COUNTY EMS


FUTURE ISSUES EMS SYSTEM

Alameda County - Highland

Hospital (ACMC)

Alameda County - John George

Psychiatric Pavilion

Children's Hospital and

Research Center

Eden Medical Center

Kaiser Permanente -

Hayward

San Leandro Hospital St. Rose Hospital Washington

Hospital Willow Rock

Center

San Leandro 219 212 75 1757 1539 1806 313 40 32 Hayward 82 258 60 2309 2535 193 3338 353 35

0

500

1000

1500

2000

2500

3000

3500

4000

4500

Insured Patients | Destination Distribution (Greater than 50 Transports - Nov 2011-Nov 2012)

San Leandro Hayward

Alameda County - Highland

Hospital (ACMC)

Alameda County - John George

Psychiatric Pavilion

Children's Hospital and

Research Center

Eden Medical Center

Kaiser Permanente -

Hayward

San Leandro Hospital St. Rose Hospital Washington

Hospital Willow Rock

Center

San Leandro 171 149 60 742 98 876 132 9 35 Hayward 49 200 69 1076 280 75 1724 110 49

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Uninsured Patients | Destination Distribution (Greater than 50 Transports - Nov 2011-Nov 2012)

San Leandro Hayward

ALAMEDA COUNTY EMS


SUMMARY

• Alameda County has a “high performance” EMS system – second to none nationally

• An effective transition was accomplished in 2011 – new provider, PCR and dispatch systems

• Some “growing pains” were experienced - identified issues have been resolved or will be

• System still has some areas for improvement but will continue to evolve with stakeholder commitment and input

ALAMEDA COUNTY EMS


QUESTIONS?

BOARD OF SUPERVISORS HEALTH COMMITTEE PRESENTATION · 28/1/2013 · BOARD OF SUPERVISORS HEALTH...

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