Committee Report to State Council
Carole Snyder provide her EMS Commissioner report – the commission last met on 3/19. New Commission chair elected: Jim Dunford. Carole touched on our continued work to maintain the ENA Chair on the commission. The EMS-Trauma Committee last met in March, next meeting is June 5th. In March the challenge of collecting LOS data was discussed, in particular behavioral health patients and how do we define a psych hold. How do we standardize the definition of the metrics? Attendance at the annual California Hospital ED Forum has not increasing significantly and it has been suggested that the date and time of the forum be changed to separate it from the Behavioral Health Symposium. They also expressed interest in pairing with Cal ENA for this ED Forum. EMSA update: the State Trauma Regulation Revisions workgroup has requested an ENA rep. Sue is working with the committee to identify a rep. The paramedic regulations are currently open for revisions. Any comments are due by May 20th. If you have suggested comments to submit as a group please send them to me by May 16 to allow enough time for the board to review prior to submission. The EMSAAC (EMS Administrators Association of California) Conference was held last week, at this same lodge. Some great speakers and topics. The last panel of the day was related to wall times. One panelist administers a large ambulance company and he recently submitted a 2.6 million dollar bill to a hospital in his area – charging for their staff time due to off load delays. It cannot be emphasized enough the importance of the hospitals taking control of collecting accurate turn over of care times. The State is requesting LEMSA’s submit their offload times on July 1 and we expect it will be posted on the publicly facing EMSA website. The National Association of EMS Physician’s group recently started a California Chapter. Two highlights from the summary they provided: They are focusing on advocating over the critical drug shortages. Also they are having a CPR video challenge to get bystander CPR videos to go viral on social media platforms. Everyone is welcome to submit a video, in fact they are encouraging participation. They provided several links related to their blog and podcast, I’ll post the links on the website, on the EMS Committee page. The Emergency Medical Director Association of California or EMDAC, scope of practice committee approval an expanded scope for flight paramedics, including pediatric intubation. Specific criteria must be met for paramedics to practice with this expanded scope. We’ve been talking with leadership of the California Paramedic Foundation. They are focusing on several things but in particular the safety and wellness of EMS providers. There’s an opportunity here for a collaboration. Finally – two LEMSA administrator’s have expressed interest in ENA representation on their Emergency Medical Care Committees. We will follow up with specific chapter leadership.
We had a good first meeting, but we all miss Judy.
We discussed the previous agendas, added a few new items as regular business. We would love input on any changes we should make to the committee to best serve our member needs. As a start we’ve added the following to the agenda: report from EMS Administrators and Medical Directors (also known as EMSACC and EMDAC) and the National Association of EMS physicians (NAEMSP). We reviewed and discussed the possibility of updating this position statement in the future: Joint Position Statement from this group and ENA, published in 2014 entitled:
Transfer of Patient Care between EMS Providers and Receiving Facilities.
Carole provided her EMS Commission report: the STEMI, Stroke and EMSC regulations have all been approved. They are currently with the Office of Administrative Law for language tweaks – wordsmith of the regulations will not change the operational content of the regulations. We are all hopeful the regs will be in place by July. Community paramedicine pilot projects were extended by the governor for one more year. (December).
Ambulance off load times. It’s critical that each hospital devise a method to gather their own times, this should not be exclusively collected by EMS agencies. This information has been presented at the EMS Commission and we expect it to sooner rather than late be posted online for all to see and compare. Take control of your data, you want it to be accurate.
Finally, the California Paramedic Foundation has written a sweeping plan for the future, The Paramedicine Modernization Act, addressing Training, Treatment, and Transport. The leadership of this group would like our support.
The meeting was held @ 1130 Hours. We were pleased to hear the STEMI and Stroke Task Forces have completed their responsibilities. There is hope that the Community Paramedic programs may continue. This item is still under discussion. The EMS Committee would like to see a member from CA ENA attend the California Emergency Physicians meetings. There were two volunteers from the Sacramento area. If meeting are rotated between the North and South, we shall seek a volunteer from Southern CA. A letter will be written to the State Council. During several recent meetings involving ENA, it was found there is confusion between ENA and CNA. when you are representing ENA, be sure it is clear you are from ENA and they are not the same thing. Hospital Wall-time statistics are still not representing the hospital fairly.
At the November meeting, we reported the Stroke and STEMI Task Forces were complete. That has been reversed and we may see more information sent out for public comment this year. There is not an update on AB 909 – placing the Stop the Bleed kits in public buildings. With a new legislative session just beginning, we need to follow the progress of this legislation. AB 1650 – Community Paramedic Programs is currently at a standstill. We may see this legislation dropped or we may see it written allowing LEMSAs to make decisions independently for their jurisdiction. The EMS and the Government Affairs Committees recommend CA ENA stay neutral but follow this legislation As always we had an interesting discussion on Wall Time. San Bernardino County reported the ambulance company puts an EMT 1 in the ED hallway to watch over patients not turned over to the Emer Dept staff. Sometimes the EMS Committee has two or more subcommittees reporting the same information. We are going to try to combine reports to eliminate giving duplicate information. At each meeting it was decided to have a discussion segment. The topic shall be send in advance to all members who are on the current mailing list so members can prepare and gather facts and figures in advance.
EMS Commissioner Report
The Trauma regulations are starting to be revised. EMSA will align with the American College of Surgeon guidelines, their verification process and their quality improvement process as the regs are reviewed and revised. They will concentrate on tracking patients and secondary transfers which may flow over to other specialty transport regulations. Other issues for trauma are how to look at regional issues. Do the current RTCCs accomplish the desired goals? Do we need to re-look at that concept and how can we integrate the concept of some regional evaluation or care into regulations? There are EDs around our state, who are beginning to initiate medically-assisted therapy. In other words, start patients on SUBOXONE, as opioid replacement, through something called the ED-BRIDGE Program. Recently the Scope of Practice Committee has recommended and Dr. Backer approved several additions to Local Optional Scope of Practice. These were either recommended through trial studies that were approved by this Commission such as TXA, or approved through evidence-based literature reviews and these include IV acetaminophen, ketorolac or Toradol which can be given through multiple routes, ketamine. Also approval for paramedics to monitor IV medications during transport to a higher level of care, medications that are initiated at the sending facilities, such as blood, pressors, anticoagulants and antibiotics. Per Dr. Backer-These expansions to Local Optional Scope of Practice provide better patient care, especially for our rural areas and our regional systems of specialty care when it is preferable to transport by paramedic ground ambulance because CCT is not readily available and air ambulance might be too much and too expensive. Dr. Backer announced his retirement from EMSA.
This is copied from the minutes “DEPUTY DIRECTOR OF LEGISLATIVE, REGULATORY & EXTERNAL AFFAIRS LIM: The next bill is the AB 1544 and that is Community Paramedicine or Triage to Alternate Destination Act. This bill would authorize the local EMS agency to adopt a community paramedicine or triage to alternate destinations program and provide community paramedicine services, in which we have had pilot programs since 2014. This bill would require EMSA to develop regulations to establish minimum standards. It also would augment the Commission as it stands now in its compilation, among other features of the bill. Again, this bill has had a similar look in last session and that bill was 3115, I believe. I can’t remember but before that it was SB 944. We understand there is a lot of discussion around this bill. Is there any discussion that anyone would like to have? CHAIR DUNFORD: Commissioner Barrow. COMMISSIONER BARROW: This bill is a pretty contentious bill at the Capitol and there are alternative legislators exploring alternatives because they are unhappy with different provisions in this. One of the biggest concerns is the local political and monetary costs associated with this bill in changing EMS system unnecessarily when there is already a collaborative setting at LEMSA to handle CP. I think there is going to be more legislation coming out soon. The administration has made it really clear that they are not really happy that this is the only discussion happening at the Capitol so it will be interesting to see what happens by our September meeting, what the landscape looks like on this. DEPUTY DIRECTOR OF LEGISLATIVE, REGULATORY & EXTERNAL AFFAIRS LIM: Thank you. CHAIR DUNFORD: And Commissioner Snyder. COMMISSIONER SNYDER: Carole Snyder, Emergency Nursing Association. Just to reiterate, this is a sneaky bill that changes the makeup of this commission. It removes the Emergency Nursing Association and it removes the California Paramedic Association, which are not representing anything but the right type of care. And I just want to reiterate that if it was a clean bill ENA may be in support of it; but we are definitely in opposition right now and I would like you guys to take that into consideration. CHAIR DUNFORD: Thank you. Other comments? Commissioner Uner. COMMISSIONER UNER: I would like to second what Carole just said. I think removing emergency nurses and paramedics from this commission is not a good move. CHAIR DUNFORD: Thank you. Others? Commissioner Hinsdale. COMMISSIONER HINSDALE: Echo that, also agree with Carole. Thank you.
Minutes to EMSA commission meeting can be found on the EMSA site: https://emsa.ca.gov/ems_commission_meetings/ Stroke and STEMI regulations were adopted, the full text of the proposed final regulations is posted on the website. Ambulance Patient Offload Time Update Mr. McGinnis stated staff continues to collect and work with data from the Ambulance Patient Offload Time project. 17 LEMSAs have provided information this year compared to 18 last year. Staff is learning more about ways to display this data. In working with the LEMSAs, staff learned that forms and ways data is collected can be difficult at times and is working to improve the process. Mr. McGinnis stated his hope that more submissions and more information will continue to come in and that, as staff learns better ways to visually display the information, it will present a good picture of what is happening in the state. Questions and Discussion Commissioner Dunford asked if there is any trend in favor of showing improvement based on the limited capacity of the current data. Mr. McGinnis stated there is no definitive trend. Dr. Backer noted that the data is only for the first year, 2017. There is variation year by year. Commissioner Dunford stated there are some significant outliers and asked if there is evidence of people trying to fix major problems. Mr. McGinnis stated it is early to say concretely. Action: Commissioner Stone moved to accept the ambulance patient offload time update as presented. Commissioner Burch seconded. . EMS Quality Core Measures Guidelines were approved. Alternate Destination The EMSA received a letter from EMS administrators and medical directors advocating implementing alternate destination by policy rather than seeking it legislatively. Staff will work with EMS administrators and medical directors on best strategies to achieve this. Disaster Medical Medical care support in times of disaster is one of EMSA’s key responsibilities. Medical and mental health care issues in shelters during large-scale evacuations are often underestimated. Individuals who end up in shelters often require a higher level of care because their usual home health care resources are unavailable in general population shelters. There is a need to explore alternative resources and concepts to medical shelters.
Minutes to EMSA commission meeting can be found on the EMSA site: https://emsa.ca.gov/ems_commission_meetings/
Core Measures: EMSA has revised the Core Measures program to accommodate the transition to the NEMSIS Version 3.4 standards. EMSA initiated an ad-hoc work group comprised of EMS stakeholders to enhance the existing Core Measure set. This group, which met on November 2nd, 2017, reviewed each of the California Core Measures as well as those developed through the EMS Compass Initiative. The recommendations from the ad-hoc group were discussed and reviewed by the Core Measures Task Force on November 28, 2017. The EMSA commission deferred approval until the June meeting.
Disaster: There will be a 4% cut to HPP funding for the state.
Drug Shortages: EMSA is reporting pain medication shortages and is considering adding Ketamine, IV Tylenol and Nirtous Oxide to the optional scope of practice for paramedics.
Regulations: The following information is an update to the regulation rulemaking calendar approved by the Commission on EMS on December 6, 2017. In accordance with Health and Safety Code Section 1797.107, the Emergency Medical Services Authority is promulgating the following regulations: EMSC Open for public comment until April 30th. STEMI and Stoke regulations passed through finance department.
APOT: Ambulance patient offload times: Ambulance patient offload times (APOT) continue to be submitted quarterly to EMSA. To date, 15 of the 33 LEMSAs have provided at least one Quarter’s worth of APOT information, represented 238 (non-unique) hospitals for 2017 Data. Of those reporting LEMSAs, only 8 LEMSAs provided the full years’ worth of 2017 data. Currently, EMSA is working to develop a repository for this information to enhance the ability for review and analysis. Doing so will help to streamline future submissions of APOT information. Additionally, EMSA revised the APOT reporting spreadsheet to include clearer instructions, formatting enhancements, additional aggregate information, and cost per unit hour. EMSA continues the review of APOT submissions and is working to determine the best ways to visualize the information in a meaningful way. LEMSAs are encouraged to complete and submit APOT information to EMSA each quarter and continue to monitor and analyze APOT data to help identify and implement quality improvement strategies where needed.
The DHV Program has over 23,500 volunteers registered. Over 20,900 of these registered volunteers are in healthcare occupations. All 58 counties have trained DHV System Administrators in their MHOAC Programs. EMSA provides routine training and system drill opportunities for all DHV System Administrators. Over 9,300 of the 23,500 plus DHV registered responders are Medical Reserve Corps (MRC) members. EMSA publishes the “DHV Journal” newsletter for all volunteers on a tri-annual basis. The most recent issue was released on January 29, 2018. The “DHV Journal” is available on the DHV webpage of the EMSA webpage: http://www.emsa.ca.gov/disaster_healthcare_volunteers_journal_page. The DHV website is: https://www.healthcarevolunteers.ca.gov.
Ongoing technical support and clarification is provided to public safety agencies, LEMSA’s and the general public regarding all AED statutes and regulations. EMSA is working on a webpage to provide information regarding AED statutes for clarification. Review and approval of public safety AED programs according to Chapter 1.5 Section 100021 continues.
California EMSA met September 13 in San Diego:
Jennifer Lim, EMSA Deputy Director of Policy, Legislative, and External Affairs, spoke about two bills that are inactive at this point but were significant and continue to be on the serious watch list for the two-year session. • AB 263 (Rodriguez) is entitled Emergency Medical Services Workers Rights and Working Conditions. It would require private employers that provide ground emergency medical services to authorize and permit its employees engaged in pre-hospital emergency services a prescribed rest and meal period. It would also require EMSA to publish an annual report containing specified information regarding violent incidents involving EMS providers. • AB 1116 (Grayson) is entitled Peer Support and Crisis Referral Services Act. It would create a Peer Support and Crisis Referral Services Program under the California Office of Emergency Services (Cal OES) with three separate tracks: o Fire service o Correctional officers o Rescue or emergency responders The Commission had some concern about the communication between the peer support member and the employee being confidential and not subject to civil or administrative disclosure.
Data: The Core Measures Report for the 2016 information will be posted soon, as will the report from UC Davis on how the Core Measures program is going. Dr. Backer felt that it is time to take a new look at the Core Measures – especially since all the providers in the state have moved over to the National EMS Information System (NEMSIS) 3.4 which gives more uniform and consistent data across the board. Data problems are now coming from the field entry level; we need to work with providers to not shortcut data entry. As they become facile in working with their ePCRs, they need to know the most important fields and the most important data to enter consistently.
APOT This Commission has shown an interest in ambulance patient offload times and delays (APOT). Because of the statute and our efforts to make standardized reporting, we need to see a statewide picture of APOT. Therefore, we are going to make the argument that we need all of the local EMSAs (LEMSAs) to report this data. An EMS fellow is going to work with us to write a report on the process. The next EMS Commission meeting will be held on December 6. Regards, Carole Snyder, RN.
Statewide Trauma Planning:
- The Trauma Plan was revised and renamed. This does not require the same levels of approvals a state-approved plan, which had unforeseen challenges.
- The American College of Surgeons’ Report on the California state-level trauma system review has now been posted on the EMSA website.
The first data on the ambulance patient offload times has started to arrive. The data confirms that the problem is localized, but it also confirms that the problem can be managed, since some health care systems with similar volumes have resolved the problem. Further data will point out examples of best practices and will also point out which medical centers the local EMS agencies and the California Hospital Association (CHA) need to work with to help improve this problem.
Community Paramedic Pilot Program Update:
The majority of the projects are moving forward with no difficulties.
The Alternate Destination Urgent Care Project has relatively few patients enrolled to date.
The UCLA Project in Santa Monica terminated on June 1st at the request of the fire chief due to the lack of patient enrollment.
The Carlsbad and Orange County urgent care projects are still active but do not have enough enrollees to support meaningful data analysis.
The San Francisco City and County Alternate Destination Sobering Center project is growing and is enrolling over one hundred patients per month.
California State EMS Commission Meet June 20, 2018
Ketamine: Commission passed- Move Ketamine from Trial Study to Local Optional Scope
Community Paramedicine: The Community Paramedicine Project Manager and the Independent Evaluator are funded by the California HealthCare Foundation. Local pilot site providers participate with in-kind contributions and any local grants or reimbursement. Strong progress continues with the Community Paramedicine Projects. The data, as well as the independent evaluator’s public report continues to show these projects have improved patient care as well as having reduced hospital re-admissions and visits to emergency departments. The UCSF’s Healthforce Center issued an update Evaluation Report in February 2018, containing their findings for the first 28 months of the project, (see link below) which in summary states:
“The evaluation found that community paramedics are collaborating successfully with physicians, nurses, behavioral health professionals, and social workers to fill gaps in the health and social services safety net. The evaluation has yielded consistent findings for six of the seven community paramedicine concepts tested. All of the post-discharge, frequent 911 users, tuberculosis, hospice, and alternate destination – mental health projects have been in operation for 21 or more months and have improved patients’ well-being. In most cases, they have yielded savings for payers and other parts of the health care system. Preliminary findings regarding the sixth concept, alternate destination – sobering center, suggest that this project is also benefiting patients and the health care system.” The following links contain the UCSF February 2018 Evaluation Report as well a Research Highlight Document: https://healthforce.ucsf.edu/publications/evaluation-california-s-communityparamedicine-pilot-program
The following is a status update on the additional Pilot Projects:
|Local EMS Agency||Sponsor||Concepts||Status|
|Santa Clara County||Santa Clara County EMS||Agency Alt Destination Behavioral Health Alt Destination Sobering Center||CORE and Site-specific training has been completed, an IRB has been approved for this Pilot Project OSHPD implementation approval is pending.|
|Sierra Sacramento Valley||Dignity Health||Post Discharge||CORE and Site-specific training and an approved IRB are pending|
|El Dorado County||Cal Tahoe JPA||Alt Destination Behavioral Health Post Discharge||This project has withdrawn due to lack of JPA Board approval and funding.|
|Marin County EMS Agency||–||Frequent 911 User||CORE and Site-specific Training and an approved IRB are pending, awaiting the outcome of the Legislative process.|
|City & County of San Francisco||San Francisco Fire Department||Frequent 911 User Alt Destination Behavioral Health Post Discharge||Site-specific Training and an approved updated IRB are pending.|
|Central California EMS Agency||Central California EMS Agency||Alt Destination – Behavioral||CORE and Site-specifc Training has been completed. Currently awaiting an approved IRB|
There are currently two (2) pieces of Legislation making their way through the legislative process which would enable the ability for EMSA and the Local EMS Agencies to approve Community Paramedicine and/or Alternate Destination to Mental Health Facilities or Sobering Centers programs throughout the State of California.
AB 1795 (Gipson) Allows a local emergency medical services agency (LEMSA) to submit, as part of its emergency medical services (EMS) plan, a plan to transport specified patients who meet triage criteria to a behavioral health facility or a sobering center. This bill authorizes a city, county, or city and county to designate, and contract with, a sobering center to receive patients, and would establish sobering center standards. Specifies the training requirements for paramedics to transport individuals to behavioral health facilities. Requires the Emergency Medical Services Authority (EMSA) to adopt guidelines for the triage criteria and assessment procedures by July 1, 2020 and requires EMSA to annually analyze administration of local plans and issue a report. (Sponsored by California Hospital Association (CHA) & Los Angeles County)
SB 944 (Hertzberg)
This Bill is sponsored by the California Professional Firefighters (CPF)
The Bill would enact the Community Paramedicine Act of 2018. This bill would create the statutory authority to transition community paramedicine (CP) from the Health Workforce Pilot Project #173 to a statewide program. The bill would authorize local EMS agencies to develop a community paramedicine program that is consistent with regulations that would be developed by the Emergency Medical Services Authority (EMSA), in consultation with the Community Paramedicine Medical Oversight Committee, which would be formed by this bill. Community paramedicine programs would provide services in one or more of the following five roles: (1) providing short term post discharge follow up; (2) providing directly observed tuberculosis therapy; (3) providing case management services to frequent emergency medical services users; (4) providing hospice services in coordination with hospice nurses to treat patients in their homes; and, (5) providing patients with transport to an alternate destination, which can either be an authorized mental health facility or an authorized sobering center.
Disaster: EMSA is working with CDPH to acquire funding to develop a Crisis Care/Scarce Resources guidance document.
The DHV Program has over 23,700 volunteers registered. There are over 21,000 healthcare occupations filled by registered volunteers. All 58 counties have trained DHV System Administrators in their MHOAC Programs. EMSA provides routine training and system drill opportunities for all DHV System Administrators. Over 9,300 of the 23,700 plus DHV registered responders are Medical Reserve Corps (MRC) members. EMSA trains and supports DHV System Administrators in each of the 36 participating MRC units. DHV System Administrator training, DHV user group webinars, and quarterly DHV drills are ongoing. On, April 4, 2018, EMSA conducted a quarterly DHV drill for System Administrators. On April 11, 2018, EMSA conducted a quarterly DHV User Group webinar.
Patient Movement Plan: EMSA is currently incorporating comments received during the public comment period. The release of the California Statewide Patient Movement Plan will be summer 2018.
Epinephrine Auto-injector Training and Certification: On January 1, 2016 the EMS Authority began accepting applications for training programs to provide training and certification for the administration of epinephrine auto-injectors to the general public and off-duty EMS personnel. EMSA has approved14 training programs and has issued 717 lay rescuer certification cards.
STEMI/Stroke Systems of Care: STEMI and Stroke Regulations EMSA has opened the rulemaking process with the Office of Administrative Law for the Stroke and STEMI regulations. The public was invited to submit written comments on the proposed regulations during the 45-day public comment period from April 6, 2018, through May 21, 2018. At the end of the public comment period, EMSA held a public hearing on May 21, 2018, beginning at 9:00 am and ending at 11:00 am to go over the regulations with any member of the public who had questions. The comments received during the comment periods will be reviewed against the draft regulations and considerations for change will be made. Should substantive changes be indicated, EMSA will engage the working group who helped develop the regulations prior to an additional comment period.
EMS for Children Program:
Regulations: The EMS for Children regulations completed the 45-day public comment period on Friday, April 27, 2018. The public hearing was held on Monday, April 30, 2018. NO members of the public appeared at the hearing to discuss the EMSC regulations draft. Revisions to the draft EMSC regulations are being considered based on the comments received during the first comment period. EMSA is engaging the EMSC TAC to assist us with revision considerations. Upon the completion of the revisions, a second comment period will be held.
Educational Forum: The 21st Annual EMS for Children Educational Forum will be held on Friday,
November 9, 2018 in Fairfield, CA. The venue has changed to the North Bay HealthCare Administration Center. Speakers and vendors/sponsors are being recruited for the forum.
The EMSC Program survey of California hospitals for Performance Measures EMSC 06 and 07 will be conducted May – August 2018. This survey will pertain to EMSC Interfacility Transfer Guidelines and Agreements of pediatric patients.
Legislative Report: http://www.emsa.ca.gov/current_legislation
Are You Registered?
The California State Emergency Medical Services Authority (EMSA) is always making strides to better prepare our State for disasters. While California does well in disaster situations because of its preparedness and mitigation activities, new resources are frequently added to enhance our response including a statewide volunteer registry for healthcare professionals called Disaster Healthcare Volunteers (DHV).
The Disaster Healthcare Volunteers (DHV) program is California’s solution to the nationwide Emergency System for Advance Registration of Volunteer Healthcare Professionals (ESAR-VHP). It’s a system specifically designed for California and its 58 counties to identify, recruit and mobilize healthcare professionals that are willing to volunteer their services and skill sets to assist locally and regionally in times of need. The registry is strictly voluntary. You can opt to help when you can and decline if you are unable to assist. And whether you’re already committed to a response team (D-MAT, MRC), DHV provides you with another opportunity to help out in case your response team is not deployed.
By registering with Disaster Healthcare Volunteers at www.healthcarevolunteers.ca.gov, you will be joining many of your professional colleagues who have already committed themselves to volunteering when they can to mitigate the negative impact disasters have on a community, including saving the lives of others.