BILL ANALYSIS Ó
AB 430
Page 1
Date of Hearing: April 28, 2015
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
AB 430
(Roger Hernández and Rodriguez) - As Amended April 20, 2015
SUBJECT: Trauma care systems.
SUMMARY: Requires local emergency medical services agencies
(LEMSAs) to commission an independent nonprofit organization or
governmental entity to conduct a comprehensive assessment of
their regional trauma system at least once every five years and
submit the results to the California Emergency Medical Services
Authority (EMSA). Requires EMSA to develop a statewide trauma
plan to address all aspects of a trauma care system and report
to the Legislature the status of the development or
implementation of the statewide trauma plan. Specifically, this
bill:
1)Requires a LEMSA implementing a trauma care system, as part of
the minimum standards for the implementation of a trauma care
system, to do all of the following:
a) Commission an independent nonprofit organization or
governmental entity qualified to assess trauma systems to
conduct an assessment at least once every five years of its
trauma system in conjunction with other LEMSAs in the same
region and with the regional trauma coordinating committee
(RTCC);
AB 430
Page 2
b) Submit the results of each assessment to EMSA at least
once every five years. Allows the RTCC, along with EMSA,
to determine if subsequent assessments are to occur on a
more frequent basis depending on the outcomes of the
initial assessment, as specified; and,
c) Establish an oversight committee composed of
representatives from county departments who have expertise
in trauma care systems, as well as in bioterrorism
preparedness programs, for the purpose of assisting, and
investigating the feasibility of, health facilities in
underserved areas serving as a trauma facility within the
trauma care system. Requires the oversight committee to
make recommendations and report on its activities to the
LEMSA.
2)Allows RTCCs to assess and provide recommendations to the
LEMSA and to EMSA. Requires the LEMSA implementing a trauma
care system to incorporate these recommendations into their
trauma care plans and submit these revised plans to EMSA for
approval.
3)Requires EMSA to develop a statewide trauma plan that
addresses all aspects of a trauma care system, including, but
not limited to, a statewide plan for trauma in the case of
bioterrorism, natural disasters, mass casualties, and access
to trauma care for rural and urban communities.
4)Requires EMSA to report the findings on the status and
development or implementation on the statewide trauma plan to
the Legislature by March 31, 2016. Sunsets this requirement
on March 31, 2020.
AB 430
Page 3
EXISTING LAW:
1)Establishes EMSA, which is responsible for the coordination
and integration of all state activities concerning emergency
medical services (EMS), including the establishment of minimum
standards, policies, and procedures.
2)Authorizes counties to develop an EMS program and designate a
LEMSA responsible for planning and implementing an EMS system,
which includes day-to-day EMS system operations.
3)Requires a LEMSA that elects to implement a trauma care system
to develop and submit a plan to EMSA according to the
regulations established prior to the implementation.
4)Requires EMSA to draft regulations specifying minimum
standards for the implementation of a trauma care system
including, among other things, data collection regarding
system operation and patient outcome, and periodic performance
evaluation of the trauma system and its components.
FISCAL EFFECT: This bill has not been analyzed by a fiscal
committee.
COMMENTS:
1)PURPOSE OF THIS BILL. According to the author, in 2002 Los
Angeles (LA) County voters passed Measure B, an initiative to
fund the trauma network countywide, maintain and expand the
trauma system, provide emergency room services, and tackle
bioterrorism. Measure B is a critical funding source to
maintain, improve, and expand the region's trauma system and
ensure the rates of diversion and wait times in emergency
rooms decrease in underserved communities. Last year, at the
AB 430
Page 4
request of the author, the California State Auditor reported
on deficiencies in the implementation of Measure B. The State
Auditor concluded that LA County is currently lacking the
ability to publicly demonstrate Measure B funds address the
most pressing trauma and emergency room needs in the region.
The Auditor recommends the establishment of an oversight
committee and the commission of a comprehensive regional
assessment.
The author states the goal of this bill is to provide better
accountability and transparency of Measure B funds in LA
County and institute best practices for trauma systems
statewide. The State Auditor found no evidence of a
comprehensive assessment to evaluate whether the LA County
Board of Supervisors (Board) has the best available data to
make evidence-based decisions regarding the investment of
Measure B resources. The author argues this bill will require
the Board to reestablish the Measure B Oversight Committee, as
it has not revisited its allocation of Measure B funds in over
a decade. To ensure strong fiscal stewardship of the funds
and ensure that the important trauma emergency services are
being provided, LA County must revisit decades old
information.
2)BACKGROUND.
a) Model Trauma System Planning and Evaluation. According
to the U.S. Department of Health and Human Services (HHS),
Health Resources and Services Administration, a trauma
system is a pre-planned, comprehensive, and coordinated
statewide and local injury response network that includes
all facilities with the capability to care for the injured.
It is the system's inclusiveness, or range of pre-planned
trauma center and non-trauma center resource allocation,
that offers the public a cost-effective plan for injury
treatment. In such an effective system, trauma care
delivery is organized through the entire spectrum of care
AB 430
Page 5
delivery, from injury prevention to prehospital, hospital,
and rehabilitative care delivery for injured persons. The
system begins with a state's authority to designate various
levels of trauma and burn centers and through data
collection and analysis processes, demonstrates its own
effectiveness time and time again.
According to the HHS Model Trauma System Planning and
Evaluation, injury is a leading cause of death in the
United States and continues to occur every day and in every
state. The rates are not declining and the threat is
magnified with the consideration of unexpected natural and
man-made incidents. A primary strategy of the public
health approach is to identify a problem based on data,
devise and implement an intervention, and evaluate the
outcome. These fundamental core functions of public health
are applied to public health assessment, policy
development, and evaluation mechanisms to ensure quality
patient outcomes.
Historically, trauma centers provided care to patients with
major injuries and focused mostly on tertiary prevention.
The trauma system, in contrast, should contribute to
reducing the entire burden of injury in a state, region, or
community. Therefore, it should integrate all three phases
of injury prevention into planning and practice. Improving
the injury health status of a community is far more complex
and extensive than just ensuring good trauma care of
injured patients. The population cared for in the trauma
system is diverse, that is, with wide regional variation in
age, ethnicity, and geography. To be most effective,
injury prevention resources need to be targeted and
customized to specific population groups. Only with the
full mobilization of the community's health care and public
health resources, in concert with the trauma system, will
injury prevention efforts be effective.
The ultimate evaluation outcome of trauma system
implementation is a reduction in morbidity and mortality.
AB 430
Page 6
This goal can be accomplished through trauma system
planning and implementation of process of care improvement,
enhancement of system performance, use of evidence-based
research, development and implementation of targeted injury
prevention programs, and revisions to trauma system plans
based on system assessments and data-based needs.
b) California's EMS System. California operates on a
two-tiered EMS system. EMSA is the lead agency and
centralized resource to oversee emergency and disaster
medical services. EMSA is charged with providing
leadership in developing and implementing local EMS systems
throughout California. California has 33 LEMSAs: seven
regional multi-county systems and 25 single-county
agencies. The regional systems are usually comprised of
small, rural, less-populated counties, and single-county
systems generally exist in the larger and more urban
counties. LEMSAs are responsible for planning,
implementing, and managing local trauma care systems,
including assessing needs, developing the system design,
designating trauma care centers, collecting trauma care
data, and providing quality assurance.
EMSA provides statewide coordination and leadership for the
planning, development, and implementation of local trauma
care systems. EMSA's responsibilities include the
development of statewide standards for trauma care systems
and trauma centers, the provision of technical assistance
to local agencies developing, implementing or evaluating
components of a trauma care system, and the review and
approval of local trauma care system plans to ensure
compliance with the minimum standards set by EMSA.
3)REGIONAL PLANNING. In 2008, EMSA defined five regions and
created corresponding RTCCs composed of trauma system
providers, LEMSA staff, and trauma system stakeholders from
within each region. The RTCCs serve in an advisory capacity
AB 430
Page 7
to promote regional cooperation, enhance and develop best
practices, assist with the analysis of regional data, and work
collaboratively with the state and LEMSAs to develop regional
policies and protocols in support of the State Trauma System.
4)STATEWIDE TRAUMA PLAN. In 2005, Governor Schwarzenegger
directed EMSA and the State Trauma Advisory Committee (STAC)
to complete the statewide trauma care plan. EMSA published a
planning document "California Statewide Trauma Planning:
Assessment and Future Direction" in 2006, which analyzes the
status of trauma care in the state and to make recommendations
for a California Statewide Trauma System. Since that time,
EMSA has been developing a Statewide Trauma Plan but has not
yet approved a final plan. EMSA has stated that the STAC is
reviewing the final draft of the State Trauma Plan.
5)LOS ANGELES COUNTY'S MEASURE B. In order to maintain and
expand the trauma system countywide, to ensure the continued
availability of EMS, and to respond effectively to biological
terrorism, voters in LA County approved Measure B in 2002.
With the passage of the measure, the LA Board of Supervisors
implemented a parcel tax of $0.03 per square foot on generally
all structural improvements, which it has increased over time.
In fiscal year 2011-12, the measure generated more than $256
million in revenue.
In recent years, concerns have been raised about the expenditure
of Measure B funds and whether they are being equitably
allocated throughout the county. Critics point to the fact
that parts of the area, such as eastern San Gabriel Valley,
are still lacking a trauma center. In 2013 the Joint
Legislative Audit Committee approved an audit by the State
Auditor to examine the spending of Measure B funds in LA
County. Among other things, the State Auditor recommended
that the LA County Board of Supervisors reinstate the Measure
B oversight committee, which was dissolved in 2004. The
Auditor also recommended that the LA County Board of
AB 430
Page 8
Supervisors use Measure B funds to perform a comprehensive
assessment, and to address any identified weaknesses in the
trauma system. In response, the LA County Board of
Supervisors stated that they had addressed the region's most
pressing trauma needs by adding two new private trauma
hospitals, adding 24/7 air medical transport services, and by
reducing overall mortality rates in LA County since 2002.
6)OPPOSITION. The EMS Administrators Association of California
and the EMS Medical Directors Association of California are
strongly opposed to this bill. This opposition writes that
currently, LEMSAs and their physician medical directors are
responsible for planning, implementing, and evaluating the
effectiveness of EMS trauma systems within their jurisdiction
in accordance with current EMSA regulations. LEMSAs, with the
oversight of EMSA and the Commission on EMS, currently perform
objective and independent trauma planning and system
evaluation. While there may be value on a case by case basis
for a LEMSA to voluntarily choose to conduct an assessment,
there exists no compelling argument to mandate a regional
trauma system assessment for each region. The increase in EMS
staff costs could surpass $100,000 a year in many counties.
Local jurisdictions would have no choice but to pass along
these costs to hospitals by increasing trauma center
designation fees.
The California State Association of Counties (CSAC) and the
Rural County Representatives of California (RCRC), also in
opposition, add that LEMSAs currently work closely with
existing RTCCs, which are voluntary committees that primarily
serve as a forum to share best practices for trauma care. By
elevating the role and responsibility of volunteer RTCCs, this
bill would usurp the proven ability of LEMSAs to effectively
and impartially oversee local EMS systems. CSAC and RCRC
contend that LEMSAs are currently required to develop and
submit a local trauma care plan to EMSA each year. Those
plans must enumerate the type, quality, and performance levels
of each of the emergency services components that the local
AB 430
Page 9
LEMSA oversees. This current framework is transparent,
accountable, and has served to support robust local EMS
systems for decades. CSAC states this bill would upend this
system by increasing the role of the volunteer RTCCs and
imposing additional mandates and costs on local LEMSAs.
7)RELATED LEGISLATION.
a) AB 70 (Waldron) changes the reporting requirement that
EMSA report annually to the Legislature on the
effectiveness of the statewide trauma system to once every
five years. AB 70 is currently pending hearing in the
Assembly Health Committee.
b) AB 503 (Rodriguez) allows a health facility to release
patient-identifiable medical information to an EMS provider
and to a LEMSA when specific data elements are requested
for the purpose of quality assessment and improvement.
Requires EMSA to develop minimum standards for the
implementation of this data collection system. AB 503 is
currently pending on the Assembly Floor.
c) AB 1129 (Burke) requires an emergency medical care
provider, when collecting and sharing data with a LEMSA, to
use a system compatible with California Emergency Medical
Services Information System and National Emergency Medical
Services Information System standards, as specified.
Prohibits a LEMSA from mandating that a provider use a
specific system to collect and share this data. AB 1129 is
currently pending hearing in the Assembly Health Committee.
8)PREVIOUS LEGISLATION.
a) AB 1975 (Roger Hernández) of 2014 would have required
LEMSAs to contract with the American College of Surgeons
every five years to conduct a comprehensive assessment of
the county trauma system. AB 1975 was held on the Suspense
file in the Assembly Appropriations Committee.
AB 430
Page 10
b) AB 1621 (Lowenthal and Rodriguez), also of 2014, would
have required EMSA to develop the State Emergency Medical
Services Data and Information System in order to assess
each EMS area or LEMSAs service area to determine the need
for additional EMS services, coordination of EMS services,
and the effectiveness of EMS. AB 1621 was held on the
Suspense file in the Senate Appropriations Committee.
c) SB 266 (Romero) of 2005 would have required EMSA to
establish a trauma care advisory committee and required the
committee to develop a statewide trauma care plan by
January 1, 2007. SB 266 was vetoed by Governor
Schwarzenegger, stating " I am directing EMSA, informed by
its Trauma Advisory Committee, to complete its statewide
trauma care plan and provide me recommendations by no later
than June 1, 2006."
d) AB 1988 (Diaz), Chapter 333, Statutes of 2002, requires
EMSA to convene a task force to study the delivery and
provision of EMS. Requires the task force, among other
things, to develop a plan to ensure that all Californians
are served by appropriate coverage areas for emergency and
trauma services and that sufficient numbers of emergency
departments and trauma centers exist to serve each area's
population.
REGISTERED SUPPORT / OPPOSITION:
Support
None on file.
AB 430
Page 11
Opposition
California State Association of Counties
Emergency Medical Services Administrators Association of
California
Emergency Medical Services Medical Directors Association of
California
Rural County Representatives of California
Analysis Prepared by:Patty Rodgers / HEALTH / (916) 319-2097