BILL ANALYSIS Ó
AB 1223
Page 1
Date of Hearing: May 12, 2015
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
AB 1223
(O'Donnell) - As Amended May 5, 2015
SUBJECT: Emergency medical services: ambulance transportation.
SUMMARY: Requires the Emergency Medical Services Authority
(EMSA) to develop, using input from stakeholders, a statewide
standard methodology for the calculation and reporting of
patient offload time by local emergency medical services (EMS)
agencies. Defines "ambulance patient offload time" as the
interval between the arrival of a patient transported by
ambulance at an emergency department (ED) and the time that the
ED assumes responsibility for care of the patient. Allows a
local EMS agency to adopt policies and procedures for
calculating and reporting ambulance patient offload time, as
specified.
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
local EMS agency responsible for planning and implementing an
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EMS system, which includes day-to-day EMS system operations.
3)Requires a local EMS agency that elects to implement a trauma
care system to develop and submit a plan to the 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.
5)Establishes the Joint Commission on Accreditation of
Healthcare Organizations (Joint Commission) that accredits
more than 20,000 health care organizations and programs,
including hospitals, hospital EDs, doctors' offices, nursing
homes, office-based surgery centers, behavioral health
treatment facilities, and providers of home care services.
FISCAL EFFECT: This bill has not been analyzed by a fiscal
committee.
COMMENTS:
1)PURPOSE OF THIS BILL. According to the author this bill
provides a definition for the term "ambulance patient offload
time" and requires EMSA to create a methodology that local EMS
agencies may use to create a policy for the measurement and
reporting of ambulance patient offload time appropriate for
their region. The author states this methodology will be
devised using stakeholder input and flexible enough to meet
the unique needs of each of the state's 33 local EMS agencies.
The author argues that delays in patient offload time are
becoming more of a problem than currently exists. A crucial
first step in dealing with this issue is to properly identify
and define what the issue is. The author concludes, this bill
creates a common definition and a standard way of measuring
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the problem across the state, while allowing for the
collection of the data needed address it.
2)BACKGROUND.
a) 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, and in setting standards for the
training and scope of practice of various levels of EMS
personnel. California has 33 local EMS systems that
provide EMS for California's 58 counties. (Seven regional
EMS systems comprised of 33 counties and 25 single-county
agencies provide the services.) Regional systems are
usually comprised of small, rural, less-populated counties,
and single-county systems generally exist in the larger and
more urban counties.
i) Local EMS agencies. Local EMS agencies 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.
ii) Trauma planning. 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.
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b) Emergency Departments. EDs are found in approximately
two out every three California hospitals. They are
licensed to provide 24-hour outpatient emergency medical
services and are a critical point of entry to inpatient
hospital care. EDs are licensed at a Standby, Basic, or
Comprehensive level depending upon the level of emergency
care provided.
The California Emergency Medical Services Authority (EMSA)
defines basic, standby, and comprehensive emergency
services as follows:
i) Basic service level provides emergency medical care
in a specifically designated part of the hospital that is
staffed and equipped at all times to provide prompt care
for any patient presenting urgent medical problems.
ii) Standby service level provides emergency medical
care in a specially designated part of the hospital that
is equipped and maintained at all times to receive
patients with urgent medical problems and is capable of
providing physician service within a reasonable time.
iii) Comprehensive service level provides diagnostic and
therapeutic services for unforeseen physical and mental
disorders that, if not properly treated, would lead to
marked suffering, disability, or even death. The scope
of services is comprehensive with in-house capability for
managing all medical situations on a definitive and
continuing basis.
c) EMSA Wall Time Collaborative (Collaborative). In 2012,
EMSA and the California Hospital Association, along with
other stakeholders including public and private EMS
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providers, joined together to collaborate on the problem of
delayed ambulance offload times (also called wall times,
patient parking, ambulance wait times, capture of emergency
medical services, patient handover delays, and patient
offload delays) and find solutions. There have been many
recent studies examining ways that can cut down the time
EMS personnel are waiting with a patient in the ED until
the hospital officially assumes responsibility of the
patient and EMS providers are released. The result of the
Collaborative is the "Toolkit to Reduce Ambulance Patient
Offload Delays in the Emergency Department." The
Collaborative Toolkit features process improvement models
and strategies to mitigate offload delays and suggests that
hospitals and EMS providers:
i) Develop metrics and measure uniformly;
ii) Develop best practices to address the problem;
iii) Dialogue with hospitals and medical systems;
iv) Encourage habitual offenders to improve; and,
v) Observe the impact of new Joint Commission metrics
on hospital throughput.
The Collaborative adopted the National Association of EMS
Physicians position statement that wall time is the
interval between arrival of an ambulance patient at the ED
until the EMS and ED personnel transfer the patient to an
ED stretcher and the ED staff assume the responsibility for
care for the patient. Some of the solutions agreed upon by
the Collaborative are rapid triage; have a physician in
triage; get patients off gurneys, if they are not needed;
institute observation areas and additional waiting
areas-treatment, lab, discharge; find solutions to decrease
traffic to the ED, including Mobile Integrated Healthcare
(Community Paramedicine) and interventions to decompress ED
EMS traffic, including: 9-1-1 triage; guidelines to
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evaluate and refer without transport when it is not needed;
establish alternate destinations; and, assist in
post-discharge patient integration and follow-up.
The Collaborative cites a study involving 200 cities
(including California cities) which found that the national
average wall time is over 45 minutes, double the average
time in 2006. The study found the results are a loss of
nearly five million hours of EMS system productivity. One
unnamed hospital in the study had 17,408 hours of wall time
in 2012, costing $2.6 million in lost production time for
crews. On average the hospital had a wall time average of
two to three hours and four ambulances waiting. According
to the Collaborative, fewer ambulances in the community may
result in longer response times; the inability for EMS
providers to meet contractual response obligations; costs
shifting from hospital to EMS systems; and, readiness cost
of paramedics and advanced life support units absorbed by
EMS system.
The Collaborative found the problem of ED overcrowding and
delayed ambulance offload times have increased nationally
and in other countries. The problem is complex and
multifactorial with causes that span the entire health care
delivery system, such as use of EDs by walk-ins, higher
patient volumes, and increased rates in the elderly
populations.
The Collaborative compared available data for several local
EMS agencies, looked at what other states are doing or have
done - including what legislation has been implemented, and
what other countries are doing. The British National
Health Service (NHS) Confederation in 2012 released the
publication, Zero Tolerance: Making Ambulance Handover
Delays a thing of the past. Patient handover means the
time when clinical handover has been completed and the
patient has been physically transferred onto a hospital
trolley bed, chair, or waiting area, and the ambulance
equipment has been returned to crew enabling them to leave.
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Handover is captured at this point in the process and the
expectation is that from arrival to handover occur within
15 minutes. Delays are jointly owned and considered a
whole system issue, although EMS systems charge hospitals
for any delays over 15 minutes and stipulates a zero
tolerance for delays more than one hour. The NHS
Confederation also established the term "never event" as an
unacceptable delay in patient handover and specified such
an event is a "serious, largely preventable patient safety
incident that should not occur if the available
preventative measures have been implemented by healthcare
providers." Also defined are ambulance arrival, clinical
handover, and patient handover. Ambulance arrival means
when the ambulance parks to offload the patient; clinical
handover means the time at which essential clinical
information about the patient has been passed from the
ambulance crew to a clinician within the ED.
d) Joint Commission. Joint Commission accreditation can be
earned by many types of health care organizations,
including hospitals, doctors' offices, nursing homes,
office-based surgery centers, behavioral health treatment
facilities, and providers of home care services. The Joint
Commission is designated by the Centers for Medicare and
Medicaid Services (CMS) as an accreditor for Medicare
initial certification, and can provide accreditation and
Medicare certification simultaneously. In order to earn
Joint Commission accreditation or certification, an
organization must first meet their state licensure
requirements. The Joint Commission sets higher standards
than the CMS Conditions of Participation (CoP). CMS
provides a baseline, but Joint Commission accreditation
goes beyond the CoP in addressing the delivery of safe,
quality patient care. The consultative nature of the Joint
Commission survey helps organizations and programs improve
patient care. The Joint Commission sets specific quality
standards and requirements for certification and
accreditation, but also provides recommendations,
guidelines, and planning assistance.
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The Joint Commission accreditation standards for Emergency
Department Patient Flow, effective January 1, 2014, state
that boarding is the practice of holding patients in the ED
or another temporary location after the decision to admit
or transfer has been made. The hospital should set its
goals with attention to patient acuity and best practice;
it is recommended that boarding time frames not exceed four
hours in the interest of patient safety and quality of
care. The Joint Commission recognizes that specific
ambulance offloading time frames will vary from one
organization to the next; for this reason, they have
established a four-hour time frame to serve as a guideline
to help hospitals set a reasonable goal for offloading.
The four-hour time frame is not a requirement for
accreditation because the Joint Commission recognizes that
meeting such a time frame is not, in some cases, within the
control of the accredited organization.
e) The Centers for Medicare and Medicaid Services. CMS
regulations recognize wall time or "parking" patients in
hospitals and refusing to release EMS equipment or
personnel jeopardizes patient health and impacts the
ability of EMS personnel to provide emergency services to
the rest of the community. CMS also states that delaying
ambulance ED offload may result in a violation of the
Emergency Medical Treatment and Labor Act (EMTALA); and,
raises serious concerns for patient care and the provision
of emergency services in a community. However, CMS
clarifies these regulations do not mean that "a hospital
will not necessarily have violated EMTALA 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 ED?. In some circumstances it
could 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. If the provider cannot perform an immediate
Medical Screening Exam, it must still triage the patient's
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condition immediately to ensure immediate intervention is
not required."
f) Community Paramedicine (CP). CP is a new and evolving
model of community-based health care in which paramedics
function outside their customary emergency response and
transport roles in ways that facilitate more appropriate
use of emergency care resources and/or enhance access to
primary care for medically underserved populations. The
aim of CP includes improving wall time waits, preventing
overuse of the 9-1-1 system for social or psychological
problems which don't require transport to or triage in an
ED; and, lessening the need for repeat ED visits or
readmissions. Interest in the CP model has substantially
grown in recent years based on the belief that it may
improve access to and quality of care while also reducing
costs.
Paramedics are presently trained to provide advanced life
support services in an emergency setting or during
inter-facility transfers. Current law limits paramedic
scope of practice to emergency care in the prehospital
environment and patients under the care of a paramedic are
required to be delivered to an ED. The paramedic scope of
practice in California is somewhat unique as compared to
other licensed health professionals in that it refers to
both a set of authorized skills/activities that EMS
personnel are allowed to perform and the places and
circumstances in which those skills/activities are allowed
to be performed.
Several other countries and states around the U.S., including
North Carolina, Colorado, Minnesota, Maine, and Texas, have
implemented variations of Community Paramedicine or a
comparable Advanced Practice Paramedic program. A full
Community Paramedic training curriculum approximately 200
hours in length has been developed by Community Healthcare
Emergency Cooperative (a multistate and multinational
collaborative) and the North Central EMS Institute in
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Minnesota. These programs have demonstrated that
paramedics can be trained to safely and effectively perform
an expanded role.
g) California CP Pilot Project. EMSA received approval
from the Office of Statewide Health Planning and
Development (OSHPD) to pilot Community Paramedicine in 12
sites across California. Beginning in January 2015, county
medical director selected Paramedics began receiving
specialized training that builds upon the training and
skill sets of experienced paramedics to include patient
assessment, clinical skills, and familiarity with the other
healthcare providers and social services available in a
local community. CPs will work under physician direction
and approved patient care protocols to ensure patient
safety while providing the right level of care for each
patient. OSHPD and EMSA have convened a Statewide Advisory
Committee to provide oversight of the pilot program to
ensure patient safety. Pilot sites are scheduled to begin
providing CP services in June 2015, the pilot sites
include:
-------------------------------------------------------------
| Lead Agency | Local EMS | Pilot Concepts |
| | agency | |
|----------------------+--------------+-----------------------|
|UCLA Center for Pre |Los Angeles |Alternate Destination |
|Hospital Care | | |
|----------------------+--------------+-----------------------|
|UCLA Center for Pre |Los Angeles |Post Hospital |
|Hospital Care | |Discharge Follow Up |
|----------------------+--------------+-----------------------|
|Orange County Fire |Orange County |Alternate Destination |
|Chief's Assoc | | |
|----------------------+--------------+-----------------------|
|Butte County EMS |Sierra-Sacrame|Post Hospital |
| |nto Valley |Discharge Follow Up |
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| |EMS | |
|----------------------+--------------+-----------------------|
|Ventura County EMS |Ventura |Directly Observed |
|Agency | |Treatment of TB |
|----------------------+--------------+-----------------------|
|Ventura County EMS |Ventura & |Hospice Support |
|Agency |Santa Barbara | |
|----------------------+--------------+-----------------------|
|Alameda County EMS |Alameda |Post Hospital |
|Agency |County |Discharge & Frequent |
| | |9-1-1 Callers |
|----------------------+--------------+-----------------------|
|San Bernardino County |San |Post Hospital |
|Fire Dept |Bernardino |Discharge Follow Up |
| |County | |
|----------------------+--------------+-----------------------|
|Carlsbad Fire Dept |San Diego |Alternate Destination |
|----------------------+--------------+-----------------------|
|City of San Diego |San Diego |Frequent 9-1-1 Callers |
|----------------------+--------------+-----------------------|
|Mountain Valley EMS |Stanislaus |Alternate Destination |
| |County |Mental Health |
|----------------------+--------------+-----------------------|
|Medic Ambulance |Solano County |Post Hospital |
| | |Discharge Follow Up |
-------------------------------------------------------------
3)SUPPORT. The California Fire Chiefs Association (CFCA),
sponsor of this bill, writes in support that current law
requires EMS providers when responding to 9-1-1 calls to
deliver their patients to licensed EDs. CFCA states that
patients suffering from serious medical conditions and those
with only minor issues go through the same process and are
delivered to the same type of facility; at the same time EDs
are busier than ever, this means that EMS responders are
spending more time waiting to offload patients at EDs and this
bill seeks to help alleviate this problem by requiring the
adoption of a methodology to keep track of wait times. CFCA
indicates that it is vital that as EDs and EMS providers take
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on a larger role in our healthcare system that state statutory
and regulatory frameworks are updated to reflect reality. The
California Professional Firefighters (CPF) also write in
support that this bill will establish an important first step
in defining "wall time" within the context of reducing or
altogether eliminating wall time in our EMS system. CPF
further writes that while a patient waits to be admitted to
the hospital, EMS personnel responsible for his or her care
cannot respond to other emergency calls while waiting to
transfer the patient. According to CPF, not only does this
prevent a patient from receiving appropriate and immediate
care, it poses a public safety risk by having fewer qualified
EMS personnel available to respond to other emergencies.
4)OPPOSITION. The Riverside County Regional Medical Center and
the Urban Counties Caucus both write in opposition to the
prior version of this bill, that although reducing ambulance
waiting times is an important issue, local EMS agencies are
currently working on a project to try and address one facet of
this issue and suggest a local solution over a statewide
construct, which may not work in all counties.
5)RELATED LEGISLATION.
a) AB 70 (Waldron) requires EMSA to report to the
Legislature information on the effectiveness of the
statewide EMS systems every five years instead of annually.
AB 70 is pending in the Assembly Health Committee.
b) AB 430 (Roger Hernández) requires local EMS agencies 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 EMSA. Requires EMSA to
develop a statewide trauma plan to address all aspects of a
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trauma care system and report to the Legislature the status
of the development or implementation of the statewide
trauma plan. AB 430 is currently on the Assembly
Appropriations Suspense File.
c) AB 1129 (Burke) requires an EMS provider, when
collecting and submitting data with a local EMS agency, to
use a system compatible with statewide and national
standards, as specified, and include those data elements
that are required by the local EMS agency. Prohibits a
local EMS agency from mandating that an EMS provider use a
specific system to collect and share this data. AB 1129 is
pending on Assembly Third Reading.
6)PREVIOUS LEGISLATION.
a) AB 1621 (Lowenthal and Rodriguez) would have required
EMSA to develop a single, statewide standard for reporting
prehospital emergency care in order to assess each EMS area
or local EMS agency 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 Senate
Appropriations Suspense File.
b) AB 1975 (Roger Hernández) would have required local EMS
agencies 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 Assembly
Appropriations Suspense File.
c) AB 2702 (Nuñez), Chapter 288, Statutes of 2008, allows
physicians providing services in a standby ED that was in
existence January 1, 2007, in a hospital in Los Angeles
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County to receive reimbursement from Proposition 99
(Tobacco Tax and Health Protection Act of 1988) and Maddy
EMS funds, as specified.
REGISTERED SUPPORT / OPPOSITION:
Support
California Fire Chiefs Association (sponsor)
California Professional Firefighters
Paramedics Plus
Opposition
California Medical Association (previous version)
County of San Diego Board of Supervisors (previous version)
Riverside County Regional Medical Center (previous version)
Urban Counties Caucus (previous version)
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Analysis Prepared by:Patty Rodgers / HEALTH / (916) 319-2097