BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                    AB 1223


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          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