BILL ANALYSIS                                                                                                                                                                                                    ”

                          Senator Ed Hernandez, O.D., Chair

          BILL NO:                    AB 1223             
          |AUTHOR:        |O'Donnell                                      |
          |VERSION:       |June 30, 2015                                  |
          |HEARING DATE:  |July 8, 2015   |               |               |
          |CONSULTANT:    |Vince Marchand                                 |
           SUBJECT  :  Emergency medical services: ambulance transportation.

           SUMMARY  :  Requires the Emergency Medical Services Authority (EMSA) to  
          adopt a statewide standard methodology for the calculation and  
          reporting by a Local Emergency Medical Services Agency (LEMSA)  
          of ambulance patient offload time, and permits a LEMSA to adopt  
          policies and procedures for calculating and reporting ambulance  
          patient offload time using the statewide methodology adopted by  
          EMSA. Requires, if a LEMSA adopts a policy for calculating and  
          reporting ambulance patient offload time, to establish criteria  
          for the reporting of, and quality assurance follow-up for, a  
          "nonstandard patient offload time."

          Existing law:
          1)Establishes EMSA, which is responsible for the coordination  
            and integration of all state activities concerning EMS,  
            including the establishment of minimum standards, policies,  
            and procedures. 

          2)Requires EMSA, utilizing regional and local information, to  
            assess each EMS area or the system's service area for the  
            purpose of determining the need for additional emergency  
            services, and the coordination and effectiveness of EMS.

          3)Requires EMSA to develop planning and implementation  
            guidelines for EMS systems which address specified components,  
            including communications, system organization and management,  
            and data collection and evaluation.

          4)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.  


          AB 1223 (O'Donnell)                                Page 2 of ?
          5)Establishes an 18-member Commission on EMS, within the  
            California Health and Human Services Agency (HHSA).  Defines  
            the duties of the Commission to include reviewing regulations,  
            standards, and guidelines developed by EMSA; advising EMSA on  
            a data collection system; advise on emergency facilities and  
            services, emergency communications, medical equipment,  
            personnel training, and various aspects of the EMS system;  
            and, to make recommendations for further development of the  
            EMS system.
          This bill:
          1)Requires EMSA to develop, and after approval by the Commission  
            on EMS, adopt a statewide standard methodology for the  
            calculation and reporting by a LEMSA of ambulance patient  
            offload time, using input from stakeholders, including, but  
            not limited to, hospitals, LEMSAs, and public and private EMS  

          2)Defines "ambulance patient offload time" as the interval  
            between the arrival of an ambulance patient at an emergency  
            department, and the time that the patient is transferred to an  
            emergency department gurney, bed, chair, or other acceptable  
            location and the emergency departments assumes responsibility  
            for care of the patient.

          3)Permits a LEMSA to adopt policies and procedures for  
            calculating and reporting ambulance patient offload time, and  
            requires a LEMSA that adopts these policies and procedures to  
            do all of the following:

                  a)        Use the statewide standard methodology for  
                    calculating and reporting patient offload time  
                    developed by EMSA pursuant to this bill; and,
                  b)        Establish criteria for the reporting of, and  
                    quality assurance follow-up for, a "nonstandard  
                    patient offload time," as defined in this bill. 

          4)Defines "nonstandard patient offload time" as an offload time  
            that exceeds a period of time designated in the criteria  
            established by the LEMSA, but excludes from this definition  
            instances in which the offload times exceeds the designated  
            period of time due to acts of God, natural disasters, or  
            manmade disasters. 



          AB 1223 (O'Donnell)                                Page 3 of ?
          EFFECT  :  According to the Assembly Appropriations Committee,  
          this bill will result in minor and absorbable costs to EMSA  
          (General Fund or federal grant funds).

          VOTES  :  
          |Assembly Floor:                     |76 - 0                      |
          |Assembly Appropriations Committee:  |15 - 0                      |
          |Assembly Health Committee:          |19 - 0                      |
          |                                    |                            |
          COMMENTS  :
          1)Author's statement.  According to the author, when someone is  
            picked up by an ambulance, they are taken to a hospital  
            emergency department. Once the patient is in the ambulance the  
            EMS crew becomes responsible for their care until they are  
            signed over to hospital staff. 
          Patients who are suffering from a serious medical condition are  
            quickly admitted into the hospital, but that is often not the  
            case with patients with minor issues, who have to wait for a  
            hospital bed to become available. A national study found that  
            patient offload times had more than doubled since 2006, from  
            25 minutes to 45 minutes. Offload times in some parts of  
            California can be much longer. EMSA reports that 13 of the  
            states' 33 LEMSAs identified the problem of ambulance patient  
            offload times as an issue. These 13 agencies serve 70 percent  
            of the state's population. While some individual counties and  
            hospitals have taken actions to alleviate the issue there has  
            been no uniform, statewide, or comprehensive attempts to solve  
            the problem of patient offload times or even define it.  
            Without a common vocabulary when discussing this issue the  
            state can't begin to identify the problem let alone devise  

          2)Background and creation of toolkit to address offload delays.  
            In 2013, the California Hospital Association and EMSA created  
            the Ambulance Patient Offload Delay Collaborative to analyze  
            and develop solutions for the offload delays that were  
            increasing pressure on both hospitals and ambulance providers.  
            The goals of this collaborative were to: 1) develop  


          AB 1223 (O'Donnell)                                Page 4 of ?
            standardized language, definitions, metrics and reporting  
            opportunities for ambulance patient throughput; 2) identify  
            ways to reduce delays and improve transfer times; and, 3)  
            assist local jurisdictions in developing processes and  
            sustainable goals to reduce the incidence of ambulance patient  
            offload delays. In a national study involving 200 cities,  
            including some in California, the national average wait time  
            for handing off ambulance patients has doubled from 20 minutes  
            in 2006 to more than 45 minutes. Through survey research, the  
            collaborative learned that the offload delay problem in  
            California is not uniform or consistently reported. Of the 124  
            hospitals that responded to the survey, 74 (or 60%) said that  
            offload delays were "neutral" or "not significant," which was  
            consistent with what 19 out of 33 LEMSAs (58%) reported as  
            well. In contrast, 45 hospitals and 13 LEMSAs reported that  
            offload delays were "extremely significant," "very  
            significant," or "somewhat significant." However, those 13  
            LEMSAs reporting a problem represent regions that include 70%  
            of California's population. 

            As a result of this collaborative effort, in August of 2014  
            the Toolkit to Reduce Ambulance Patient Offload Delays in the  
            Emergency Department (Toolkit) was published by the California  
            Hospital Association.  The Toolkit includes definitions,  
            process guidelines and strategies to be considered to evaluate  
            current practices and develop specific process improvements at  
            the local level. The theme of the Toolkit was that local EMS  
            systems and hospitals are unique, and that collaborative  
            problem solving should be used to identify and solve problems  
            locally. However, the Toolkit did identify three key factors  
            for success, starting with improving the emergency department  
            intake process, followed by continuous quality improvement  
            measures, and hospital and LEMSA collaboration.
          3)Related legislation. AB 503 (Rodriguez), would permit a  
            hospital to release patient-identifiable medical information  
            to an emergency medical services provider, to a LEMSA, or to  
            EMSA, for quality assessment and improvement purposes. AB 503  
            passed the Senate Health Committee by a vote of 8-0 on July 1,  

          AB 1129 (Burke), requires an emergency medical care provider,  
            when submitting data to a LEMSA, to use an electronic health  
            record system that is compatible with specified standards, and  
            that includes those data elements that are required by the  


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            LEMSA. Prohibits a LEMSA from mandating that a provider use a  
            specific electronic health record system. AB 1129 passed the  
            Senate Health Committee by a vote of 8-0 on July 1, 2015.  

          4)Prior legislation. AB 1621 (Lowenthal, 2014), would have  
            required EMSA to adopt a single statewide standard for the  
            collection of information regarding pre-hospital care for  
            CEMSIS, required EMSA to develop standards for electronic  
            patient care records systems used by LEMSAs and local  
            pre-hospital EMS providers to ensure compatibility with  
            CEMSIS, and required LEMSAs to submit patient information to  
            EMSA utilizing the single statewide standard in a timely  
            manner. AB 1621 was held on the Senate Appropriations  
            Committee suspense file.

          AB 1975 (R. HernŠndez, 2014) would  have required LEMSAs to  
            contract with the American College of Surgeons every five  
            years to conduct a comprehensive assessment of their regional  
            trauma system. AB 1975 was held on the Assembly Appropriations  
            Committee suspense file. 

          SB 535 (Nielsen, 2013), would have increased the membership of  
            the EMS Commission from 18 to 20 members, and required the  
            additional members to be an air ambulance representative  
            appointed by the Senate Committee on Rules, and representative  
            appointed by the Speaker of the Assembly from a public agency  
            that provides air rescue and transport. SB 535 was vetoed by  
            the Governor.

          5)Support.  According to the author, this bill is sponsored by  
            the California Fire Chiefs Association (CFCA), which states in  
            support that hospital emergency departments are more crowded  
            and busier than ever, which means that EMS responders are  
            spending more of their time waiting to offload patients at  
            emergency departments than fulfilling their primary duty of  
            responding to emergency calls. CFCA states that this bill  
            seeks to help alleviate these issues by requiring EMSA to  
            develop a methodology for determining an acceptable amount of  
            time for EMS crews to offload their patients at emergency  
            departments. The California Ambulance Association (CAA) states  
            that it supports this bill because it believes that it will  
            ultimately result in cost savings to the EMS system. According  
            to CAA, patient offload time has been a significant problem  
            for ambulance providers. CAA agrees that a crucial first step  
            in dealing with this issue is to properly identify and define  


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            metrics to measure the issue. The California Professional  
            Firefighters states in support that this bill represents a  
            good first step toward the development of standards to  
            expedite the transfer of care between ambulance personnel and  
            the emergency department staff of a general acute care  
            hospital and mitigate delays in returning ambulances and  
            pre-hospital care personnel to the EMS system. Paramedics Plus  
            states in support that a five minute wait time reduction in  
            Alameda County equates to one 24 hour ambulance deployment per  
            day back into the 911 EMS system.

          6)Opposition.  The California Hospital Association (CHA) states  
            in opposition that numerous issues contribute to ambulance  
            patient offload delays and emergency department crowding, and  
            that hospitals are not the main problem. According to CHA,  
            excess demand for emergency services, for the most part, is  
            beyond both hospitals and EMS providers to exclusively solve.  
            CHA states that standardization of ambulance patient offload  
            delay methodology is a laudable goal, however, it does not  
            address the individual local needs of each LEMSA and  
            neighboring hospitals to solve problems with their existing  
            resources. Finally, CHA states that the Ambulance Patient  
            Offload Delay initiative has been operating for more than two  
            years with many regional collaboratives already working  
            collectively and cooperatively to solve this issue, and that  
            legislation is unnecessary. According to CHA, one local area  
            has discovered that offload delays are a product of their  
            counties' massive population growth with increased Medi-Cal  
            patients seeking care in the area emergency departments, while  
            another area showed that delays were attributable to the EMS  
            crews restocking and completing their paperwork. CHA states  
            that legislation that requires measurements that will be used  
            in a retaliatory manner against hospitals is unfair and  
          Support:  California Fire Chiefs Association (sponsor)
                    California Ambulance Association
                    California Professional Firefighters
                    California State Firefighters' Association
                    League of California Cities
                    Paramedics Plus
          Oppose:   California Hospital Association


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