BILL ANALYSIS
AB 2456
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Date of Hearing: April 13, 2010
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
AB 2456 (Torrico) - As Amended: April 5, 2010
SUBJECT : Emergency medical services: regulation.
SUMMARY : Requires the State Emergency Medical Services
Authority (EMSA) guidelines to include model policies,
procedures, treatment protocols, and licensure and certification
requirements applicable to all emergency medical technician
(EMT) personnel and requires all local emergency medical
services (LEMSA) programs to adhere to these guidelines.
Specifically, this bill :
1)Specifies that planning and implementation guidelines for
LEMSAs that EMSA is required to develop shall also include
model policies, procedures and treatment protocols for all EMT
and the respective licensure and certification requirements
for the following:
a) Local accreditation;
b) Competency-based written skills examinations;
c) Demonstration of skills competency;
d) Medical control and the use of optional skills;
e) Approval of service providers utilizing approved
optional skills;
f) Additional training and maintenance of accreditation for
optional skills;
g) Continued competency in optional skills;
h) Field internships;
i) Preceptor evaluation criteria for trainees;
j) Approval and evaluation of advance EMT service
providers;
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aa) Replacing medical supplies and equipment used by limited
advanced life support (LALS) personnel; and,
bb) Supply and replacement of controlled substances
administered by LALS personnel.
2)Requires mandatory adherence by LEMSAs to the guidelines,
policies and procedures developed by EMSA.
3)Requires approval of EMSA director and the EMS Commission
before a LEMSA may implement any additional policies, not in
accordance with EMSA guidelines and requires that the
additional policies, procedures, and treatment protocols must
further the purpose of the existing requirements.
4)Clarifies that existing guidelines relate to medical disaster
response.
5)States legislative intent and declarations.
EXISTING LAW .
1) Establishes the state EMSA which is responsible for the
coordination and integration of all state activities
concerning EMS including establishing the minimum standards
for the policies and procedures necessary for medical
control of the EMS system.
2) Authorizes counties to develop an EMS program and
designate a LEMSA responsible for planning and implementing
an EMS system.
3) Establishes the 16-member EMS Commission within the
Health and Human Services Agency and specifies its
membership and appointing authorities and defines the
duties.
4) Provides for the certification of EMTs through the
issuance of certificates, including EMT-I and II
certificates by LEMSAs; public safety agencies, for public
safety personnel; and, the State Board of Fire Services,
for fire safety personnel, for EMT-I certificates. Requires
all persons certified to have completed a training program
approved by the LEMSA or EMSA.
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5) Requires EMSA to adopt, upon approval of the EMS
Commission, regulations for the training and scope of
practice for EMT-I certification and EMT-paramedic (EMT-P)
licensure; guidelines for disciplinary actions and
regulations for disciplinary processes for EMT-I and EMT-II
certificate holders; and, regulations for issuing and
re-issuing EMT-I and EMT-II certificates.
6) Requires EMSA to establish and maintain a statewide
registry with specified publicly available data elements
and the status of all EMT licenses and certificates, to be
used by certifying entities, as defined.
7) Requires the Medical Director of a LEMSA to investigate
possible EMT-I or EMT-II misconduct that threatens public
health and safety, and if necessary, to take disciplinary
action, if the employer of the EMT chooses not to conduct
the investigation, or if the employer is an ambulance
service that is not licensed by a public safety agency and
specifies procedures and timelines.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, this bill is
intended to clarify existing law established by AB 2917
(Torrico), Chapter 274, Statutes of 2008, with respect to
EMSA's current ability to establish guidelines that direct
LEMSAs and other essential EMS stakeholders in their
operations for the coordinated delivery of EMS in this state.
The author explains that EMS personnel, such as in Kern and
San Bernardino counties provide multi-county services but are
subject to differing requirements. The author argues that
this bill is necessary to streamline this incongruent process
and that policies need to be driven by research and consensus
rather than the personality of the local administrator and
doctor. The author also asserts that policies should ensure
the safety and competency of EMS personnel through
standardized training and accreditation, as well as
consistency in training programs and medical oversight-all of
which ensures safe and effective delivery of EMS to the
public. This means one state standard for all EMS certified
and licensed personnel, regardless of where the service is
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delivered.
2)BACKGROUND. California operates on a two-tiered EMS system.
EMSA is the state lead agency and centralized resource to
oversee emergency and disaster medical services. EMSA is
charged with providing leadership in developing and
implementing EMS systems throughout California and setting
standards for the training and scope of practice of various
levels of EMS personnel. EMSA also has responsibility for
promoting disaster medical preparedness throughout the state,
and, when required, managing the state's medical response to
major disasters. According to EMSA it operates through
standard setting, consensus building, and leadership.
Responsibilities for EMS systems planning and development
include assessment of EMS systems in order to coordinate EMS
activity based on community needs; technical assistance to
local agencies; developing, implementing, or evaluating
components of an EMS system; development of statewide
standards and guidelines for EMS systems as well as guidelines
for the assessment of critical care capabilities of hospitals;
and, review and approval of local EMS plans to ensure
compliance with the minimum standards set by EMSA
3)LOCAL EMERGENCY SERVICES AGENCIES. In California, day-to-day
EMS system management is the responsibility of the local and
regional EMS agencies. California has 32 local EMS systems
that are providing 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, more rural, less-populated
counties and single-county systems generally exist in the
larger and more urban counties.
Prior to 1980, California did not have a central state agency
responsible for ensuring the development and coordination of
EMS services and programs statewide. According to EMSA,
although the many stakeholders in EMS, including local
administrators, fire agencies, ambulance companies, hospitals,
physicians, nurses, and other health care providers did not
agree on many issues, there was a consensus that a more
unified approach to emergency and disaster medical services
was needed. After several years of effort by the EMS
constituents to establish a state lead agency and centralized
resource to oversee emergency and disaster medical services,
the EMS System and Prehospital Emergency Care Personnel Act
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was passed, creating EMSA.
The relative roles of EMSA and the LEMSAs are not uniform. In
some areas, such as trauma care, EMSA develops statewide
standards, but LEMSAs implement and ensure compliance. EMSA
operates the licensure and discipline program for paramedics.
However, the LEMSAs are responsible for certifying EMT-Is and
EMT-IIs. EMTs employed by public safety agencies, such as
fire departments and law enforcement agencies, may be
certified by their departments. In other areas, such as EMS
system operation, EMSA's role may be limited to the
development of guidelines which are advisory.
4)PROBLEMS WITH EMS SYSTEMS . The trend towards an enhanced role
of a state entity has persisted. AB 2917 requires EMSA to
establish a statewide EMT registry and to develop standards,
guidelines, and regulations for certification of EMTs. AB
2917 also establishes rules for EMT certification and
discipline and for the investigation of conduct that threatens
public health and safety. EMSA is in the final stages of
adopting the implementing regulations through the
Administrative Procedures Act (APA).
AB 2917 was enacted in response to failures in the oversight
and discipline of EMTs. Prior to its passage, numerous
problems had been identified in the media. A series of
articles in the Los Angeles Times (Times) for instance,
reviewed all regulatory actions from 2000 to 2006 statewide
and concluded that there was no coherent system for reporting
problems or processing complaints that could lead to
discipline. They found substantial variation from region to
region. The articles also found that very few EMTs were
disciplined even in cases of serious medical lapses, negligent
care, and fraudulent or counterfeit credentials. The Times
reported that EMTs who were disciplined were able to find
employment with another agency due to the lack of a statewide
registry. According to a Times article in 2007, a large part
of the problem is the culture in which the emergency response
system developed. It was essentially welded onto fire
departments, which functioned primarily as public safety
providers with a paramilitary tradition, not as medical
caregivers. According to the Times, now, the bulk of what
these departments do is medical response-but their regulatory
standards area still catching up with the rest of the medical
professions.
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5)SUPPORT . According to the sponsor, California Professional
Firefighters (CPF), this bill clarifies the law with respect
to EMSA's ability to establish guidelines that direct LEMSAs
and other essential EMS stakeholders in their operations for
the coordinated delivery of EMS in this state. The sponsors
state that during the development of the implementing
regulations to AB 2917, they identified a need for
EMSA-established guidelines that direct LEMSAs in the
establishment of policies and procedures implementing or
overseeing any component of the EMS system-from local
accreditation of optional skills and competency tests for EMT
training programs to demonstration of skills competency,
additional training requirements and medical control. The
sponsor writes in support that the intent of the author,
Legislature and the bill's supporters in enacting AB 2917 was
to create standardized policies as a means to ensure the
effective statewide coordination of emergency medical care and
in doing so, maintain consistent and accountable policies.
Oftentimes, such requirements can differ by county-mandating
that EMS personnel who operate in multiple counties perform
additional, varied, or sometimes disparate activities in order
to serve as an EMT in the more than one county. CPF concludes
that the policies need to be driven by research and consensus
and applied broadly across the EMS delivery system.
6)OPPOSITION . The Emergency Medical Services Administrators
Association of California (EMSAAC) is opposed to the
provisions of this bill that require mandatory compliance by
LEMSAs. EMSAAC writes in opposition that these changes are
unnecessary in light of existing statutory oversight.
According to EMSAAC, adopting standardized medical guidelines
on behalf of all counties is inherently problematic due to the
diversity of settings and available resources. According to
EMSAAC, this was demonstrated when EMSA previously attempted
to create universal paramedic treatment guidelines for LEMSAs.
EMSAAC cites as an example the difference in delivery of
prehospital care in rural counties where ambulance transport
times may exceed one hour as compared to an urban setting with
a short transport time. EMSAAC further argues that EMSA may,
under existing statute, adopt regulations that set or revise
the minimum standards which LEMSAs must follow. However, the
opposition concludes that the use of voluntary guidelines
enables each of the counties to provide the best possible
prehospital patient care based on resources available.
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The California Hospital Association (CHA) writes in opposition
that this bill would require LEMSAs to follow guidelines
established by EMSA, thereby giving every guideline document
the power of regulation. Regulations are required to follow
the APA and be subject to public comment. CHA argues that
this bill would allow a bypass of this deliberative process.
CHA further explains that EMSA has a consensus process for
adoption of guidelines. When necessary, EMSA determines that
the guidelines are imperative and it uses the regulatory
process. Otherwise guidelines allow for regional differences
and LEMSAs work with local hospitals, pre-hospital providers,
and others to determine the best policies and procedures for
the area.
7)PREVIOUS LEGISLATION .
a) AB 2917 requires EMSA to establish a statewide EMT
registry and develop standards, guidelines, and
regulations for certification of specified EMTs.
Establishes rules for EMT certification and discipline,
and for investigation of conduct which threatens public
health and safety, as defined.
b) SB 997 (Ridley-Thomas), Chapter 275, Statues of 2008,
adds two members to the EMS Commission.
c) AB 941 (Torrico) of 2007 would have required EMSA to
maintain a central registry of EMT-I and EMT-II
certification status and EMT-P licensure status, to be
used by LEMSAs and employers of EMTs; would have required
LEMSAs to provide certification status updates; required
EMS providers to verify background checks; would have
required EMSA to establish guidelines for certification
and disciplinary hearings and actions; would have required
EMS providers to investigate EMTs and implement and report
disciplinary plans to the LEMSA; and would have revised
LEMSAs' disciplinary authority. Governor Schwarzenegger
vetoed AB 941. In his veto message, he wrote: that the
bill lacks requirements and penalties to assure timely
notice when an investigation is initiated, does not
provide sufficient authority for local medical directors
to independently initiate investigations, and fails to
establish clear standards for background checks. In
addition, he wrote he is concerned that the bill would
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significantly limit public disclosure.
d) SB 583 (Ridley-Thomas) of 2007 would have required
EMSA to adopt policies and procedures for EMT-I and EMT-II
disciplinary proceedings; required public safety agencies
to report discipline imposed on an EMT certificate holder
to the LEMSA; would have authorized a LEMSA medical
director to temporarily suspend an EMT-I or EMT-II
certificate holder employed by a public safety agency if
discipline imposed by the public safety employer was not
sufficient; and, would have required EMSA to make the
final decision on whether to uphold the temporary
suspension order issued by the LEMSA. SB 583 was held on
the Senate Appropriations Committee Suspense File.
e) SB 254 (Ashburn) of 2007 would have required EMSA to
establish standards for EMT-Is and EMT-IIs and would have
required EMSA and LEMSAs to be jointly responsible for
statewide licensing and discipline of EMT-Is and EMT-IIs,
pursuant to regulations adopted by EMSA, and required EMSA
to develop and implement an alcohol and drug diversion
program for EMT-I, EMT-II, and EMT-P license holders. SB
254 would have required all applicants for EMT-I and
EMT-II licensure to have a state and federal criminal
history background check. SB 254 was set for hearing in
the Senate Health Committee, but was not heard at the
request of the author.
f) AB 1086 (Torrico) of 2007 would have required EMSA to
maintain a centralized system for monitoring EMT-I and
EMT-II certification and EMT-P licensure status to be used
by employers and LEMSAs as part of the background check
process, and would have required EMS providers to verify
completion of background checks on all EMT-Is and EMT-IIs.
AB 1086 would also have required EMSA and LEMSAs to
establish and implement other disciplinary guidelines. AB
1086 was set for hearing in the Assembly Health Committee,
but was not heard at the request of the author.
g) SB 1811 (Romero) of 2006, sponsored by EMSA, would
have prohibited a medical director of a LEMSA from taking
action against any EMT-I certificate issued by a public
safety agency until certain policies and procedures were
approved by EMSA. SB 1811 would have authorized the
medical director to temporarily suspend an EMT-I or EMT-II
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certificate upon specified determinations. SB 1811 was
set to be heard in the Senate Health Committee, but was
not heard at the request of the author. SB 1811 was
opposed by firefighter unions, which argued that
firefighter EMTs should only be disciplined by their fire
departments.
h) AB 2554 (Ridley-Thomas) of 2006, sponsored by CPR,
would have revised the disciplinary authority of LEMSAs
over EMTs. Governor Schwarzenegger vetoed AB 2554,
stating that it would risk public safety by limiting the
authority of the LEMSA to take disciplinary action against
EMTs. The governor also encouraged stakeholders to work
with the Legislature and the California Health and Human
Services Agency to craft legislation that would protect
public safety, reduce duplicative enforcement, and support
more consistent oversight of EMTs.
8)POLICY CONCERN: According to the Office of Administrative
Law, regulation means every rule, regulation, order, or
standard of general application or the amendment, supplement,
or revision of any rule, regulation, order, or standard
adopted by any state agency to implement, interpret, or make
specific the law enforced or administered by it, or to govern
its procedure. If a state agency issues, enforces, or
attempts to enforce a rule without following the APA, the rule
is called an "underground regulation." State agencies are
prohibited from enforcing underground regulations. This bill
appears to authorize underground regulations.
9)PROPOSED AMENDMENTS : As currently drafted this bill requires
LEMSAs to adhere to guidelines adopted by EMSA. In order to
further the author's intent in manner that cannot be
interpreted as promoting underground regulations and to
clarify that the intent is to apply the regulations only to
personnel, the author is proposing the following amendments:
a) Delete Section 2
b) Amend Section 1797.184 of the Health and Safety Code
to read:
1797.184. The authority shall develop and, after approval by
the commission pursuant to Section 1799.50, adopt all of
the following:
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(a) Guidelines for disciplinary orders, temporary
suspensions, and conditions of probation for EMT-I and
EMT-II certificate holders that protect the public health
and safety.
(b) Regulations for the issuance of EMT-I and EMT-II
certificates by a certifying entity that protects the
public health and safety.
(c) Regulations for the recertification of EMT-I and EMT-II
certificate holders that protect the public health and
safety.
(d) Regulations for disciplinary processes for EMT-I and
EMT-II applicants and certificate holders that protect the
public health and safety. These disciplinary processes
shall be in accordance with Chapter 5 (commencing with
Section 11500) of Part 1 of Division 3 of Title 2 of the
Government Code.
(e) Regulations establishing standards for policies,
procedures and treatment protocols, applicable to the
functions, certification and licensure of EMT personnel as
defined in Sections 1797.80, 1797.82 and 1797.84, which
address all of the following components:
(1) Local accreditation.
(2) Competency-based written and skills examinations.
(3) Demonstration of skills competency.
(4) Medical control and the use of the optional skills.
(5) Approval of service providers utilizing approved
optional skills.
(6) Additional training and maintenance of accreditation for
optional skills.
(7) Continued competency in the optional skills, which is
monitored through various methods, including organized
field care audits, periodic training sessions, or
structured clinical experience, remediation plans.
( 8) Field internships.
(9) Preceptor evaluation criteria for trainees.
(10) Approval and evaluation of advanced EMT service
providers.
c) SEC. 3. Section 1797.200 of the Health and Safety
Code is amended to read:
1797.200. (a) Each county may develop an emergency medical
services program. Each county developing such a program
shall designate a local EMS agency which shall be the
county health department, an agency established and
operated by the county, an entity with which the county
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contracts for the purposes of local emergency medical
services administration, or a joint powers agency created
for the administration of emergency medical services by
agreement between counties or cities and counties pursuant
to the provisions of Chapter 5 (commencing with Section
6500) of Division 7 of Title 1 of the Government Code.
(b) A local EMS agency designated pursuant to subdivision
(a) shall adhere to the guidelines standards developed
by the authority pursuant to subdivision (e) of Section
1797.103 1797.184 in establishing its policies and
procedures required by statute or regulation.
(c) Any additional policies, procedures, and treatment
protocols implemented by a local EMS agency designated
pursuant to subdivision (a) that are not in accordance
with the authority's guidelines standards developed
pursuant to subdivision (e) of Section 1797.103 1797.184
are subject to approval by the Director of the Emergency
Medical Services Authority and the Emergency Medical
Services Commission prior to implementation. Approval by
the director and the commission pursuant to this
subdivision shall only be granted if the policies,
procedures, and treatment protocols implemented by the
local EMS agency further the purposes of this division.
REGISTERED SUPPORT / OPPOSITION :
Support
California Professional Firefighters (sponsor)
California Department of Forestry Firefighters Local 2881
Opposition
American Medical Response
California Hospital Association
California State Association of Counties
Emergency Medical Services Administrators Association of
California
Emergency Nurses Association
San Bernardino County Board of Supervisors
San Bernardino County Sheriff's Office
Analysis Prepared by : Marjorie Swartz / HEALTH / (916)
319-2097
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