BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K. Alquist, Chair
BILL NO: AB 2456
A
AUTHOR: Torrico
B
AMENDED: June 23, 2010
HEARING DATE: June 30, 2010
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CONSULTANT:
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Tadeo/
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SUBJECT
Emergency medical services: regulation
SUMMARY
Requires the Emergency Medical Services Authority (EMSA) to
develop regulations establishing standards for policies and
procedures applicable to the functions, certification, and
licensure of emergency medical technician (EMT) personnel.
Allows an Emergency Medical Services (EMS) provider to
appeal a determination made by the Director of EMSA,
regarding these regulations, to the EMS Commission, and
allows the Commission to overrule the determination of the
Director.
CHANGES TO EXISTING LAW
Existing law:
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.
Authorizes counties to develop an EMS program and designate
a Local Emergency Medical Services Agency (LEMSA)
Continued---
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responsible for planning and implementing an EMS system.
Allows EMSA to determine that a LEMSA EMS and trauma care
system plan is not consistent with its applicable
guidelines or established regulations, and allows a LEMSA
to appeal the decision to the EMS Commission. The EMS
Commission may sustain the determination of the authority
or overrule it, and permit local implementation of a plan.
The decision of the commission is final.
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 EMSA or a LEMSA.
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
reissuing EMT I and EMT II certificates.
Requires EMSA to establish and maintain a statewide
registry containing specified publicly available data
elements and the status of all EMT licenses and
certificates, to be used by certifying entities, as
defined.
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 provider that is not licensed by a public safety
agency, and specifies procedures and timelines for those
investigations and disciplinary procedures.
Establishes an 18-member EMS Commission within the Health
and Human Services Agency. Defines the duties of the EMS
Commission to include reviewing regulations, standards, and
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guidelines developed by EMSA, advising EMSA on a data
collection system, advising the EMSA director regarding
various aspects of the EMS system, and making
recommendations for further development of EMS.
This bill:
Requires EMSA to develop, and after approval by the EMS
Commission, adopt regulations establishing standards for
policies and procedures applicable to the functions,
certification and licensure of EMT I, EMT II and EMT
Paramedic personnel, which address:
Local accreditation;
Competency-based written and skills examinations;
Demonstration of skills competency;
Medical control for the use of the optional skills;
Approval of service providers utilizing approved
optional skills;
Additional training and maintenance of
accreditation for optional skills;
Continued competency in the optional skills, and
requires these to be monitored through various
methods;
Field internships;
Preceptor evaluation criteria for trainees; and,
Approval and evaluation of advanced EMT service
providers.
Requires a LEMSA to adhere to the standards developed by
EMSA for policies and procedures applicable to the
functions, certification and licensure of EMT I, EMT II and
EMT Paramedic personnel, as listed above.
Requires, upon notification by an EMS service provider, any
policies and procedures applicable to the functions,
certification, and licensure of EMT personnel, implemented
by a LEMSA to that are not in accordance with EMSA's
standards to be subject to approval by the Director of
EMSA. Requires approval to be granted by the Director only
if the policies further the purposes of this division.
Allows an EMS service provider to appeal a determination
made by the Director of EMSA to the EMS Commission.
Provides that the EMS Commission may sustain or override
the Director's determination. Establishes that the
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decision of the EMS Commission is final.
Requires EMSA to develop, and after approval by the EMS
Commission, adopt the following guidelines and regulations
that affect EMT I and EMT II:
Guidelines for disciplinary orders, temporary
suspensions, and probationary conditions for EMT I and
EMT II certificate holders;
Regulation for the issuance of EMT I and EMT II
certificates;
Regulations for the recertification of EMT I and
EMT II certificate holders; and,
Regulations for disciplinary processes for EMT I
and EMT II certificate holders in accordance with
existing law.
Allows EMSA to develop and, after approval by the EMS
Commission, adopt a schedule of fees to be collected in
amounts sufficient to support EMSA's actual additional
costs to promulgate the regulations proposed in this bill.
States findings and declarations regarding the statewide
EMS system.
FISCAL IMPACT
According to the Assembly Appropriations Committee analysis
of AB 2456, this bill would result in annual General Fund
costs of $800,000 for EMSA to establish regulations and
statewide oversight of emergency medical professionals.
BACKGROUND AND DISCUSSION
According to the author, existing policies must be
augmented to facilitate a linkage among local EMS agencies
so that they may collaborate more effectively. The author
states that EMS personnel, in some counties such as Kern
and San Bernardino counties provide multi-county services,
but are subject to differing requirements. The author
argues that AB 2456 is necessary to streamline this
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,
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as well as consistency in training programs, which ensures
the safe and effective delivery of EMS to the public. The
author contends that this means one state standard for all
EMS certified and licensed personnel, regardless of where
the service is delivered.
Statewide and local EMS system
California operates a two-tiered EMS system. EMSA is the
state lead agency which oversees 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. Among EMSA'a responsibilities are
assessing local EMS systems, technical assistance to local
agencies; developing, implementing, or evaluating
components of an EMS system; developing statewide standards
and guidelines for EMS systems as well as guidelines for
the assessment of critical care capabilities of hospitals;
and, reviewing and approving local EMS plans to ensure
compliance with the minimum standards set by EMSA
California has 32 LEMSAs that provide EMS for California's
58 counties. Seven regional EMS systems, comprised of 33
counties and 25 single county agencies, provide 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 EMS constituents and stakeholders 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 was passed,
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creating EMSA.
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.
Problems and improvements in the EMS system
In the recent past, failures in EMT oversight have been the
focus of media scrutiny, with numerous articles questioning
the adequacy of state and local oversight of EMTs. In 2007
the Sacramento Bee (Bee) published an investigative series
that reported that paramedics whose licenses had been
revoked for sexual misconduct and patient neglect had been
able to obtain rescue jobs as EMTs. The Bee series also
noted that people with criminal records of patient abuse,
who stole morphine from employers, and who stole money from
patients were able to obtain and keep EMT certificates.
A series of articles in the Los Angeles Times (Times)
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. The articles found substantial variation
from region to region. The articles noted that, only
through settlement agreements and media reports were cases
brought to the attention of regulators. 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.
AB 2917 (Torrico), Chapter 274, Statutes of 2008, was
enacted in response to failures in the oversight and
discipline of EMTs. AB 2917 requires EMSA to establish a
statewide EMT registry and to develop standards,
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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.
EMS Commission
The duties of the EMS Commission are defined to include
reviewing regulations, standards, and guidelines developed
by EMSA, advising EMSA on a data collection system,
advising the EMSA director regarding various aspects of the
EMS system, and making recommendations for further
development of EMS. Regulations and guidelines addressing
medical control and skills, recently promulgated by EMSA
and approved by the EMS Commission, are currently on review
at the Office of Administrative Law as part of the APA
process.
The Governor appoints the following members of the EMS
Commission, based on names submitted by the listed
agencies:
A county health officer - California Conference of
Local Health Officers,
A registered nurse - Emergency Nurses Association,
A fire protection services manager - California
Fire Chiefs Association,
A hospital administrator - California Association
of Hospitals and Health Systems,
An EMT II or EMT Paramedic police officer -
California Peace Officers Association,
Two public members with experience in local EMS
policy issues, one of which must reside in a rural
area,
A LEMSA administrator - Emergency Medical Services
Administrator's Association of California,
A LEMSA medical director who is an active member of
the Emergency Medical Directors Association of
California,
An active member of the California State Firemen's
Association,
A person employed by the Department of Forestry and
Fire Protection - California Professional
Firefighters
A person employed by a city, county, or special
district that provides fire protection - California
Professional Firefighters.
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The Legislature appoints the following members of the EMS
Commission, based on names submitted by the listed
agencies:
A physician and surgeon - California Medical
Association,
A physician and surgeon who is a trauma surgeon -
California Chapter of the American College of
Surgeons,
A physician and surgeon whose primary practice is
emergency medicine - California Chapter of the
American College of Emergency Physicians,
A physician and surgeon who is certified in the
specialty of emergency medicine by the American Board
of Emergency Medicine,
An EMT II or EMT Paramedic who is not a police
officer - California Rescue and Paramedic Association,
and,
A prehospital emergency services provider from the
private sector - California Ambulance Association.
Related bills
AB 2331 (Skinner) would provide that if provisions of the
Firefighters Procedural Bill of Rights Act pertaining to
administrative appeals are in conflict with grievance
arbitration provisions of a memorandum of understanding in
effect on and or after January 1, 2008, the memorandum of
understanding shall be controlling without further
legislative action.
This bill is located in the Senate Judiciary Committee.
Prior legislation
SB 997 (Ridley-Thomas), Chapter 275, Statutes of 2008, adds
two members to the EMS Commission, one who is an employee
of the Department of Forestry and Fire Protection (CAL
FIRE) and one who is an employee of a city, county, or
special district that provides fire protection, each
appointed by the governor from lists submitted by the
California Professional Firefighters.
AB 2917 (Torrico), Chapter 274, Statutes of 2008, requires
EMSA to establish and maintain a statewide centralized
system for monitoring and tracing EMT I and EMT II
certification status and EMT Paramedic licensure status to
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be used by certifying entities. Establishes rules for EMT
certification and discipline, and for investigation of
conduct which threatens public health and safety, as
defined.
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. This bill was held on the
Senate Appropriations Committee Suspense File.
AB 220 (Bass) Chapter 591, Statutes of 2007 enacts the
Firefighters Procedural Bill of Rights Act, to mirror the
Public Safety Officers Procedural Bill of Rights Act that
is applicable to public safety officers.
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 Paramedic 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. This bill was set for hearing in
the Senate Health Committee, but was not heard at the
request of the author.
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
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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
significantly limit public disclosure. This bill was
vetoed by the Governor.
AB 1086 (Torrico) of 2007 would have required EMSA to
maintain a centralized system for monitoring EMT I and EMT
II certification and EMT Paramedics 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.
This bill was set for hearing in the Assembly Health
Committee, but was not heard at the request of the author.
SB 1811 (Romero) of 2006, 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. Would have
authorized the medical director to temporarily suspend an
EMT I or EMT II certificate upon specified determinations.
This bill was set to be heard in the Senate Health
Committee, but was not heard at the request of the author.
AB 2554 (Ridley-Thomas) of 2006, 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.
Arguments in support
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The California Professional Firefighters (CPF), the sponsor
of AB 2456, argue that this bill simply clarifies existing
law with respect to EMSA's current ability to establish
guidelines that direct LEMSAs and other essential EMS
stakeholders in their operations. CPF adds that EMS
personnel must fulfill certain requirements to attain
certifications and licenses, which can differ by county,
mandating EMS personnel who operate in multiple counties to
perform additional, varied, or sometimes disparate
activities in order to serve as an EMT in more than one
county. CPF contends that in order to streamline this
process, policies must be driven by research and consensus,
applied broadly across the EMS delivery system, and support
the statewide mutual aid process by providing a minimum
level of service delivery as defined by the EMS community.
Arguments in opposition
According to EMSAAC, adopting standardized medical
guidelines applicable to EMT personnel, 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. EMSAAC further argues that fees that may be
assigned to fulfill the requirements of AB 2456 will
disproportionately effect EMT personnel in rural areas.
Finally, EMSAAC contends that AB 2456 not only takes
medical control away from LEMSA medical directors, but also
from the EMSA Director.
PRIOR ACTIONS
Assembly Health: 17- 2
Assembly Appropriations: 12- 5
Assembly Floor: 53-19
COMMENTS
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1. Major change in the duties of the EMS Commission.
Under current law, the EMS Commission is charged with the
review and approval of regulations, standards, and
guidelines developed by EMSA and serves in an advisory
capacity to EMSA on a variety of EMS related issues, such
as assessment of emergency facilities and services,
communications, medical equipment, training personnel,
facilities, and other components of an EMS system. The EMS
Commission reviews and comments upon the EMS portion of
the State Health Facilities and Service Plan. The EMS
Commission makes recommendations for further development
and future directions of EMS in the state.
EMSA may determine that a LEMSA EMS and trauma care system
plan is not consistent with its applicable guidelines or
established regulations, and in such cases, a LEMSA may
appeal the decision to the EMS Commission. The EMS
Commission may sustain the determination of the authority
or overrule and permit local implementation of a plan, and
the decision of the commission is final.
The bill would additionally establish that the EMS
Commission can also sustain the determination of the
authority or overrule it in an appeal by an individual EMS
provider in regards to EMT personnel policies and
procedures addressing medical control and skills. This
would establish that the EMS Commission has authority over
EMSA in medical skills and procedures when EMT personnel do
not agree with a LEMSA, even though the policies and
procedures would be promulgated by EMSA and approved by the
EMS Commission.
By doing this, the function of the EMS Commission would
change from a policy setting body to an appeals panel for
complaints filed by individual EMT personnel. Is this an
appropriate role for the EMS Commission?
POSITIONS
Support: California Professional Firefighters (sponsor)
CDF Firefighters Local 2881
Oppose: American Medical Response
California Ambulance Association
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California State Association of Counties
City of Eureka
County of Fresno
County of Orange Board of Supervisors
County of Humboldt Board of Supervisors
County of San Bernardino
Emergency Medical Services Administrators'
Association of California
Emergency Medical Directors Association of
California
Emergency Medical Services Authority (unless
amended)
Emergency Nurses Association
Health Officers Association of California
Health Officers of California
Los Angeles County Board of Supervisors
Regional Council of Rural Counties
San Bernardino County Sheriff's Office
San Joaquin County Board of Supervisors
Santa Clara County Board of Supervisors
Urban Counties Caucus
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