John Brown, MD, FACEP Medical Director Emergency Medical Services Agency Department of Emergency Management. February 16, 2010

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1 Status of Emergency Medical Services and Medical Oversight in San Francisco John Brown, MD, FACEP Medical Director Emergency Medical Services Agency Department of Emergency Management February 16, 2010 Presentation to Community and Public Health Committee

2 Components of EMS System System Demographics 1.2 million daytime population, 775,000 nightime population Response needs vary by time of day and location Lower proportion of pediatric, higher proportion of geriatric calls System Organizational Structure State EMS Authority Local EMS Agency EMS Providers EMS Advisory Committee, Trauma System Advisory Committee

3 Components of EMS System Medical Oversight Off line: EMS Agency, Provider Medical Directors develop field treatment protocols and policies, assist with QI processes On line: SFGH Base Hospital Communications Public Safety Answering Point: DEC EMS Provider Agency dispatch centers Mobile Data Terminals and Automatic Vehicle Locators 800 Megahertz radio system

4 Components of EMS System Personnel EMT: certified by SF EMS Agency Paramedic: licensed by State EMS Authority Dispatchers: accredited by Advanced Medical Priority Dispatch System Recruitment, Retention, Workload, Performance System Facilities Specialty Centers: stroke, OB, critical pediatrics, trauma, burn Receiving Hospitals Sobering Center

5 Components of EMS System Training City College nationally accredited PM training program; EMT program SF Paramedic Association: continuing education for all levels of providers; EMT program System orientation Skills maintenance

6 Components of EMS System Response/Transport Operations (tiered system) First response mixed Advanced and Basic Life Support by SFFD Transport by Advanced Life Support Units by SFFD, backup private ambulance providers System status management utilized Interfacility transfer services (BLS, CCT, CCT-P) Response interval goals Vehicle and equipment management

7 Components of EMS System Quality Improvement and Data Collection LEMSIS CARES Trauma registry Risk Management Investigations Certificate and license actions, due process Medical error prevention

8 Components of EMS System Disaster Medical Operations Multi Casualty Incident Planning MCI post-event reviews and reports Medical Operations Area Health Coordinator functions Integration into DPH DOC and EOC structure Administrative Operations Annual and as needed policy and protocol revisions Application processing and site visits EMS plans for special events Ambulance diversion monitoring

9 Components of EMS System System Finances Current budget approximately 1 million Grant and fees funding support (EMS fund from traffic citations, fees for EMT certification and ambulance permits, EMS provider Certificates of Operation) Public Information, Education and Prevention Participation in AHA s Operation Heartsafe Cities program Assisting DEM with disaster preparedness outreach

10 Local Emergency Medical Services Information System Phases I and II: Modernizes prehospital data collection, analysis and reporting processes Resolves longstanding gaps in timely and reliable data collection to evaluate indicators of EMS response and quality patient care Phase III Integration of selected hospital data

11 Local Emergency Medical Services Information System FirstWatch monitoring of EMS call volume increases associated with July 2006 record temperatures in San Francisco

12 Using LEMSIS Data Patient outcomes Treatment effectiveness Resource allocation EMS policy and planning Trauma and specialty care Response times & patterns Policy/Protocol compliance Real-time web-based remote monitoring of 911 system performance during routine operations and disasters SFStat & CEMSIS reports Reduction of errors Benchmarking Identify training needs Disaster response Injury surveillance Research Data sharing with other programs: e.g., SFGH Trauma Registry & HOME Team

13 24 Hour Snapshot of EMS Call Locations on a Busy January 2010 Weekday (n=172)

14 Response Interval Goals Vehicle Response Dispatch Que Interval* BLS & AED On Scene Response Time Interval ALS On Scene Transport On Scene Code 3 Red lights and siren. 2 minutes 4 minutes, 30 seconds 7 minutes, 0 seconds ALS 10 minutes, 0 seconds Code 2 No Red lights and siren. 2 minutes NA NA 20 minutes 0 Seconds *Interval for time call receivied to time that response unit is notified

15 911 Dispatch & Response Intervals Jan - Dec 2009: Code 3 Dispatch and Unit Response Intervals th Percentile EMSA Requirement th Percentile (Minutes) Call Received to Unit Dispatched 1st Unit On Scene 1st ALS Unit On Scene ALS Tranport On Scene Call Response for 1st Unit On Scene 90th Percentile EMSA Requirement

16 First Responder Intervals 90th Percentile Response Interval (mins) Jan - Dec 2009 : Code 3 Response Intervals for First Unit On Scene by Emergency Response Districts* EMSA Requirement = 4.5 mins C Town - N Beach Civic Center SOMA - Tloin - TI Pac Hghts -Marina W Add - U Hght Noe Vly - Mission Richmond Sunset Ingelside P Hill - B View - HP CY *Starts at "Time Unit Dispatched" and Ends at "First Unit On Scene Time" PRES- IDIO Overall

17 Ambulance Response Intervals Code 3 Transport Unit On Scene Code 3 90 th Percentile 9:54 8:59 9:05 8:04

18 Ambulance Response Intervals Code 2 Transport Unit On Scene Code 2 90 th Percentile 20:50 23:35 14:25 15:19

19 Monthly Ambulance Provider Reporting: Audit Filters/Trends for Late 911 Responses Timestamp entry errors Dispatch error Driver Error Scene access issues Caller language and/or location problems Scene safety issues Distance Vehicle mechanical problem Unit availability Dispatch upgrades from code 2 to code 3

20 Monthly Provider Reporting to EMSA: Audit of Infrequently Used Skills Advanced airway placements Needle crichothyrotomy Pleural (chest cavity) decompression Adult & pediatric intra-osseus fluid administration Pre-existing vascular access device Synchronized cardioversion Transcutaneous cardiac pacing

21 Use of Sobering Center by EMS Average Monthly Transports to Sobering Center by EMS Total Transports Since Aug 03 3,812 Avg Mo FY0304 Avg Mo FY0405 Avg Mo FY0506 Avg Mo FY0607 Avg Mo FY0708 Avg Mo FY

22 Ambulance Diversion 14% Annual ED Diversion Hours (%) for Non Critical & Non Speciality Care Patient Transports 14% 12% 12% 11% 10% 10% 10% 9% 9% 8% 6% 6% 4% 2% 0%

23 Continuing Collaborations for Improvements in EMS Care Move of EMS Agency to Division of Emergency Service, Department of Emergency Management to increase integration of EMS and Disaster Planning Revision of Multi Casualty Incident Plan to include Patient Distribution Center and Alternate Care Sites Development of EMS/Disaster Fellowship program and backup Medical Health Operations Area Coordinator Full implementation of RescueNet Tablet (electronic) patient care records

24 Continuing Collaborations for Improvements in EMS Care Trauma system audits to improve burn treatment and retriage policies for trauma victims Full implementation of a system-wide Automatic Vehicle Locator system Monitoring of ambulance transport and hospital drop off time intervals to evaluate and adjust ambulance staffing and positioning

25 Recent EMS System Collaborative Successes Performance during 2009 ambulance inspections exceeded all prior years Ongoing evaluation of EMS plans for special events Support for Multi Casualty incident plans and exercises CARES data base implementation RAMPART EMS research study Support for prehospital provider training at all levels of students

26 System Challenges No standard first responder documentation (pilot in progress) Cardiac arrest survival rates in mid range for EMS systems Response intervals are mixed: first defibrillator at patients side too long, first ALS, transport and code 2 intervals exceed goals Accommodating new EMS provider capacity without downgrading system capabilities Full implementation of LEMSIS

27 Future Directions Complete strategic planning process and utilize this unique opportunity to implement system improvements Resume regular reporting of EMSA quality indicators Expand cardiac arrest survival initiatives: CPR training, Public Access Defibrillator programs, STEMI Heart Attack Receiving Center system Continue the shared commitment to excellence in caring for the patients served by the EMS system

28 Are you prepared? In a major disaster, it might be several days before vital services are restored

29 CARES, QI and Cardiac Arrest Survival Presentation by EMS Division, San Francisco Fire Department

30 Communications Center Issues Presentation by Division of Emergency Communications

31 Medical Oversight of EMS Questions?

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