San Joaquin County Emergency Medical Services Agency

Transcription

1 San Joaquin County Emergency Medical Services Agency EMS Liaison Committee Thursday, July 12, 2018 at 0900 hours Health Plan of San Joaquin Community Room 7751 S. Manthey Road A G E N D A Mailing Address PO Box 220 Health Care Services Complex Benton Hall 500 W. Hospital Rd. Phone Number (209) Welcome - Call to Order 2. EMS Agency Administrator s Report (no attachment) 3. System Organization and Management A. EMS Maddy Fund 4. Staffing and Training A. EMS Training Programs (no attachment) B. EMS Personnel (no attachment) 5. Response and Transport A. Emergency Ambulance Service Performance B. Basic Life Support Ambulance Services in EMS System 6. Facilities and Critical Care A. Treatment Protocol Revision Update B. Stroke System Implementation Report C. Trauma System Report D. STEMI System Report E. Ambulance Patient Offload Delay Report 7. Data Collection and System Evaluation A. BLS Service Provider QI Report 8. Disaster Medical A. ICS Training Opportunities B. HAvBed Drill Report 9. Hospital and Prehospital Care Service Provider Reports - Roundtable 10. Public Comment 11. Next Meeting Thursday, October 11, 2018

2 EMS Liaison Committee Agenda July 12, 2018 Page 2 of 2 A full agenda packet will not be provided at the meeting. A full agenda packet may be viewed or downloaded from the EMS Agency s website at

3 San Joaquin County Emergency Medical Services Agency Mailing Address PO Box 220 DATE: July 5, 2018 TO: EMS Liaison Committee PREPARED BY: Natisha Plummer, Accounting Technician I SUBJECT: EMS Maddy Fund Health Care Services Complex Benton Hall 500 W. Hospital Rd. Phone Number (209) Fax Number (209) RECOMMENDED ACTION: Receive information on the EMS Maddy Fund. FISCAL IMPACT: The EMS Agency s FY17-18 budget includes revenue for administering the EMS Maddy Fund. By statute administrative fees are capped at 10% of annual Maddy Fund revenue. DISCUSSION: EMS Maddy Fund In 1987, legislature found that emergency medical service providers incurred higher costs for their services than providers of other medical services, but often received little to no payment from patients. In response, the Maddy Fund (SB 12) was established to provide revenue to compensate physicians and medical facilities for emergency services provided to medically indigent patients during the first 48 hours of continuous service. The EMS Maddy Fund is derived from county penalty assessments for various criminal offenses and motor vehicle violations, traffic violator school fees and revenue from taxes on tobacco products deposited in the State s Cigarette and Tobacco Products Surtax Fund. EMS Maddy Fund revenue, minus administrative costs, is proportioned as follows: 58% for eligible physicians and surgeons in a general acute care hospital providing basic or comprehensive emergency services; 25% to San Joaquin General Hospital for providing disproportionate trauma and emergency medical services; and 17% to the San Joaquin County EMS Agency for capital projects.

4 EMS Maddy Fund Report EMS Liaison Committee July 5, 2018 Page 2 of 2 FY 2016/17 Physician and surgeon claims are due from providers and payments are disbursed on a quarterly basis. A total of $151, was disbursed to participating physicians through FY 2016/17. FY 2016/17 Amount Disbursed Qtr 1 $47, Qtr 2 $33, Qtr 3 $32, Qtr 4 $37, Total: $151, FY 2017/18 Provider agreements for 2017/18 were sent to participating providers in July Claims for the second quarter of FY 2017/18 were due from providers on 4/30/18, with a target payment date of 7/31/18. FY 2017 Amount Disbursed Qtr 1 $35, Qtr 2 Pending Qtr 3 n/a Qtr 4 n/a Total: $35,698.19

5 San Joaquin County Emergency Medical Services Agency Mailing Address PO Box 220 DATE: July 5, 2018 TO: EMS Liaison Committee Health Care Services Complex Benton Hall 500 W. Hospital Rd. PREPARED BY: SUBJECT: Shahloh Jones-Mitchell, EMS Analyst Report on Emergency Ambulance Service Performance Phone Number (209) Fax Number (209) RECOMMENDED ACTION: Receive information on emergency ambulance performance for American Medical Response (AMR), Manteca District Ambulance (MDA), Escalon Community Ambulance (ECA) and Ripon Consolidated Fire District (RCFD). FISCAL IMPACT: The San Joaquin County EMS Agency budget includes ground and air ambulance monitoring and permit fees totaling $852,877 to offset the costs associated with monitoring compliance and evaluating performance. Emergency and non-emergency ambulance service providers operate without subsidies from San Joaquin County. San Joaquin County sets the allowable billing rates for emergency ambulance service through a competitively awarded performance agreement to AMR and by non-competitively awarded performance agreements with MDA, ECA, and RCFD. Non-emergency ambulance service rates are unregulated and may be established by each non-emergency ambulance service provider based on market conditions. DISCUSSION: SJCEMSA publishes bi-monthly reports on the exclusive emergency ambulance provider service contract compliance for AMR, MDA, ECA, and RCFD. These reports primarily focus on service provider response time performance and other related measures included in their respective ambulance service contract. Copies of these performance reports are available on the SJCEMSA s website at:

6 Emergency Ambulance Performance - EMS Liaison July 5, 2018 Page 2 of 4 Compliance Review by Provider: A summary analysis of the first 4 months of 2018 s prehospital performance for each ALS ambulance provider is shown below. AMR AMR s Red Lights and Sirens (RLS) call volume was 15,432 with a combined compliance percentage of 90.73% for the first four months of The RLS call volume in the chart below is an increase of nearly 1% compared to the first four months of AMR s Non Red Lights and Sirens (NRLS) call volume was 8,145 with an overall compliance of 95.52%. NRLS call volume increased 3.78% compared to the first four months of 2017.

7 Emergency Ambulance Performance - EMS Liaison July 5, 2018 Page 3 of 4 (Not shown) AMR s January through April 2018 s combined RLS and NRLS call volume was 23,577 with an overall compliance of 92.72%. The call volume for ALS-IFT and CCT-IFT was 321 and 47 respectively. MDA MDA s RLS call volume for the first four months of 2018 was 2037 with an overall compliance of 96.73%. MDA s Non Red Lights and Sirens call volume was 981 with an overall compliance of 98.71%. (Not shown) MDA s January through April 2018 s combined call volume was 3018 with an overall compliance of 97.33%.

8 Emergency Ambulance Performance - EMS Liaison July 5, 2018 Page 4 of 4 Escalon Community Ambulance ECA s RLS call volume for the first 4 months of 2018 was 200, with an overall compliance of 92.98%. Ripon Consolidated Fire Department RCFD s total RLS call volume for the first 4 months of 2018 was 343 with an overall compliance of 95.53%.

9 San Joaquin County Emergency Medical Services Agency Mailing Address PO Box 220 DATE: July 5, 2018 TO: EMS Liaison Committee Health Care Services Complex Benton Hall 500 W. Hospital Rd. PREPARED BY: SUBJECT: Rick Jones, EMS Analyst Report on BLS Ambulance Response to 911 Calls Phone Number (209) Fax Number (209) RECOMMENDED ACTION: Receive information on the use of basic life support (BLS) ambulances responding to emergency ambulance requests. FISCAL IMPACT: Potential for system wide cost savings through increased efficiency. DISCUSSION: As demonstrated by statewide flu and influenza like illness (ILI) epidemic that resulted in a marked increase in patients seeking care in emergency departments, it is prudent to continue to anticipate occasional sudden increases in requests for ambulance services in San Joaquin County through the 911 system. SJCEMSA Policy Memorandum No increased the availability of ambulance transport resources by allowing all emergency ambulance service providers to use BLS ambulances to respond to: 1) Emergency requests for service classified by the Valley Regional Emergency Communications Center (VRECC) through the Medical Priority Dispatch System (MPDs) as Protocol 26 (Sick Person) Alpha and Omega; and 2) Any emergency request for service if no advanced life support ambulance is immediately available for assignment. SJCEMSA continues to evaluate the use of BLS ambulances in the emergency ambulance system. From February 1, 2018 through May 31, 2018, there were 528 instances of BLS ambulances being dispatched to calls for emergency ambulance service by VRECC. In all 528 instances the BLS ambulance transported a patient to a receiving hospital of their choice without the use of red lights and siren (NRLS). SJCEMSA randomly audited 8% of the corresponding patient care records (PCRs) to determine the appropriateness of the care and transport provided to the patient. The chart below summarizes the findings of PCR reviews.

10 Report on BLS Ambulance Response to 911 Calls July 5, 2018 Page 2 of 2 BLS Ambulance Services in EMS System February 1, 2018 thru May 31, 2018 Complaint Reported by Dispatch Transport Mode NRLS PCR Primary Clinical Impression Abdominal Pain/Problems 1 Non-acute Back Pain (Non-Traumatic) 1 Non-acute Chest Pain (Non-Traumatic) 1 Pain X1 day Convulsions/Seizure 1 Epilepsy Hx Post Ictal Falls 1 Ground level fall due to weakness/diabetes Heart Problems/AICD 2 S1 Paramedic examined pt. with 12 Lead and BLS transport. S1 Paramedic attended patient with BLS transport. No Other Appropriate Choice 10 Misc. sick Psychiatric Problem/Abnormal Behavior/Suicide Attempt 6 Non-acute Sick Person (Alpha and Omega) 311 Misc. sick Stab/Gunshot Wound/Penetrating Trauma 1 Left shoulder pain from minor auto accident Unconscious/Fainting/Near-Fainting 1 Non-acute Unknown Problem/Person Down 1 Leg pain Transfer/IFT/Palliative Care 191 Misc. sick Summary: The use of BLS ambulances to respond to likely low acuity medical incidents and to potentially high acuity medical incidents during periods of high demand appears to be a safe and effective use of limited prehospital care resources.

11 San Joaquin County Emergency Medical Services Agency Mailing Address PO Box 220 DATE: July 5, 2018 TO: EMS Liaison Committee Health Care Services Complex Benton Hall 500 W. Hospital Rd. PREPARED BY: SUBJECT: Matthew R. Esposito, MSc, MICP, Pre-Hospital Care Coordinator ALS Treatment Protocols Revisions Phone Number (209) Fax Number (209) RECOMMENDED ACTION: Receive information on current efforts to update and revise the advanced life support treatment protocols. FISCAL IMPACT: N/A DISCUSSION: In 2017, the San Joaquin County EMS Agency started a comprehensive review of existing treatment protocols with the goal of releasing a revised set of advanced life support (ALS) and basic life support (BLS) treatment protocols. A first draft document was developed by Dr. Buys and Dr. Shafer with the assistance of SJCEMSA staff and released for public comment in the spring of Dr. Shafer formed a working group comprised of CQI Council members and other paramedics and registered nurses to assist in reviewing public comments further refining the treatment protocols for clarity and ease of use by prehospital and base hospital personnel. An abridged summary proposed changes includes: 1. Revised definition of a pediatric patient. Currently pediatric treatment policies have been based solely on age. A simple age cut off established hospital destinations and medication dosages. Current best practice is to use weight based treatment tapes that measure a child s height and weight, to determine medication dosages and treatment protocols. The new definition of pediatric patient which is already being included in the revised medical and trauma destination policies is: a patient 12 years of age or younger, is not taller than a Broselow Tape (146.5 cm). 2. Movement of the following skills and medications to standing orders to potentially include: a. Cardioversion of Symptomatic Supra Ventricular Tachycardia.

12 Treatment Protocol Revisions Update EMS Liaison Committee July 5, 2018 Page 2 of 2 b. Cardioversion of Symptomatic Ventricular Tachycardia. c. Determination of death for non-obvious conditions in specific situations. d. Dopamine for cardiogenic shock. e. Sedation procedures for suspected excited delirium. f. Magnesium sulfate for eclampsia. 3. Continued use of the igel for pediatric airway management replacing oral endotracheal intubation. 4. Use of igel as the preferred rescue airway for adult patients replacing the King tube. 5. Revised cardiac arrest treatment algorithm to improve upon existing MICR process. 6. Potential new medications and uses: a. Racemic epinephrine. b. Epinephrine drips. c. Magnesium sulfate. d. Oral diphenhydramine. e. Ketamine. f. Acetaminophen. g. Tranexamic acid h. Ketorolac. 7. Expanded medications and procedures for use during inter-facility transfers to accommodate the increasing need to transfer acutely ill patients requiring complex management more often from community hospitals to a special care centers. 8. An improved format to enhance readability and functionality. NEXT STEPS: An updated draft is expected to be released for public comment in September 2018, with the goal of implementing the revised treatment protocols in January SJCEMSA encourages all prehospital and base hospital personnel to share recommendations for protocol revisions with their department s CQI representative.

13 San Joaquin County Emergency Medical Services Agency Mailing Address PO Box 220 DATE: July 5, 2018 TO: EMS Liaison Committee Health Care Services Complex Benton Hall 500 W. Hospital Rd. PREPARED BY: SUBJECT: Rick Jones, MPA Luann Serafine, RN, BSN Stroke System of Care Implementation Phone Number (209) RECOMMENDED ACTION: Receive information on the stroke system of care in San Joaquin County. FISCAL IMPACT: The San Joaquin County EMS Agency (SJCEMSA) receives $25,000 per year from each designated stroke center to offset the costs associated with stroke system planning, implementation, and evaluation. DISCUSSION: On May 25, 2018, the SJCEMSA announced the creation of specialty stroke system of care designed to ensure that patients experiencing signs and symptoms of an acute stroke are provided with rapid access to evaluation and treatment at primary stroke centers located throughout San Joaquin County. Adventist Health Lodi Memorial, Doctors Hospital Manteca, Kaiser Hospital Manteca, San Joaquin General Hospital, St. Joseph s Medical Center, Sutter Tracy Community Hospital applied for and received designation as primary stroke centers following a ten month implementation process. The implementation of the stroke system of care in San Joaquin County also includes: 1. Current modification of EMS Policy 5201, Medical Patient Destination to direct patients with suspected stroke to a designated primary stroke center. 2. Convening a quarterly Multidisciplinary Stroke QI Committee with representatives from each primary stroke center and prehospital ALS system providers. The first meeting was held on April 27, The next meeting is scheduled for July 27, Collection of prehospital and in-hospital stroke-related data to measure efficiency, effectiveness, and coordination of patient care from initial dispatch of EMS resources to

14 Stroke System Report Stroke System of Care Implementation Update EMS Liaison Committee Meeting July 5, 2018 Page 2 of 2 destination and in-hospital treatment. SJCEMSA staff developed and distributed a data collection tool to all designated stroke centers for implementation beginning July 9, 2018.

15 San Joaquin County Emergency Medical Services Agency Mailing Address PO Box 220 DATE: July 5, 2018 TO: EMS Liaison Committee PREPARED BY: Shahloh Jones-Mitchell, EMS Analyst SUBJECT: Trauma System Report RECOMMENDED ACTION Health Care Services Complex Benton Hall 500 W. Hospital Rd. Phone Number (209) Fax Number (209) Receive information on the Trauma System of San Joaquin County. FISCAL IMPACT State law allows local EMS agencies to recoup the costs associated with the development of a trauma system plan and ongoing monitoring of the trauma system in the fees charged for designating trauma centers. The trauma center monitoring fee totals $238,000 and will offset the costs associated with monitoring the trauma center contract, legal fees, and a site team verification of San Joaquin General Hospital (SJGH) by the American College of Surgeons (ACS) Committee on Trauma. Revenue from the trauma center designation fee is included in the approved EMS budget. DISCUSSION Trauma Center Verification San Joaquin General Hospital (SJGH) has been verified as a Level III Trauma Center through April 20, 2021 by the American College of Surgeons (ACS) Committee on Trauma (COT). This achievement recognizes the trauma center's dedication to providing optimal care for injured patients. Established by the American College of Surgeons in 1987, the COT's Verification Program for Hospitals promotes the development of trauma centers in which participants provide not only the hospital resources necessary for trauma care, but also the entire spectrum of care to address the needs of all injured patients. This spectrum encompasses the prehospital phase through the rehabilitation process. Verified trauma centers must meet the essential criteria that ensure trauma care capability and institutional performance, as outlined by the American College of Surgeons' Committee on Trauma in its current Resources for Optimal Care of the Injured Patient manual. The ACS- COT's verification program does not designate trauma centers. Rather, the program provides confirmation that a trauma center has demonstrated its commitment to providing the highest

16 Trauma System Report EMS Liaison Committee July 5, 2018 Page 2 of 3 quality trauma care for all injured patients. The actual establishment and the designation of trauma centers is the responsibility of the San Joaquin County EMS Agency (SJCEMSA). SJGH was originally designated as a level III trauma center by SJCEMSA in August 2013, in accordance with state statute and regulations. SJGH Trauma Process Improvement and Patient Safety Program The SJGH Trauma Services Department holds meetings of its multidisciplinary Trauma Process Improvement and Patient Safety (PIPS) Committee each month. The objective of a trauma PIPS program is to improve patient outcomes, eliminate problems, and reduce variation in patient care. All trauma centers are expected to systematically and critically scrutinize their trauma care using performance measurements as a means to validate and improve patient care and provide clinicians with the tools to remain competent with current medical best practice. While there is no precise prescription for a PIPS program, such programs must demonstrate a continuous process of monitoring, evaluating, and improving the performance of the trauma program. As part of its PIPS program, SJGH collects and evaluates information related to trauma activations and follows each trauma patient through their hospitalization and disposition. The charts below show a summary of the data regularly evaluated by the SJGH Trauma PIPS Committee. Trauma Data Summary Trauma Volume & Utilization Definition Total YTD Qtr 1 Qtr 2 Jan Feb Mar Apr May Jun Month is Complete Completed Month in Registry X X X Total Patients in Registry Total Patients listed by Month Total Tier 0 Activations Total Tier 0's Called Total Tier 1 Activations Total Tier 1's Called Total Tier 2 Activations Total Tier 2's Called Total Tier 3 Activations Total Tier 3's Called Total Other/Non-Activations Total Not Activated listed as Other Total Burn Activations Total Patients that were Burn Activations 0 X X X X X X Total Pediatric Activations Total Patients there were Peds Activations 0 X X X X X X Total Admissions to ICU from ED Went from ED to ICU Total Admissions to the Floor from ED Total Admissions to the OR from the ED Went from ED to Tele/Non-Tele Floor/ER Hold Went from ED to OR Total Number of Admissions Number of Trauma Pts. Admitted to hospital Disposition Sample of patients Total Discharges from the ED Discharged from the ED Total Pediatric Admissions Total Pediatric Patients Admitted 0 X X X X X X Total Pediatric Transfers Out Total Pediatric Patients Transferred for HLC 0 X X X X X X Total Transfers Out Total Transfers Out for Higher Level of Care Total Burn Transfers Out Total Transfers IN Total Burn Patients Transferred for HLC Total Transfers In for a Higher Level of Care 0 68 X 5 X 7 X 21 X 18 X 17 X

17 Trauma System Report EMS Liaison Committee July 5, 2018 Page 3 of 3 Mechanisms Mechanisms for majority of patients Motor Vehicle Accidents (MVA) Total number of motorvehicle accidents Motorcycle Accidents Total number of motorcycle accidents GSW Total number of GSW patients Stabbings Total number of stabbing injuries Falls Falls including elderly ground level falls Assaults Patients assaulted with traumatic injuries Auto vs. pedestrian Pedestrian or bicycle vs. automobile Total Trauma Patients requiring Surgery Trauma Pts. that had at least 1 OR case Length of Stay - Median Median Length of Stay for All Trauma Pts Length of Stay in ICU Median Length of Stay for Trauma ICU Pts Massive Transfusion Protocol (MTP) MTP initiated Trauma Services Definition Total Qtr 1 Qtr 2 YTD Jan Feb Mar Apr May Jun Trauma MD Response - Tier 0 >15 minutes of Patient Arrival Time Trauma MD Response - Tier I >15 minutes of Patient Arrival Time Trauma MD Response - Tier II >15 minutes of Patient Arrival Time ISS > 9 Admitted to Non-Trauma Service Admitted to any svc other than Trauma ISS <9 Pts. w/iss Score Less Than ISS 9-15 Pts. w/iss Score from ISS Pts. w/iss Score from ISS 25 and Above Pts. w/iss Score from 25 and higher Total Total YTD/Per Month Bypass Time Total time on Trauma Bypass in minutes

18 San Joaquin County Emergency Medical Services Agency Mailing Address PO Box 220 DATE: July 5, 2018 TO: EMS Liaison Committee Health Care Services Complex Benton Hall 500 W. Hospital Rd. PREPARED BY: SUBJECT: Rick Jones, MPA, EMS Analyst Shahloh Jones-Mitchell, EMS Analyst STEMI st Quarter Review Phone Number (209) RECOMMENDED ACTION: Receive information on the STEMI System in San Joaquin County for January 1, 2018 through March 31, FISCAL IMPACT: The San Joaquin County EMS Agency (SJCEMSA) receives $25,000 per year from each designated STEMI center to offset the costs associated with STEMI system planning, implementation, and evaluation. DISCUSSION: The SJCEMSA developed and implemented a system to identify heart attack patients experiencing an ST elevated myocardial infarction (STEMI) and to direct these patients to specially designated hospitals staffed and equipped with cardiac catheter laboratories capable of providing immediate life-saving intervention. The ability of SJCEMSA to evaluate the STEMI system relies upon data measuring the performance of prehospital and hospital timeliness and adherence to policies and procedures. The STEMI system of care began with the designation of St. Joseph s Medical Center and Dameron Hospital as the two STEMI Receiving Centers (SRCs) in San Joaquin County beginning April 1, The following Quality Indicators, used as a means to measure the effectiveness of the STEMI system in San Joaquin County, rely upon data derived from both prehospital and in-hospital sources. Prehospital Quality Indicators include measurement of the following: 1. Accurate and complete documentation 2. Time spent on-scene 3. Appropriate use of 12 lead ECGs (Pts correctly identified as possible cardiac patients)

19 STEMI System Report 1 st Quarter Review 2018 EMS Liaison July 5, 2018 Page 2 of Identification of STEMI patients (using criteria set forth in SJCEMSA policy) 5. Timely and correct notification of SRCs for patients identified as having STEMI 6. Efficacy of ECG transmission In-Hospital Quality Indicators include measurement of the following: 1. Timeliness of in-hospital STEMI alert in response to prehospital STEMI alert 2. Efficacy of prehospital STEMI identification method (e.g. percentage of false positives) 3. Timeliness of prehospital alert and ED arrival to cath lab/balloon times Data Analysis The data in this report is derived from a review of patient care reports and in-hospital care at each SRC. The focus of this process is appropriate STEMI documentation,12-lead ECG interpretation and application, and whether timely and correct notification of SRCs for patients identified as having STEMI has occurred. Data collected for this report that comprise N contains two subsets: 1) Ambulance transports with STEMI patients identified in the prehospital setting and 2) ambulance transports that arrive at SRCs that were not identified as possible STEMI patients in the prehospital setting. When cases from both subsets are included, they can be broken into the following categories: Table 1. Reporting Categories SJMC Dameron True Positive 37 2 False Positive Evolving Subsequent 7 0 False Negative 1 0 Atypical Presentation 0 0 True Negative 1 0 Total Cases in the second subset include those reported as True Negative, NA, False Negative, and Evolving Subsequent. True Negative are cases in which the SRC concurred with the prehospital finding of no STEMI, but were included for review because the case appeared to be cardiac in nature. False Negatives and Evolving Subsequent include those cases in which the prehospital ECG did not indicate a STEMI, but was determined to be a STEMI sometime after arriving at the STEMI Receiving Center.

20 STEMI System Report 1 st Quarter Review 2018 EMS Liaison July 5, 2018 Page 3 of 10 SRC STEMI Alert Performance Report The premise for alerting a SRC of a STEMI patient in the prehospital setting is to provide the hospital with early notification in order to ensure that the cardiac cath lab team is prepared to provide the care necessary to perfuse the heart and stop heart muscle cell death. The goal is that upon receipt of a STEMI alert from the prehospital setting, the SRCs will immediately call an internal STEMI alert. Charts 1 and 2 show SJMC and Dameron Hospital s In-Hospital STEMI Alert performance for the 1 st quarter of Chart 1 Chart 2

21 STEMI System Report 1 st Quarter Review 2018 EMS Liaison July 5, 2018 Page 4 of 10 Transmission of ECGs from the Prehospital Setting In order to minimize on-scene delays in the prehospital setting caused by waiting for the completion of an ECG transmission, SJCEMSA policy did not require that prehospital personnel transmit an ECG to the STEMI Receiving Center. Instead, paramedics were encouraged to transmit ECGs to the SRC during transport whenever possible. As shown in the table below, there has been over a seventy-five percent success rate in transmissions. The increase in ECG transmissions is attributed to improvements in ECG transmission technology. Chart 3

22 STEMI System Report 1 st Quarter Review 2018 EMS Liaison July 5, 2018 Page 5 of 10 Ratio of True Positive to False Positive Alerts False Positive cases are shown by month in Chart 4 below. False Positive cases occurred 54.1% of the time in the 1 st quarter of 2018, which is a 4% increase compared to Chart 4 As summarized in Table 2 shows the ratio of True Positive and False Positive cases at each SRC for the 1 st quarter of Table 2 Cases with Prehospital STEMI Alerts SJMC Dameron Combined True Positive False Positive Total Prehospital STEMI Alerts

23 STEMI System Report 1 st Quarter Review 2018 EMS Liaison July 5, 2018 Page 6 of 10 The impact of the high number of false positive cases has been moderated by timely transmission of ECGs. While 9 of the 46 ECG False Positive cases were not transmitted, 20 of the False Positive cases were transmitted simultaneously or prior to the STEMI alert called in by prehospital personnel. Of the remaining 17 False Positive cases, the elapsed time from prehospital STEMI alert to ECG transmission to the hospital averaged only 8 minutes and ranged from1 minute to 20 minutes. This data strongly suggests that timely ECG transmission is routine and effective. ECG transmission is required as of July 1, Chart 5

24 STEMI System Report 1 st Quarter Review 2018 EMS Liaison July 5, 2018 Page 7 of 10 Return of Spontaneous Circulation Per EMS Policy No. 5201, Medical Patient Destination, medical patients with a return of spontaneous circulation (ROSC) shall be transported to the closest STEMI receiving center. SJMC and Dameron reported (17) patients transported by ambulance due to ROSC for the 1 st quarter of Patient outcomes are categorized below by whether they remained in the emergency department, or were moved to the cath lab. Chart 6 Pt. Not Moved to Cath Lab 6 Expired in ED 1 Prior lesion 1 True Negative (non-stemi per ECG) 1 TP with Alert Pt. Moved to Cath Lab 1 True Negative (confirmed in Cath Lab) 2 Successful PCI 5 Unsuccessful PCI

25 STEMI System Report 1 st Quarter Review 2018 EMS Liaison July 5, 2018 Page 8 of 10 Time Spent On-Scene Chart 7 The SJCEMSA policy that directs patient care in the prehospital setting (EMS Policy No. 5719, ALS Chest Pain) directs prehospital providers to initiate rapid transport to a STEMI receiving center. Chart 7 above shows the elapsed time from patient contact to the initiation of transport for all patients that were determined to have a STEMI in the prehospital setting. Cardiac arrest is the typical cause of extended on-scene times. Volume of Cath Lab Interventions Originating via 911 System The number of patients identified in the prehospital setting as STEMI patients exceed the number of patients that ultimately receive care in a cardiac cath lab, usually a percutaneous intervention (PCI), for two reasons. First, the identification of STEMI patients in the prehospital setting relies upon the analysis of each patient s 12-Lead ECG by the computer in each device. Upon arrival at the emergency department at the SRC, or upon review of an ECG transmitted from the prehospital setting, the emergency department physician either confirms or cancels the SRC STEMI alert. Second, some patients confirmed at the SRC as a STEMI patient may not be candidates for PCI for a variety of reasons related to their particular medical condition.

26 STEMI System Report 1 st Quarter Review 2018 EMS Liaison July 5, 2018 Page 9 of 10 SJMC received 74 prehospital STEMI alerts and performed 24 reperfusions in the cath lab during the 1st quarter of 2018 (Chart 8). Dameron Hospital received 14 STEMI alerts and performed 1 cath lab intervention during the same period. Door to Balloon Times Charts 8 and 9 show the time of arrival of an ambulance patient at the hospital emergency department until completion of a PCI in the hospital cardiac cath lab. This data only includes those cases in which a STEMI alert was initiated in the prehospital setting. As shown in Chart 8 and 9 below, SJMC and Dameron Hospital consistently meet or exceed the ACC/AHA < ninety (90) minute the door to balloon time (D2B) interval minimum standards. Chart 8

27 STEMI System Report 1 st Quarter Review 2018 EMS Liaison July 5, 2018 Page 10 of 10 Chart 9

28 San Joaquin County Emergency Medical Services Agency Mailing Address PO Box 220 DATE: July 5, 2018 TO: EMS Liaison Committee Health Care Services Complex Benton Hall 500 W. Hospital Rd. PREPARED BY: SUBJECT: Shahloh Jones-Mitchell, EMS Analyst Report on Ambulance Patient Off-load Delays Phone Number (209) Fax Number (209) RECOMMENDED ACTION: Receive information on Ambulance Patient Off-load Delays (APOD) occurring in San Joaquin County. FISCAL IMPACT: The estimated financial loss of ambulance availability to the EMS system caused by hospitals encumbering emergency ambulances by refusing to accept patients and delaying the ability of ambulances to promptly return to service is calculated to be $466,881 for the months of January 2018, February 2018, and March DISCUSSION: Health and Safety Code, Section requires the state EMS Authority (EMSA) to develop a standard methodology for calculation of, and reporting of ambulance patient offload times (APOT) by local EMS agencies (LEMSAs). Health and Safety Code, Section mandates LEMSAs to adopt policies and procedures for calculating and reporting ambulance offload time based on standards established by EMSA. EMSA s standardized model to measure APOT includes the following definitions: Ambulance Patient Offload Time (APOT) - the time interval between the arrival of an ambulance patient at an ED and the time the patient is transferred to the ED gurney, bed, chair or other acceptable location and the emergency department assumes the responsibility for care of the patient. The adoption of this definition ensures uniformity of measurement for comparison purposes statewide, and establishes a more accurate method to determine transfer of care time at the ED than used prior to This APOT report follows the standardized model recommended

29 APOD Report EMS Liaison Committee July 5, 2018 Page 2 of 5 by the EMS Commission and adopted by the EMSA utilizing the categories defined as APOT- 1 and APOT-2. a. APOT-1: The number reported is the APOT in minutes for transfer of care of 90% of ambulance patients and the number of ambulance runs included in the report. b. APOT-2: The number reported is the percentage of ambulance patients transported by EMS personnel with an offload time within twenty (20) minutes and those transports with an ambulance patient offload delay beyond 20 minutes. APOD is further stratified by sixty (60) minute intervals up to one hundred eighty (180) minutes then any APOT exceeding one hundred eighty (180) minutes. Twenty minutes has been selected as the target standard for statewide reporting consistency based on precedence from other systems outside of California, as well as experience of some of the California LEMSAs. The APOT standard adopted by the San Joaquin County EMS Agency (SJCEMSA) is twenty (20) minutes. An APOT delay (APOD) shall be deemed to have occurred when the APOT interval exceeds this standard. Goal SJCEMSA s goal is for every patient care transfer between ambulance personnel and emergency department personnel to occur within 20 minutes thereby allowing ambulances to return to service. SJCEMSA believes this is an attainable goal for all receiving hospitals. Patient Care Impact When an ambulance is kept at an emergency department over 20 minutes due to an ambulance patient offload delay, this impacts the ability of the EMS system to meet demand and may adversely impact the care of the patient waiting on an ambulance gurney. While definitive patient outcome data is not available to support the claim that offload delays are deleterious to patient care, one way in which the impact of offload delays can be measured is through an analysis of ambulance response compliance data. Such an analysis indicates that offload delays directly reduce the number of ambulances available to respond to emergencies with response times required for contract compliance. 1 The reduction in available ambulance services caused by offload delays can be measured in two ways: the relative increase in the number of exemption requests and the real impact of off-load delays on ambulance response time compliance. 1 The process for determining response time compliance includes a review of late response exemption requests to determine if a delay in response may be attributed to factors outside of the control of the ambulance provider. If an exemption request is approved (e.g. fog, train crossings, road construction) those responses are not included in response time compliance calculations.

30 APOD Report EMS Liaison Committee July 5, 2018 Page 3 of 5 Increase in Ambulance Response Compliance Exemptions: When the frequency and length of offload delays reach a trigger point, an ambulance provider may request an exemption from meeting ambulance response compliance requirements. An offload delay exemption trigger is activated when all of the following occurs: There are a minimum of 3 ambulances delayed at one or more Stockton area hospital (Dameron, St. Joseph s Medical Center, San Joaquin General Hospital) for a time period > 50 minutes for each ambulance. There are five (5) or fewer ambulances available in the greater Stockton area (Status 5 or less). The three (3) ambulances referenced above must have been delayed at hospitals during the 50 minutes prior to the call in which an exemption is being sought. Ambulance staffing must be at or above the contracted minimum staffing levels. The EMS system continues to experience a profound impact on ambulance availability and response caused by ambulance patient offload delays (APODs) at emergency departments. The inability of emergency departments to readily accept ambulance patients has a direct negative effect on the availability of ambulances to respond to emergency requests. APODs continue to rob the EMS system of efficiency and steals precious response-time minutes from acutely ill and injured patients. During the first quarter of 2018, hospital caused APODs continued to decrease monthly response-time compliance by more than 6%. Ambulance Patient Off-load Delay Performance The performance of the seven hospitals in San Joaquin County during the first quarter of 2018 is shown in the table and chart below. Table 1 shows the volume of ambulance patient off-loads by each hospital and the number of minutes required to off-load patients at the 90 th %ile (APOT-1) during the first quarter of Table 1 APOT-1 Jan-Feb-Mar 2018 Instances of APOD 90 th Percentile APOT Minutes St. Joseph s Medical Center 5,705 1:01:58 San Joaquin General Hospital 2,805 45:39 Adventist Health Lodi Memorial Hospital 2,021 30:06 Dameron Hospital 1,555 37:14 Doctors Hospital Manteca :40 Sutter-Tracy Community Hospital :53 Kaiser Hospital Manteca :22 *Data not entered on PCR

31 APOD Report EMS Liaison Committee July 5, 2018 Page 4 of 5 Chart 1 shows the volume of ambulance patient offload times stratified within APOT-2 intervals (0-20; 21-60; ; ; >180) during the first quarter of 2018 for each hospital. Table 2 shows a detailed count of the volume and percentage within each APOT-2 interval per hospital. APOT-2 Volume & Percentage 1st Quarter >20 to 60 >60 to 120 >120 to 180 >180 Total Volume St. Josephs Medical Center % % % % % 5705 San Joaquin General Hospital % % % % % 2805 Adventist Health Lodi Memorial Hospital % % % % % 2021 Dameron Hospital % % % % % 1555 Doctors Hospital Manteca % % % % % 958 Sutter-Tracy Community Hospital % % % % % 897 Kaiser Hospital Manteca % % % % % 808

32 APOD Report EMS Liaison Committee July 5, 2018 Page 5 of 5 Financial Impact Every minute that an ambulance must remain at a hospital emergency department longer than 20 minutes (APOD), the financial impact to the system is approximately $3.00 per minute for 155,627 cumulative APOT minutes which cost the system $466,881 during the first three months of The breakdown of cost of APOD by hospital is shown below in Chart 2. Chart 2

33 San Joaquin County Emergency Medical Services Agency Mailing Address PO Box 220 DATE: July 5, 2018 TO: EMS Liaison Committee Health Care Services Complex Benton Hall 500 W. Hospital Rd. PREPARED BY: SUBJECT: Matthew R. Esposito, MSc, MICP, Pre-Hospital Care Coordinator BLS QI Program Phone Number (209) Fax Number (209) RECOMMENDED ACTION: Receive information on basic life support (BLS) service provider quality improvement program activities. FISCAL IMPACT: N/A. DISCUSSION: With the addition of naloxone and epinephrine auto injectors to the basic life support (BLS) scope of practice the SJCEMSA is focusing attention on the implementation of QI plans and programs by BLS service providers. The state legislature expanded the role of emergency medical technicians to include potential dangerous and invasive skills and medications. This role expansion makes imperative the need for BLS service providers to have in place highly effective QA/QI processes. SJCEMSA personnel have been meeting with individual BLS service providers and reviewing their QI plans and programs. SJCEMSA s initial focus has been with those BLS service providers that have entered into agreements authorizing the implementation of the expanded BLS scope of practice to include naloxone administration and epinephrine auto injectors. BLS QI Plan Outline 1 PCR review / audit 2 Department QI peer review committee 3 Public education 4 100% review of naloxone and epinephrine administrations 5 Tracking of employee EMS certifications and training 6 Tracking BLS equipment and medication expiration dates

34 BLS QI Program EMS Liaison Committee July Page 2 of 2 BLS Service Provider Clements Fire District Collegeville Fire Department Escalon City Fire Department Farmington Fire District French Camp McKinley Fire District Lathrop Manteca Fire District Liberty Fire District Linden-Peters Fire Department Lodi Fire Department Manteca City Fire Department Mokelumne Rural Fire District Montezuma Fire District NorCal Ambulance Thornton Fire District Waterloo Fire District Woodbridge Rural Fire District BLS QI Plan Status Pending Approved Pending Pending Approved Approved Pending Pending Pending Approved Pending Pending Pending Pending Pending Pending In FY18-19, SJCEMSA intends to work with each BLS service provider in creating and implementing a QI program that meets the requirements of EMS Policy No. 6620, Continuous Quality Improvement Process, to include prospective, concurrent, and retrospective activities along with reporting and loop closure.

35 San Joaquin County Emergency Medical Services Agency Mailing Address PO Box 220 DATE: July 5, 2018 TO: EMS Liaison Committee PREPARED BY: Phillip Cook, Disaster Medical Health Specialist SUBJECT: Incident Command System (ICS) Training Courses RECOMMENDED ACTION: Health Care Services Complex Benton Hall 500 W. Hospital Rd. Phone Number (209) Fax Number (209) Provide an overview of the scheduled Incident Command System (ICS) training courses. FISCAL IMPACT: Estimated $12,500 funding provided through the FY Hospital Preparedness Program Grant DISCUSSION: The San Joaquin County Emergency Medical Services Agency and San Joaquin Operational Area Healthcare Coalition are sponsoring a series of six Incident Comand System (ICS) training courses: 1. ICS-100: Introduction to the Incident Command System August 14, ICS-200: Incident Command System for Single Resources and Initial Action Incidents October 8-9, Incident Action Plan (IAP) Training October 9, 2018 ( hours after the ICS-200 course) 4. Incident Planning Process for Extended Operations (Train-the-Trainer) - April 17, ICS-300: Intermediate Incident Command for Expanding Incidents January 7-9, ICS-400: Advanced Incident Command System - June 19-20, 2019 See attached flyers for details.

36 San Joaquin Operational Area Healthcare Coalition Presents ICS-100 Introduction to the Incident Command System Course August 14, 2018 San Joaquin County Agriculture Center 2101 E. Earhart Ave., Stockton, CA Hours Purpose This course provides training and resources for personnel who require a basic understanding of the Incident Command System (ICS). ICS-100 introduces ICS and provides the foundation for higher level ICS training. This course describes the history, features and principles, and organizational structure of the Incident Command System. It also explains the relationship between ICS and the NIMS. Audience The target audience includes healthcare personnel and volunteers involved with emergency planning and response or recovery efforts. Course Topics: ICS Overview Basic Features of ICS Incident Commander and Command Staff Functions General Staff Functions ICS Facilities Common Responsibilities Course prerequisites: N/A Tuition: FREE (Funding provided by the 2018/19 HPP Grant). Course participation is limited to members of the following: San Joaquin Operational Area Healthcare Coalition San Joaquin County Disaster Healthcare Volunteers This course is offered at no cost to participants. Upon the successful completion, participants will receive a course completion certificate for 8 hours of EMS Continuing Education and/or BRN Contact hours. Provider is approved by the California Board of Registered Nursing, Provider Number 1524 for 8 contact hours. CA EMS CE provided by San Joaquin County EMS Agency CEP# Space is Limited to 50 Students Register online at For more information contact: Phillip Cook (209) or pcook@sjgov.org

37 San Joaquin Operational Area Healthcare Coalition Presents ICS-200 Incident Command System for Single Resources and Initial Action Incidents Course October 8-9, 2018 San Joaquin County Agriculture Center 2101 E. Earhart Ave., Stockton, CA Hours Day 1, Hours Day 2 Purpose ICS-200 provides training and resources for personnel who are likely to assume a supervisory position within the ICS. This course is designed to enable personnel to operate efficiently during an incident or event within the ICS. This course focuses on the management of single resources. Audience The primary target audience is response personnel at the supervisory level. Course Topics: Describe the ICS organization appropriate to the complexity of the incident or event Use ICS to manage an incident Leadership and Management Delegation of Authority and Management by Objectives Functional Areas and Positions Briefings Organizational Flexibility Transfer of Command Course prerequisites: ICS-100. Students must provide proof of meeting the course prerequisites on the first day of class. Tuition: FREE (Funding provided by the 2018/19 HPP Grant) Course participation is limited to members of the following: San Joaquin Operational Area Healthcare Coalition San Joaquin County Disaster Healthcare Volunteers This course is offered at no cost to participants. Upon the successful completion, participants will receive a course completion certificate for 12.0 hours of EMS Continuing Education and/or BRN Contact hours. Provider is approved by the California Board of Registered Nursing, Provider Number 1524 for 12.0 contact hours. CA EMS CE provided by San Joaquin County EMS Agency CEP# Space is Limited to 30 Students Register online at For more information contact: Phillip Cook (209) or pcook@sjgov.org

38 San Joaquin Operational Area Healthcare Coalition Presents ICS-300 Intermediate Incident Command for Expanding Incidents Course January 7-9, 2019 San Joaquin County Agriculture Center 2101 E. Earhart Ave., Stockton, CA Hours Purpose ICS-300 provides training and resources for personnel who require advanced application of the ICS. The course expands upon information covered in the ICS-100 and ICS-200 courses. Audience This course is intended for individuals who may assume a supervisory role in expanding incidents or Type 3 incidents. Course Topics: Describe how the NIMS command and management component supports the management of expanding incidents. Describe the incident or event management process for supervisors and expanding incidents as prescribed by ICS. Implement the incident management process in a simulated Type 3 incident. Develop an incident action plan for a simulated incident. Course prerequisites: ICS-100 and ICS-200, IS-700, IS-800 Students must provide proof of meeting the course prerequisites on the first day of class. Tuition: FREE (Funding provided by the 2018/19 HPP Grant) Course participation is limited to members of the following: San Joaquin Operational Area Healthcare Coalition San Joaquin County Disaster Healthcare Volunteers This course is offered at no cost to participants. Upon the successful completion, participants will receive a course completion certificate for 18 hours of EMS Continuing Education and/or BRN Contact hours. Provider is approved by the California Board of Registered Nursing, Provider Number 1524 for 18 contact hours. CA EMS CE provided by San Joaquin County EMS Agency CEP# Space is Limited to 30 Students Register online at For more information contact: Phillip Cook (209) or pcook@sjgov.org

39 San Joaquin Operational Area Healthcare Coalition Presents ICS-400 Advanced Incident Command System Course June 19-20, 2019 San Joaquin County Agriculture Center 2101 E. Earhart Ave., Stockton, CA Hours Purpose This course provides training and resources for personnel who require advanced application of the ICS. This course expands upon information covered in ICS-100 through ICS-300 courses. These earlier courses are prerequisites for ICS-400. Audience The target audience for this course is senior personnel who are expected to perform in a management capacity in an area command or multiagency coordination entity. Course Topics: Explain how major incidents engender special management challenges. Describe the circumstances in which an area command is established. Describe the circumstances in which multiagency coordination systems are established. Course prerequisites: ICS-100, ICS-200, ICS-300, IS-700 and IS-800 Students must provide proof of meeting the course prerequisites on the first day of class. Tuition: FREE (Funded by the 2018/19 HPP Grant) Course participation is limited to members of the following: San Joaquin Operational Area Healthcare Coalition San Joaquin County Disaster Healthcare Volunteers This course is offered at no cost to participants. Upon the successful completion, participants will receive a course completion certificate for 14 hours of EMS Continuing Education and/or BRN Contact hours. Provider is approved by the California Board of Registered Nursing, Provider Number 1524 for 14 contact hours. CA EMS CE provided by San Joaquin County EMS Agency CEP# Space is Limited to 30 Students Register online at For more information contact: Phillip Cook (209) or pcook@sjgov.org

40 San Joaquin Operational Area Healthcare Coalition Presents Incident Action Plans Training October 9, 2018 San Joaquin County Agriculture Center 2101 E. Earhart Ave., Stockton, CA 1300 to 1700 Hours Description This 4 hour course is designed to teach participants how to complete a NIMS compliant Incident Action Plan (IAP), and will be taught in a hands on learn by doing format. Topics include: What is an Incident Action Plan (IAP)? Required Forms and Components Optional Forms and Components How to Complete Each Form and Component Operational Period Briefings Pre Course Participant Requirements: Complete an IS-200 or ICS-200 course Develop a plausible incident scenario for your facility that will require a minimum of three12 hour Operational Periods (36 hours) to mitigate. Develop SMART incident objectives for one 12 hour Operational Period for your scenario Bring the following: 1. The Transmit (TX) and Receive (RX) frequencies for the radio channels used at your facility or by your agency. 2. The telephone numbers (cell or landline) for your facility s Incident Management Team members. 3. A minimum of one 8.5 x 11 facility or incident map 4. Two copies of the following NIMS ICS Forms, with instructions: 202, 203, 204, 205, 205A, 206, and 208. Copies of these forms are available online at (Funding provided by the 2018/19 HPP Grant) Course participation is limited to members of the following: San Joaquin Operational Area Healthcare Coalition San Joaquin County Disaster Healthcare Volunteers Target Audience: Members of agency or organization Incident Management Teams (IMT): Especially the following positions: Operation Section Chief Planning Section Chief Resources Unit Leader Logistics Section Chief Tuition: FREE Space is Limited to 50 Participants Register online at For more information contact: Phillip Cook (209) or pcook@sjgov.org

41 San Joaquin County Operational Area Healthcare Coalition Presents The Incident Planning Process for Extended Operations (Train-the Trainer) April 17, 2019 San Joaquin County EMS Agency Classroom Hours Purpose: The purpose of this course is to teach Incident Management Team (IMT) personnel the all-hazards incident planning process. This course will be taught in a hands-on learn by doing format and is based upon the FEMA All-Hazards National Incident Management System (NIMS) training curriculum. Target Audience: Command and General Staff personnel from San Joaquin Operational Area Healthcare Coalition member agencies and organizations Topics include: Introduction Incident Briefing Incident Objectives Strategy Meeting Tactics Meeting Planning Meeting Incident Action Plan Preparation and Approval Operational Period Briefing Course prerequisites: ICS-100, ICS-200 o ICS-300 Highly Recommended Tuition: FREE (Funding provided by the 2018/19 HPP Grant) Space is Limited to 16 Participants (2 Eight Member Incident Management Teams) Register online at For more information contact: Phillip Cook (209) or pcook@sjgov.org

42 San Joaquin County Emergency Medical Services Agency Mailing Address PO Box 220 DATE: July 5, 2018 TO: EMS Liaison Committee Health Care Services Complex Benton Hall 500 W. Hospital Rd. PREPARED BY: SUBJECT: Phillip Cook, Disaster Medical Health Specialist Hospital Available Beds for Emergencies and Disasters (HAvBED) Drills Phone Number (209) Fax Number (209) RECOMMENDED ACTION: Provide a report of the last quarterly Region IV Hospital Available Beds for Emergencies and Disasters (HAvBED) drill. FISCAL IMPACT: N/A DISCUSSION: I. OVERVIEW The 2017/18 Hospital Preparedness Program (HPP) Grant requires San Joaquin County and each acute care hospital to conduct and participate in quarterly HAvBED drills. HAvBED polls are used to immediately ascertain local and regional hospital inpatient bed availability during disasters, such as hospital evacuations. The purpose of the drill is to provide hospitals with an opportunity to practice collecting and entering the HAvBED data into EMResource, to identify strengths to be built upon, and to identify areas for improvement and correction. II. AFTER ACTION REPORTS / IMPROVEMENT PLANS (AAR/IP) An ongoing area for improvement is the hospital s inability to collect and enter accurate HAvBED data. June 5, 2018 Drill AAR/IP

43 HAvBED Report EMS Liaison Committee July 5, 2018 Page 2 of 2 REFERENCES: 1. San Joaquin Operational Area Healthcare Coalition EMResource HAvBED Instructions 2. Entering HAvBED Data into EMResource instructional video 3. San Joaquin Operational Area Healthcare Coalition Governance, Section IV pdf

44 San Joaquin Operational Area Draft HAvBED Drill After Action Report / Improvement Plan (AAR/IP) June 5, to 2200 Hours Strengths: 1. Four hospitals (57%) reported statistically reliable bed data: Kaiser Manteca, Lodi Memorial, San Joaquin General, and St. Joseph s. Areas for Improvement: 1. Dameron reported all staffed beds as zero, indicating that the hospital has no patients and no staff; yet reported 4 Med Surg beds were available. a. Available beds can never be greater than staffed beds. 2. Doctor s Manteca erroneously reported having 2 staffed PICU beds; however the hospital doesn t have any licensed PICU beds. 3. Sutter Tracy reported 2 available OR beds; however reported zero staffed OR beds. a. Available beds can never be greater than staffed beds.