Emergency Medical Services Agency

Transcription

1 2005/2006 Annual Program Report - September Arnold Drive, Suite 126 Martinez, CA (925) fax (925)

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3 TABLE OF CONTENTS I. INTRODUCTION...1 A. OVERVIEW OF EMS...3 B. LOCAL EMS AGENCY FUNCTIONS...3 C. EMERGENCY MEDICAL CARE COMMITTEE....4 D. DELIVERY OF EMS SERVICES....5 E. COUNTY SERVICE AREA EM-1 (MEASURE H) FUNDING....6 II. LIST OF MAJOR ACCOMPLISHMENTS...9 III. ISSUES IN THE FOREFRONT...13 A. EMS RESPONSE TO SUDDEN CARDIAC ARREST...15 B. PUBLIC PARTICIPATION CPR TRAINING AND DEFIBRILLATION...20 C. THE PAST AND THE FUTURE...23 IV. EMS SYSTEM PARTICIPANTS...25 A. ADVISORY COMMITTEES...27 B. PSAP'S AND DISPATCH CENTERS...28 C. FIRST RESPONDERS...28 D. EMERGENCY AMBULANCE PROVIDERS...30 E. EMS HELICOPTERS...30 F. HOSPITALS...30 V. EMS PROGRAM ACTIVITIES...31 A. EMERGENCY AMBULANCE SERVICES...33 B. FIRST RESPONDER SERVICES...36 C. DISPATCH AND COMMUNICATIONS...38 D. HELICOPTER TRANSPORT...39 E. HOSPITAL EMERGENCY SERVICES...40 F. BASE HOSPITAL AND PARAMEDIC SERVICE PROGRAMS...41 G. TRAUMA SYSTEM...42 H. DISASTER/MULTICASUALTY PLANNING AND RESPONSE...43 I. CERTIFICATION PROGRAMS...46 J. TRAINING PROGRAMS...46 K. PUBLIC INFORMATION EDUCATION PROGRAM...47 L. INTERFACILITY TRANSFER PARAMEDIC PROGRAM...47 M. DNR PROGRAM...48 N. EMS FOR CHILDREN PROGRAM...48 O. OTHER EMS PROGRAMS...48 VI STATISTICAL REPORT...51 A. AMBULANCE DISPATCH REPORT...53 B. HELICOPTER UTILIZATION REPORT...59 C. BASE HOSPITAL CONTACT REPORT...63 D. TRAUMA SYSTEM REPORT...67 E. HOSPITAL CENSUS AND DIVERSION REPORTS...71 VII. EMS AGENCY ORGANIZATIONAL CHART...77 VIII. EMS EXPENDITURES...81 IX. DEVELOPMENT OF EMS IN CONTRA COSTA...85 X. EMS & RELATED ABBREVIATIONS...95 XI. GLOSSARY OF EMS TERMS...99 XII. DOCUMENTS AVAILABLE FROM THE EMS AGENCY XIII. CPR & FIRST AID RESOURCES

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5 I. INTRODUCTION

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7 A. Overview of EMS Emergency Medical Services is a system of services organized to provide rapid emergency medical response to serious medical emergencies, including immediate medical care and patient transport to definitive care in an appropriate medical setting. An effective EMS system involves a variety of agencies and organizations working together to accomplish this goal. While most EMS responses are day-to-day emergencies, EMS agencies also plan and prepare for disaster medical response. The EMS system includes: Public safety dispatch centers Fire services Ground and air ambulance services Law enforcement agencies Hospitals and specialty care centers Training institutions and organizations Citizen, professional, and technical advisory groups Local and State EMS Agencies Other governmental and voluntary organizations In California, EMS systems are organized on a county or regional basis. Local EMS Agencies (LEMSAs) are designated by county boards of supervisors as the lead agencies responsible for coordinating EMS services at the county or regional level consistent with State law and regulations. The California Emergency Medical Services Authority (EMSA) approves local EMS system plans, provides guidance to local EMS agencies, develops EMS regulations, administers the Regional Poison Control Center program, and carries out other EMS activities. The State EMS Commission, with members appointed by the Governor and certain other State officials, is advisory to the EMSA and reviews and approves all EMS regulations. In Contra Costa County, the Board of Supervisors has designated County Health Services as its Local EMS Agency. The EMS Director, EMS Medical Director, and staff carry out the EMS functions of Health Services. The EMS Medical Director has statutory responsibilities to oversee medical aspects of the EMS program. An Emergency Medical Care Committee (EMCC) provides advice regarding EMS matters to the Board of Supervisors and to the EMS Agency. B. Local EMS Agency Functions Principal functions of a local EMS agency as specified in the Health & Safety Code include: Planning, implementing, and evaluating emergency medical services. Monitoring and approving EMT-I, paramedic, and Mobile Intensive Care Nurse (MICN) training programs. Conducting credentialing programs for EMT-Is, paramedics and MICNs. Authorizing advanced life support (ALS) programs. Establishing policies and procedures for EMS system medical control, including those for Contra Costa Health Services EMS Annual Report for

8 dispatch, patient destination, patient care, and quality improvement. Establishing ordinances and/or exclusive operating areas for the regulation of ambulance services. Approving and monitoring Prehospital Continuing Education Providers. Developing and implementing a trauma system plan. Conducting an impact evaluation when notified that an acute care hospital plans to downgrade or cease providing emergency medical services. The County Board of Supervisors has further charged the Health Services Department as the local EMS Agency with the following responsibilities: Implementing EMS program enhancements funded under County Service Area EM-1 (Measure H). Tracking and monitoring hospital emergency and critical care capacity. Additionally, the EMS Agency is the lead agency responsible for: Procuring and monitoring emergency ambulance services countywide. Planning for and coordinating disaster medical response at local and regional levels. Implementing and monitoring an Emergency Medical Services for Children Program countywide. To accomplish these functions, the EMS Agency employees a staff of 11, including the EMS director, EMS medical director, EMS assistant director, Health Services disaster preparedness manager, prehospital care coordinator, trauma coordinator, training coordinator, Regional Disaster Medical Health Specialist, a secretary, and a clerk. C. Emergency Medical Care Committee Each county may, under the Health & Safety Code, establish an Emergency Medical Care Committee (EMCC) with membership prescribed and appointed by the county board of supervisors. A County EMCC acts as an advisory body to its board of supervisors and to its local EMS agency on all matters relating to EMS. The Contra Costa EMCC consists of five consumer representatives and five consumer alternate representatives, one representative and alternate representative from each of the five supervisorial districts, and representatives and alternate representatives of the following groups and organizations: Alameda-Contra Costa Medical Association American Heart Association American Red Cross California Highway Patrol Contra Costa Contract Ambulance Provider Air Medical Transportation Provider Emergency Department Physicians Emergency Nurses Association Contra Costa Fire Chiefs' Association Field Paramedic (1 private/1public) County Health Services Hospital Council Bay Area Division 4 EMS Annual Report for 2005 Contra Costa Health Services

9 Contra Costa EMS Training Institution Contra Costa Police Chiefs' Association Contra Costa Public Managers' Association Contra Costa Sheriff-Coroner Base Hospital Trauma Center Community Awareness and Emergency Response (CAER) Communications Center Managers Association EMS Director The EMCC meets quarterly and all meetings of the EMCC are open to the public. The Emergency Medical Care Committee will provide reasonable accommodations for persons with disabilities planning to attend Emergency Medical Care Committee meetings. D. Delivery of EMS Services EMS services are typically provided in response to a medical emergency reported through the emergency telephone system. A call placed from any telephone is automatically routed to the appropriate designated Public Safety Answering Point (PSAP). Most calls from cellular phones are routed to the Vallejo California Highway Patrol dispatch center, although some are routed to local police departments and Sheriff s Dispatch. A dispatcher or complaint operator at the PSAP determines the nature of the emergency and, if the PSAP is part of a fire/medical dispatch center, obtains information necessary to dispatch appropriate response units. If the PSAP is not part of a fire/medical dispatch center, the call is transferred to a "secondary PSAP" where a dispatcher then obtains information necessary to dispatch appropriate fire/medical units. The initial response to a potentially life threatening incident generally includes both a paramedic-staffed fire first responder unit and a paramedic-staffed ambulance. The location of fire stations throughout the county enables firefighters to make a rapid initial response to a medical emergency. All fire fighters are trained in first aid, CPR and defibrillation. Most are trained and certified as Emergency Medical Technicians (EMTs), which provide basic life support and many are trained and licensed as paramedics. Fire fighters arriving early on scene may be able to initiate lifesaving measures and achieve some patient stabilization before the ambulance arrives. A private company, American Medical Response, under contract with the County, provides emergency ambulance services in most areas of the County. In the San Ramon Valley and Moraga- Orinda areas, emergency ambulance service is provided by the fire service. Depending upon the nature of the incident, an ambulance may be dispatched Code 3 (red lights and siren) or Code 2 (immediate response, but following normal traffic regulations). The staffing standard for response to potentially life threatening incidents is an advanced life support (ALS) ambulance staffed with 1 paramedic and 1 EMT-I, or 2 paramedics in areas where the first responder units are not staffed with paramedics. Paramedics are able to administer lifesaving drugs and perform other lifesaving procedures. Basic life support (BLS) ambulances are staffed with two EMT-I s and may be used for non-emergency response or to provide additional support at an emergency incident. Patient treatment and transport are carried out under State and local EMS agency policies and procedures. These policies include, in the case of paramedics, making contact with a mobile Contra Costa Health Services EMS Annual Report for

10 intensive care nurse (MICN) or physician at the designated base hospital for medical consultation in patient management according to County EMS treatment guidelines. Patients are transported to hospitals able to provide needed services. Hospital destination is determined based upon patient preference and County EMS protocols. Critical patients may be directed to the nearest emergency department or to the trauma center. Non-critical patients may be transported to hospitals of choice within reasonable travel time. Medical helicopter service is available to transport critical patients when ground ambulance transport time would be excessive. Two medical helicopter services, CALSTAR and REACH, are authorized to respond to local EMS calls on a daily rotation schedule. Both agencies provide advanced life support services and maintain 24-hour helicopter unit availability based at Buchanan Field in Concord. Other helicopter services are available to respond from neighboring counties if both CALSTAR and REACH are unavailable. Anatomy of an EMS Incident EMS Time on Task Interval SERVICE RESPONSE TIME Communications Unit Response Interval Dispatch Interval Patient Contact Interval Call-Taking Interval Chute Time Unit Transport Interval 911 PSAP Processing EMS Activation Interval Call Processing (AMPDS) Travel Time UNIT ON SCENE INTERVAL Destination/Recovery Interval Incident/ Discovery Initial Access To 911 Call Transfer to EMS EMS Phone Pick up Location Verified Default Response Established Unit Pre-alert Unit Assigned Unit Enroute Determinant Reached Response Upgrade/ Downgrade Unit Arrival At Scene Patient Contact First CPR (EMS) CPR (EMS) Terminated First Defibrillatory Shock (EMS) ROS Circulation Intubation Attempted/Achieved ROS Ventilation IV Access Attempted/Achieved Medications Administered Unit Departs Scene Unit Arrives Destination Patient Care Transferred Available for Assignment Unit Departs Unit on Post T0 T1 T2 T3 T4 T5 T6 T4.1 T7 Time T8 T9 T10 T11 T12 E. County Service Area EM-1 (Measure H) Funding In 1988 Contra Costa voters countywide passed ballot Measure H which provides for enhancements to the EMS system including increased paramedic service, additional medical training and equipment for firefighter first responders, and an improved EMS communications system. Following a 71.6% affirmative vote, the Board of Supervisors, with the support of the 18 city councils, formed County Service Area EM-1 to levy charges on real property as specified in Measure H. Assessments are limited to $10 annually for a single-family residence. Commercial and industrial 6 EMS Annual Report for 2005 Contra Costa Health Services

11 properties are generally assessed at $30 or higher, depending upon the use code classification of the parcel. Measure H assessments have been used to finance or assist with financing the following: Increased paramedic ambulance units available to respond to calls, A countywide firefighter first responder defibrillation program including automated external defibrillators purchased and maintained for all fire response units, Fire first responder paramedic services, First responder training, equipment, and supplies, Medical supply caches purchased and maintained for multicasualty/disaster response, An upgrade to the MEDARS radio system used for ambulance-to-hospital communications, Radios for ambulances to communicate with fire first responders, An upgraded ambulance dispatch system and dispatcher preparedness and, Enhanced response to Hazardous Materials incidents. Contra Costa Health Services EMS Annual Report for

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13 II. LIST OF MAJOR ACCOMPLISHMENTS

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15 EMS Major Accomplishments 2005 Provided ongoing oversight to the Countywide emergency medical services and trauma system, which included 65,052 responses to emergency medical calls made by County-contracted ambulance services, 372 medical helicopter transports by County-designated air ambulance services, and 917 serious trauma patients treated at John Muir Medical Center, the County-designated trauma center. Responded to post-katrina information and resource requests, including support of the Northern California DMAT team CA-6 as it responded to New Orleans to provide aid. Implemented a Public Access Defibrillation (PAD) Program in the County by purchasing and placing 42 Automatic External Defibrillators (AEDs) to public entities throughout the County, and by providing training to the recipients. Established a countywide EMS-Fire training consortium to develop standardized training for EMTs and paramedics, and to facilitate interagency training. Expanded the EMS website ( to include data reports and other information used to monitor emergency ambulance contract compliance. Provided support to local fire services in developing their first responder paramedic programs. Facilitated a link between Richmond Police/Fire dispatch center and AMR s dispatch center allowing requests for ambulances to go directly to AMR via computer versus a secondary phone call saving time in ambulance dispatch. Provided staffing and funding support towards the development of a new countywide EMS Fire Training Consortium at the request of local fire services. Initiated a multidisciplinary committee to consider a Multicasualty Plan revision. Participated along with local hospitals, ambulance providers, Public Health and others in the Golden Guardian exercise and supported regional activities. Facilitated Code Orange, a full-scale, Countywide exercise that simulated an accidental pesticide release exposing patients that converged into our medical system. Assisted in the development of IRIS, an in-house software program for use by Health Services to facilitate communications among its various divisions and physical sites during major disasters affecting the region or state, or during minor incidents of local significance. Interfacility transport paramedics transferred 772 in-patients to other acute care facilities as part of the County Interfacility Transfer Paramedic Program. Contra Costa Health Services EMS Annual Report for

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17 III. ISSUES IN THE FOREFRONT

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19 A. EMS Response to Sudden Cardiac Arrest In a series of articles appearing in USA Today in May 2005 ( Six Minutes to Live or Die ), results of an 18-month survey of EMS response to sudden cardiac arrest in the 50 largest American cities were presented. Only 12 of the 50 cities were found to use precise measures of cardiac arrest survival. Among these 12, actual survival rates, measured by patients discharged from hospital without serious deficit, ranged from a low of 3% to a high of 45%. Major conclusions of the series were that few EMS systems are effective in saving cardiac arrest victims and that most systems are unable to measure key factors related to successful cardiac arrest saves. Success, according to the series, has been achieved in cities like Seattle (45%) and Boston (40%) through strong community leadership resulting in widespread public CPR training and rapid defibrillation. While recognizing that cardiac arrests comprise only a small portion of EMS patients, the series theorizes that EMS systems responding well to cardiac arrest are likely to respond well to other emergencies. Cardiac arrest occurs when the heart s pumping action ceases. Cardiac arrest can occur from many causes. Traumatic injury, electrocution, drowning, and drug overdose, for example, can bring about cardiac arrest. Among adults, the major cause of out-of-hospital sudden cardiac arrest is coronary heart disease. Among children, trauma, Sudden Infant Death Syndrome, and respiratory failure are the most common causes of cardiac arrest. The terms cardiac arrest and heart attack are often confused by the public and in the media. While a heart attack may lead to cardiac arrest, many persons experience heart attacks without going into cardiac arrest, and many cardiac arrests are not a result of heart attack. As there are different underlying causes of cardiac arrest, there are different conditions of the heart that can result in cardiac arrest. Asystole, also called flatline, is cessation of all electrical activity in the heart. A person whose heart is in asystole is seldom resuscitated. But between extremes of asystole and the heart s normal sinus rhythm is a wide array of abnormal heart rhythms, or arrhythmias, some more dangerous than others. Several arrhythmias can be associated with sudden cardiac arrest, but ventricular fibrillation (V-fib) is the most common. It is the rhythmic contraction of the heart s ventricle chambers that pumps blood to the brain and other parts of the body. Ventricular fibrillation can be described as a condition where the heart s ventricular muscles go into a quivering state no longer capable of pumping blood. In a related condition known as pulseless ventricular tachycardia (V-tach), contractions of the ventricles are so rapid that pumping is ineffective. V-fib and pulseless V-tach, if untreated, are deadly, but most victims stand a good chance of survival without serious deficit if defibrillation occurs immediately following onset. After 5 or 6 minutes, brain death begins to set in, and very few victims are saved if not shocked within 10 minutes. Defibrillation is the only treatment known to revive a patient in ventricular fibrillation or pulseless ventricular tachycardia. It was the need for rapid defibrillation that led to the development of mobile coronary care units that could bring defibrillation to the scene of a cardiac arrest. The first mobile coronary care units in the 1960s were staffed by physicians. The first paramedic programs were developed in 1969 in Miami, Florida and Seattle, Washington. Physicians in these cities trained firefighters to use portable defibrillators to treat cardiac arrest victims. Defibrillators used by paramedics are manually operated devices requiring assessment of the patient s heart rhythm before delivering a shock. Development of automated external defibrillators (AEDs), first introduced in 1979, enabled persons with very little training to administer defibrillation. AEDs have computers which, when the AED is properly attached to the patient, determines if the patient should be shocked and delivers an appropriate shock. An AED will only deliver a shock to a person in ventricular fibrillation or ventricular tachycardia. Contra Costa Health Services EMS Annual Report for

20 With the availability of funding for EMS enhancements following passage of Measure H in 1988, Contra Costa County became one of the early California counties to implement a countywide first responder defibrillation program. All firefighters were trained in first responder defibrillation and all engines equipped with AEDs. Currently all ambulances and all fire engines within the County are equipped with defibrillators either manual defibrillators used by paramedics or AEDs used by non-paramedic responders. 1 Several police departments are also equipping squad cars with defibrillators. AEDs are currently being carried or are planned for police units in Antioch, Brentwood, Hercules, Kensington, Lafayette, Moraga, Orinda, Pittsburg, San Ramon, Alamo, and Blackhawk. But even with widespread first responder defibrillation, many cardiac arrest victims cannot be reached by EMS in time to be helped. Response times for rescue crews coming from the nearest fire station average 5 to 7 minutes in most systems. Response times are usually measured from the time the call is received at the fire dispatch center until the engine arrives at the scene. Added allowance must be made for the time it takes to place and process the call and for the crew to get from their vehicle to the patient, assess the patient, and apply the shock. These steps add at least 3 to 5 minutes, sometimes much longer. If the patient is located in a large building or complex, it may take several minutes once on scene for the EMS crew to actually locate the patient. As the need for faster access to defibrillation was recognized and as confidence grew in the use of automated defibrillators, laws were passed allowing for the development of public access defibrillation programs (PADs). California law establishes minimum requirements for public access defibrillation programs and provides liability protection to lay persons who use an AED. No specific training is required for lay use of an AED. In Contra Costa County, the EMS Agency estimates that there are approximately 350 public use defibrillators located in office buildings, commercial facilities, and community facilities. While most of these were privately acquired, the EMS Agency working with the Board of Supervisors provided some 40 AEDs to community facilities at no charge. Under the County s emergency ambulance service contract, American Medical Response has agreed to provide 25 AEDs to community facilities at no charge during each year of its contract beginning July 1, What role does cardiopulmonary resuscitation (CPR) play in treatment of cardiac arrest victims? In cases of respiratory arrest due to near drowning or drug overdose where the patient may be in respiratory arrest but not cardiac arrest, the process of CPR including clearing the airway and administering rescue breaths, may stimulate the return of spontaneous breathing. But for a cardiac arrest victim in ventricular fibrillation, only defibrillation can bring about a return of spontaneous circulation. CPR, in the case of cardiac arrest, has traditionally been viewed as a mechanism to supply some oxygenation to the brain and heart extending the time that a patient might be successfully defibrillated. Some experts believe that CPR performed correctly and started immediately following arrest can double the time available for successful defibrillation in effect extending a 5-6 minute window to a minute window for defibrillation. American Heart Association promotes the concept of Chain of Survival. This chain of survival consists of four links that must be undertaken immediately to save a victim of sudden cardiac arrest: 1 Manual defibrillators enable a paramedic to view the heart rhythm on a monitor and deliver an appropriate shock based on interpretation of the rhythm. Manual defibrillators provide the paramedic greater flexibility than is available with an AED, which is limited to defibrillation of computer-confirmed ventricular fibrillation and pulseless tachycardia. 16 EMS Annual Report for 2005 Contra Costa Health Services

21 The first link is early access to emergency care by calling The second link is early CPR to be started and maintained until EMS arrives. The third link is early defibrillation, the only response that can re-start the heart function of a person in V-fib. The fourth link is early advanced care administered as needed by EMS. In Contra Costa County, approximately 60% of patients with witnessed sudden cardiac arrests are reported to have received bystander CPR prior to the arrival of EMS. Only one of 50 cities in the USA Today survey, Albuquerque, reported a higher bystander CPR rate than Contra Costa County. Contributing to the high bystander CPR rate in Contra Costa County is the County s Emergency Medical Dispatch program in which dispatchers at the 3 fire/medical dispatch centers (Contra Costa Fire, San Ramon Valley Fire, and Richmond Police) are trained to give pre-arrival instructions to callers to provide emergency assistance while EMS responders are en route. These instructions include CPR. Many people who are reluctant to start CPR for fear of making mistakes will perform CPR when prompted and instructed by a trained emergency dispatcher. Based upon 7 months (November 2005 May 2006) of patient data, American Medical Response responds to about 513 cardiac arrests annually. 2 Of these, about 147 (28.7%) per year are witnessed cardiac arrests. Of all witnessed cardiac arrests, about 43 (29.3%) experience a return of spontaneous circulation (ROSC). Of the estimated 147 witnessed cardiac arrests annually, about 31 (21.1%) are reported to have an initial rhythm of ventricular fibrillation (26%) or ventricular tachycardia (5%). Of the 31 witnessed arrests with v-fib or v-tach, about 21 (66.7%) receive bystander CPR and about 12 (38.9%) have a return of spontaneous circulation. Data are not currently available on the number of patients surviving to hospital admission or discharge. Also, existing data does not fully distinguish between cardiac arrests of cardiac and non-cardiac etiology. Out-Of-Hospital Sudden Cardiac Arrests Contra Costa County Nov May 2006 American Medical Response Annual Number Population served 901,000 Percents Confirmed cardiac arrests considered for resuscitation /100,000 pop. Resuscitation not attempted Resuscitation attempted % 54.8/100,000 pop. No return of spontaneous circulation % Return of spontaneous circulation % Non-cardiac etiology Unk Cardiac etiology Unk Not witnessed/witnessed by EMS % 100.0% No return of spontaneous circulation % Return of spontaneous circulation % Witnessed % 100.0% No return of spontaneous circulation % Return of spontaneous circulation % No bystander CPR % 100.0% No return of spontaneous circulation % Return of spontaneous circulation % Bystander CPR % 100.0% 2 AMR s service area includes all of Contra Costa County except the San Ramon Valley and Moraga-Orinda Fire District and includes about 89% of the County s population. Contra Costa Health Services EMS Annual Report for

22 Out-Of-Hospital Sudden Cardiac Arrests Contra Costa County (cont.) Nov May 2006 American Medical Response Annual Number Percents No return of spontaneous circulation % Return of spontaneous circulation % Asystole % 100.0% No return of spontaneous circulation % Return of spontaneous circulation % Died en route or in ED Admitted to hospital Died in hospital Discharged alive No bystander CPR % 100.0% No return of spontaneous circulation % Return of spontaneous circulation % Bystander CPR % 100.0% No return of spontaneous circulation % Return of spontaneous circulation % Other rhythm % 100.0% No return of spontaneous circulation % Return of spontaneous circulation % Died en route or in ED Unk Admitted to hospital Died in hospital Discharged alive No bystander CPR % 100.0% No return of spontaneous circulation % Return of spontaneous circulation % Bystander CPR % 100.0% No return of spontaneous circulation % Return of spontaneous circulation % V-Fib/V-Tach % 100.0% No return of spontaneous circulation % Return of spontaneous circulation % Died en route or in ED Admitted to hospital Died in hospital Discharged alive No bystander CPR % 100.0% No return of spontaneous circulation % Return of spontaneous circulation % Bystander CPR % 100.0% No return of spontaneous circulation % Return of spontaneous circulation % Time from telephone off-hook at fire/medical dispatch center until first EMS unit on scene: 6:19 average; 8:20 90%. Add 0:15 for transfer from primary PSAP, 1:00 for response from vehicle to patient site, and 0:45 to deliver first shock, giving an overall average time from call to shock of about 8.5 minutes. Source: Contra Costa EMS Agency Unk Unk Unk Unk Unk Unk Unk Unk Unk Unk Unk 18 EMS Annual Report for 2005 Contra Costa Health Services

23 While rapid CPR and rapid defibrillation have traditionally been associated with successful resuscitation of cardiac arrest victims, there has been a frustrating lack of correlation between these variables and survival rates when comparing outcomes for different communities. There is little or no correlation, for example, in USA Today data between cardiac arrest survival rates and either bystander CPR or time to shock. In fact, one of the lowest survival rates was reported by a city (Colorado Springs) with one of the highest bystander CPR rates and one of the shortest time-to-shock rates. The lack of expected relationships between cardiac arrest survival and factors commonly thought to contribute to survival such as short response times and bystander CPR in the USA Today survey is consistent with the findings of a recent study published in the American Journal of Emergency Medicine. Combining data from 14 published studies of cardiac arrest in which data was reported based on the Utstein template, the authors concluded that there is tremendous variability in outcome not explained by the traditional risk factors for low survival. 3 Specifically, this analysis did not find a relationship between bystander CPR and cardiac arrest survival. Conclusions with respect to the effectiveness or ineffectiveness of traditional CPR, however, may be moot. Based on the 2005 International Consensus Conference on Cardiopulmonary Resuscitation, the American Heart Association has issued revised standards making significant changes in the way CPR is performed and in the use of CPR in conjunction with defibrillation. The major change in CPR is an emphasis on compressions rather than breaths. Rescuers are to be taught to "push hard, push fast" (at a rate of 100 compressions per minute) allowing complete chest recoil and minimizing interruptions in chest compressions. EMS personnel are instructed to provide CPR between defibrillation cycles and, on unwitnessed arrests, prior to defibrillation. It is thought that these changes, just now being introduced into CPR instruction, may significantly improve CPR results. The authors of the American Journal of Emergency Medicine article did not speculate on what other factors might be at play in affecting the widely ranging cardiac arrest survival rates reported in different systems. Some differences are no doubt due to health status variations among different populations and variations in the levels of hospital treatment of cardiac arrest victims. It seems clear, however, that, even in systems making good faith efforts to adhere to the Utstein 4 template, there is room for extensive variation in data measurement and data quality. Much of the reported variation in survival rates is no doubt due to inconsistencies in measurement. An important conclusion of the USA Today series was that most EMS systems are unable to accurately measure response times and patient outcomes. This has been the case in Contra Costa County as well. The measurement of ambulance response time starts when the fire/medical dispatch center requests the ambulance and ends with the arrival of the ambulance at the nearest public road access point. While this is an appropriate measure of contract compliance, it does not accurately assess the time from the placement of the call until arrival of EMS at the patient site. There may be delays between the placement of the call and the time the request is relayed to the ambulance provider. There may be delays between the arrival of the ambulance vehicle at the scene and the arrival of the crew at the patient site. First responder response times, although available on a 3 Fredriksson, Martin, J. Herlitz, MD, and G. Nichol, MD, Variation in Outcome in Studies of Out-of-Hospital Cardiac Arrest: A Review of Studies Conforming to the Utstein Guidelines, American Journal of Emergency Medicine, Vol. 21, No. 4, July The internationally recognized Utstein standards for uniform reporting of data from out-of-hospital cardiac arrests were developed in 1991 to provide a template for consistent measurement of survival rates in different systems. The standards provide definitions of terms and a template for data analysis. The so-called Utstein gold standard looks only at witnessed cardiac arrests with cardiac etiology and an initial rhythm of either ventricular fibrillation or pulseless ventricular tachycardia. The percent of this group who survive to hospital discharge gives the gold standard survival rate. Contra Costa Health Services EMS Annual Report for

24 case-by-case basis, have not been linked with ambulance dispatches in a manner enabling the EMS Agency to analyze overall EMS response times. Under the first responder defibrillation program, first responders were able to upload data, including time stamps, EKGs, and a voice recording of the incident, from AEDs on all defibrillation attempts directly to EMS providing a good data source for monitoring, evaluation, and quality improvement. Unfortunately, a side effect of the movement to first responder paramedics using manual defibrillators was the loss of the data source that had been available from uploaded information on each first responder AED usage. The EMS Agency together with EMS providers has been working on a number of improvements in data collection and EMS access to data. Ambulance dispatch data has long served as the basic data system available to the EMS Agency. Ambulance patient care reports are available to the EMS Agency, but not in a format conducive to statistical reporting. First responder dispatch data and patient care reports have been available on a case-by-case basis, but not in a form suitable for statistical reporting. Two new products will enhance EMS data capability. FirstWatch has been put in place at the San Ramon Valley and Contra Costa County Fire dispatch centers to capture EMS incident data related to first responder and ambulance dispatch. FirstWatch now gives the EMS Agency the ability to track response time from when the call is answered at the fire/medical dispatch center through hospital transport. Plans are in place to expand FirstWatch to include the Richmond dispatch center and American Medical Response. (AMR responses to Contra Costa County Fire incidents are already captured by FirstWatch.) The second new product is the Zoll patient data system recently obtained for use by all first responder agencies. This will enable each first responder agency to monitor its own patient care data and will enable the EMS Agency to monitor all first responder patient care data. Ultimately, it is planned that FirstWatch will facilitate the linkage of both dispatch and patient care records for both first responder and ambulance. Using the new data analysis tools now or soon to be available, the EMS Agency has undertaken a rigorous perusal and analysis of data on sudden cardiac arrests using the Utstein template. Data will include measurement of the time interval from telephone pickup at the fire/medical dispatch center to EMS arrival on the scene to delivery of shock, identification of witnessed arrests, identification of initial heart rhythm and probable etiology (cardiac or non-cardiac), and, if possible, emergency department disposition and final hospital disposition. B. Public Participation CPR Training and Defibrillation Most CPR training in the United States is conducted under the auspices of either the American Heart Association (AHA) or the American Red Cross (ARC). While both organizations provide CPR training, ARC focus is on emergency and disaster preparedness for individuals, families, and communities, while the AHA focus is on reducing death and disability due to cardiovascular disease and stroke. CPR courses given by ARC and AHA certified instructors adhere to CPR standards established by AHA. American Heart Association approved CPR training includes a variety of courses aimed at both professional rescuers and the public. Courses vary in length depending on content and whether a certifying examination is given. A Friends and Family course including adult, child, and infant CPR but no examination or certification is taught in 4.5 hours. Shorter courses are available covering just adult or just infant and child CPR. Courses including a final examination and certification and those aimed at health professionals run longer. Charges for CPR classes typically run between $35 and $75 depending on the length and whether a certification card is issued. The American Heart Association has recently introduced a 30-minute self-taught Friends and Family CPR Anytime course for adult CPR. Using an inexpensive kit (available from AHA for $30) that includes a manual, video, and practice manikin, the American Heart Association has found that CPR for adults can be taught in as little as 20 minutes plus an additional 5 minutes each for choking and AED. In some communities, kits can be checked out from public libraries or local fire stations. 20 EMS Annual Report for 2005 Contra Costa Health Services

25 California regulations require a minimum of 4 hours of training for first responder rescue personnel approved to use AEDs. However, there is no specific requirement for lay personnel to have training in order to use an AED. AEDs intended for lay use are fully automatic and very easy to use. Easy-to-follow instructions and voice prompts guide the user through the process. An onboard computer analyzes the heart rhythm and assures that a shock is delivered only when appropriate. Most CPR classes now include instruction on use of AEDs. Public Access Defibrillation The EMS Agency has been working collaboratively since 2002 with the American Heart Association in support of the AHA s Operation Heartbeat to promote public access defibrillation. In 2004, with Board of Supervisors approval, the EMS Agency was able to acquire 42 AEDs, used in the County by first responders as a part of a vendor-sponsored testing program, for distribution to community agencies for public access defibrillation. This program is being continued in concert with American Medical Response with its community AED donations. EMS and AMR staffs have been working with community agencies in each supervisorial district to establish programs and train staff. Most AEDs obtained for public access defibrillation are purchased by businesses for employee use. AED vendors are required by statute to notify the local EMS agency when AEDs are placed. Information on AED location can then be entered into a database used by emergency medical dispatchers so dispatchers will know when an emergency call is received that an AED is on site and suggest its use if appropriate. Altogether, some 350 public use AEDs have been registered with the Contra Costa EMS Agency. Information of public access defibrillation including a program implementation guide, state regulations, and a vendor list is available on the EMS Agency website at EMCC Proposal / AMR CPR Classes In 2004 Rod Talavera (District 5 Alternate) proposed to the Emergency Medical Care Committee that a program be developed to provide no-cost CPR training to large numbers of the public. A subcommittee was appointed to further explore the proposal. Following meetings with representatives of various organizations including the American Heart Association, the American Red Cross, Contra Costa County Fire Protection District, and American Medical Response, a concept plan was presented to and endorsed by the EMCC at its meeting of December 8, The plan as presented would entail a massive campaign enlisting the support of community leadership, the media, and community and labor organizations with a goal of training 50,000 persons annually in CPR, AED use, and first aid. Recognizing the importance of citizen CPR training and public access defibrillation, American Medical Response offered to provide CPR training to the public and to donate a number of AEDs for use by community organization. Specifically, AMR agreed as a part of its emergency ambulance service contract with the County to provide 25 free CPR classes to the public, annually, in addition to its commitment mentioned above to donate AEDs for community agency use. AMR s CPR classes have been averaging about 15 attendees each. CPR Classes Available to the Public in Contra Costa County In order to promote the availability of CPR, the EMS agency maintains a phone number GIVE CPR to provide information to the public on where CPR training can be obtained. A list of CPR training resources available to the public in Contra Costa County and known to the EMS Agency is contained in Section XII of the Annual Report. Since any individual with CPR instructor certification can give CPR instruction, there may be other resources not included on this list. Contra Costa Health Services EMS Annual Report for

26 A View of Three Selected Cities A number of communities have taken on CPR training as major communitywide goals. Most notable of the large-scale community CPR training initiatives is probably the Medic II program in Seattle, Washington. This section describes the cardiac care and CPR initiatives of three communities Seattle/Kings County, Boston, and Tucson. These community programs were selected for description here for different reasons. Seattle is widely recognized as one of the first communities to make a major communitywide commitment to improving cardiac arrest survival. Boston has been cited as a major city that has been successful in turning a low-performing EMS system into a highperforming system. Tucson accepted academic direction in changing its approach to cardiac arrest care. A common element in the three initiatives undertaken in these three cities was a strong belief by community leadership that deaths from sudden cardiac arrest could be significantly improved by changes in response to cardiac arrest by both the public and EMS. Seattle/King County Medic II and Student CPR Training Programs. Seattle began its Medic II mass citizen CPR training in 1972 as an adjunct to its Medic I paramedic program. Seattle s Medic I, spearheaded by the University of Washington Medical School and the Seattle Fire Department, was one of the nation s first paramedic programs. Recognizing that paramedics would be unable to arrive on the scene quickly enough to save many cardiac arrest victims unless bystander CPR could be initiated immediately following the incident, Seattle s Medic I leadership initiated the Medic II program to train as many residents as possible in CPR. Medic II received extensive community support. Initial funding was provided through local businesses. The Seattle Rotary Club, for example, donated some $100,000 between 1972 and 1978 to the Medic II program. During its first two years, the program trained some 200,000 persons in CPR. Some 650,000 persons have been trained since Medic II s inception, and the program continues to train about 18,000 persons annually. Training is conducted by Seattle and surrounding King County firefighters and is free to the public. Private donations from the United Way and other sources now sustain the instructional budget. Fire departments provide needed equipment and absorb the administrative costs of scheduling classes and running the program. Seattle Fire Department s Medic II program has long been recognized internationally as one of the most successful models for community CPR training and claims to have doubled the save rate for witnessed out-of-hospital sudden cardiac arrests. In addition to the community CPR training classes provided by Seattle and other King County fire departments, the King County Emergency Medical Services Division offers a major CPR training initiative focusing on the public schools. Seventeen King County school districts participate in the Student CPR Training Program, which provides CPR training to students in grades 6 through 12. Funds are provided through EMS to school districts to hire substitute teachers while regular teachers participate in a two-day CPR instructor certification program or a one-day recertification program required every two years. About 200 schoolteachers in King County actively participate in the program providing CPR instruction to students in their respective schools. According to EMS, some 18,000 students receive CPR training annually through this program, about the same number as trained through the Medic II program. Boston Defibrillator and Cardiovascular Program. In 1992, Boston s Mayor Thomas Menino spearheaded an effort to upgrade that city s EMS system. Mayor Menino, who had a practice of riding along on a city ambulance to observe first hand how the EMS system worked, took on resolving the historical turf war between fire and ambulance service crews, hired a medical director to oversee the city s EMS program and a number of physicians to review EMS cases, and enlisted public response to help improve cardiac arrest survival. Eight years later, the City of Boston announced an increase in cardiac arrest survival from 14.0% in 1993 to 32.5% in This was attributed by Boston EMS to placement of AEDs on all of the city s EMS response units and on strategic police units, enlistment of over 50 public and private partners including some of Boston s major employers 22 EMS Annual Report for 2005 Contra Costa Health Services

27 in a public access defibrillation program, promotion of early access to 9-1-1, and citizen CPR. Boston EMS offers various CPR classes to the public at a fee. University of Arizona Tucson Sarver Heart Center Be a Lifesaver Program. The University of Arizona Sarver Heart Center has advocated a form of CPR known as continuous chest compression CPR (CCC-CPR) or cardiocerebral resuscitation (CCR). This approach, not endorsed by the American Heart Association, provides compressions only at a rate of 100 compressions per minute to adult cardiac arrest victims. CCC-CPR was adopted by the Tucson Fire Department in 2002 and has since spread to other communities in Arizona and to some areas outside Arizona. Through its Be a Lifesaver program, the University of Arizona Sarver Heart Center has instituted a program of public education teaching CCC-CPR in Tucson and other Arizona communities. Sarver Heart Center researchers believe that survival rates for witnessed cardiac arrests with bystander CPR can be significantly improved through the use of CCC-CPR for a couple of reasons. CCC-CPR, according to the Sarver Heart Center, is more effective than standard CPR as performed by most persons, and more persons are willing to perform bystander CPR using chest compressions only than with mouthto-mouth resuscitation. The Sarver Heart Center claims high success with CCC-CPR and the increased emphasis in chest compressions has, in fact, been incorporated into the 2005 American Heart Association standards. C. The Past and the Future Since initiating paramedic services in 1977, the Contra Costa EMS Agency, with the guidance of the Emergency Medical Care Committee and support of the Board of Supervisors and from Health Services management, has engaged in a continuous process of EMS system improvement, including response to sudden cardiac arrest and other cardiac emergencies. With funding available from the passage of Measure H in 1988, Contra Costa was able to train and equip all fire first responder units Countywide with AEDs. Several police departments have also begun carrying AEDs and respond to cardiac arrests within their jurisdictions. Contra Costa EMS has supported the upgrading of first responder units to the paramedic level. Most fire engines in the County are now include paramedic staffing. Measure H funding was used to implement the protocol-driven ProQA Emergency Medical Dispatch (EMD) system in each of the fire/medical dispatch centers in the County. Emergency Medical Dispatchers are trained to give pre-arrival instructions for bystander patient care while rescue crews are en route. Pre-arrival instructions include directions to perform CPR in the case of cardiac arrest. This has resulted in a very high (60%) bystander CPR rate. The EMS Agency has worked closely with the American Heart Association through its Operation Heartbeat program to promote public access defibrillation and has provided some 40 defibrillators to community organizations. Beginning in 2005, American Medical Response, under its County emergency ambulance agreement, is providing 25 free CPR classes to the public annually and is donating 25 AEDs annually to community organizations. Priorities for the coming year include compilation of cardiac arrest outcome data in accordance with the Utstein Style, continued promotion of public access defibrillation and CPR training, and promotion of AED programs in law enforcement agencies. A major initiative planned for late 2006 is the expansion of the 12-lead EKG program currently in place at Moraga-Orinda Fire and San Ramon Valley Fire to include American Medical Response and Contra Costa County Fire. Cardiac monitor/defibrillators that have been used by paramedics in the field have progressed from being fairly basic instruments capable only of providing a limited view of the electrical activity of the heart and of providing defibrillation, to devices that today can offer 12 different views of the heart s electrical function as well as manual or automatic defibrillation and various other functions. The major advantage of the 12-lead EKG in the field is that it enables the identification in many cases of acute myocardial infarction (AMI) prior to patient transport. Early identification of AMI can reduce the time to definitive care by if hospital cardiac catherization teams are mobilized based on field information. Contra Costa Health Services EMS Annual Report for

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29 IV. EMS SYSTEM PARTICIPANTS

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31 A. Advisory Committees Emergency Medical Care Committee (EMCC) The EMCC is a multidisciplinary committee appointed by the County Board of Supervisors, to provide advice and recommendations on EMS related matters to the Board, Health Services Director and its EMS Agency. Membership consists of consumer representatives, and representatives of EMS related organizations and groups. The EMCC meets quarterly (March, June, September, December), and meetings are open to the public. Specific meeting information is available through the EMS Agency offices or website at Medical Advisory Committee (MAC) The MAC provides advice and recommendations to the EMS Agency and EMS Medical Director on medically related topics. Examples include ALS and BLS medical treatment guidelines; new prehospital skills and/or medications; and prehospital policies and procedures related to patient medical management. Membership consists of a base hospital coordinator/liaison physician, ALS provider agency representatives, and receiving hospital emergency physician representatives. MAC meets bimonthly. Trauma Audit/Pre-Trauma Audit Committees (TAC/Pre-TAC) The Pre-TAC and TAC committees evaluate trauma system care and monitor compliance to the trauma system standards established in the County Trauma System Plan according to provisions of State trauma regulations. TAC is held jointly with Alameda County and provides monitoring for two separate trauma systems. County EMS Medical Directors appoint members of these confidential quality improvement committees. Pre-TAC is responsible for initial committee review of all trauma related system issues, including select trauma center cases. Cases identified by Pre-TAC are referred to the Bi-County TAC. Co-chaired by the County EMS Medical Directors, TAC meets bimonthly and includes multidisciplinary representation from the four Alameda/Contra Costa County trauma centers, as well as representatives of non-trauma center receiving hospitals, prehospital care providers, ACCMA, coroner's offices, and EMS agency staff. Trauma surgeons from trauma centers outside of Contra Costa and Alameda County also participate in case review activities. Quality Improvement Committee (QI) The QI Committee monitors, reviews, evaluates and identifies steps to improve the delivery of prehospital care services. Membership includes representatives from fire agencies, emergency ambulance providers, and base hospital. Organizations involved in the Contra Costa EMS delivery system are committed to assuring the highest level of care to their patients. The QI committee meets bimonthly. Facilities/Critical Care Committee TheFacilities/Critical Care Committee evaluates and makes recommendations to the EMS Agency with respect to issues that impact hospitals and their interface with the EMS system. Membership includes ED Nurse Managers and others. This committee meets four times each year. Hospital Disaster Forum (HDF) The Hospital Disaster Forum provides for discussion of issues of mutual concern regarding the disaster preparedness of medical centers and the medical health system. Contra Costa HDF meets quarterly and has membership consisting of preparedness coordinators for hospitals, clinics, cities, ambulance, fire, OES, EMS, and Contra Costa Health Services. Contra Costa Health Services EMS Annual Report for

32 Multicasualty Advisory Committee (MCAC) The ad hoc multidisciplinary MCAC was originally organized by the EMS Agency in 1978 to develop an integrated emergency response plan for multicasualty incidents. There have been several revisions of the Multicasualty Plan since that time. Representatives from police, fire, ambulance, public safety dispatch agencies, receiving hospitals, and EMS staff began working on a revision of the Multicasualty Incident Plan in First Responder Defibrillation Operations Committee The First Responder Defibrillation Operations Committee is charged with reviewing and evaluating operational matters related to the first responder defibrillation program. Membership consisting of training representatives of fire first-responder agencies meets semiannually or as needed. B. PSAPs and Dispatch Centers Public Safety Answering Points Antioch Police Department California Highway Patrol Concord Police Department East Bay Regional Park Police Martinez Police Department Pinole Police Department Pleasant Hill Police Department Richmond Police Department Sheriff's Communications Walnut Creek Police Department Fire/Medical Dispatch Centers Contra Costa County Fire Dispatch West County Consolidated Communications Operations (Richmond Police) San Ramon Valley Fire Dispatch Sheriff's Dispatch (multicasualty coordination) Ambulance Dispatch Centers American Medical Response San Ramon Valley Fire Contra Costa County Fire (Moraga-Orinda only) C. First Responders County Fire Protection Districts Contra Costa County Fire Protection District - 30 stations Crockett-Carquinez Fire Protection District - 2 stations East Contra Costa County Fire Protection District - 8 Stations Pinole Fire Protection District (served by Pinole Fire Department) 28 EMS Annual Report for 2005 Contra Costa Health Services

33 Municipal Fire Departments El Cerrito Fire Department - 3 stations Pinole Fire Department - 2 stations Richmond Fire Department - 7 stations Independent Fire Protection Districts San Ramon Valley Fire Protection District (10 stations) Rodeo-Hercules Fire Protection District (2 stations) Moraga-Orinda Fire Protection District (5 stations) Kensington Fire Protection District (served by El Cerrito Fire Department) Paramedic First Responder Programs Moraga-Orinda Fire Protection District - Paramedic Engine (3 units) American Medical Response - Byron/Discovery Bay, Bethel Island, Oakley and Crockett areas ALS Quick Response Vehicles - QRVs (4 units) Contra Costa Fire Protection District - Paramedic Engine (28 units as of 4/2006) San Ramon Valley Fire Protection District Paramedic Engine/Ambulance (8 units) El Cerrito Fire Department Paramedic Engine (2 units) Rodeo-Hercules Fire Protection District (2 units as of 1/2006) Pinole Fire Department (1 full-time unit, 1 part-time unit) California Highway Patrol - Helicopter Unit East Bay Regional Park - Helicopter Unit Law Enforcement Defibrillation Programs Antioch Police Department Brentwood Police Department Hercules Police Department Kensington Police Department Lafayette Police Department (Planning) Moraga Police Department Orinda Police Department Pittsburg Police Department San Ramon Police Department Alamo (Sheriff) Blackhawk (Sheriff) Other First Responders East Bay Regional Parks California Division of Forestry Private & military fire services Contra Costa Health Services EMS Annual Report for

34 D. Emergency Ambulance Providers American Medical Response (15 48 ambulances) San Ramon Valley Fire (5 ambulances) Moraga-Orinda Fire (2 ambulances) E. EMS Helicopters Air Ambulances CALSTAR Buchanan Field in Concord (additional helicopters in Gilroy, Auburn, Ukiah, Salinas, South Lake Tahoe, and Santa Maria. Fixed wing base in Sacramento). REACH Buchanan Field in Concord (additional helicopters in Santa Rosa, Acampo, Redding, Lakeport, and Marysville. Fixed wing bases in Santa Rosa and Sacramento). Helicopter services available in surrounding counties include Stanford Life Flight, Palo Alto; Medi-Flight, Modesto; Air Med Team, Stanislaus County Rescue Aircraft California Highway Patrol (ALS helicopter, including hoist ability) East Bay Regional Parks (ALS helicopter) U.S. Coast Guard (BLS rescue capabilities, including hoist ability) F. Hospitals Receiving Hospitals Contra Costa Regional Medical Center, Martinez Doctors Medical Center, San Pablo Campus John Muir Health, Walnut Creek Campus John Muir Health, Concord Campus Kaiser Medical Center, Richmond Kaiser Medical Center, Walnut Creek San Ramon Regional Medical Center, San Ramon Sutter Delta Medical Center, Antioch Base Hospital John Muir Health, Walnut Creek Campus Trauma Centers John Muir Health, Walnut Creek Campus Children s Hospital and Research Center (regional trauma center for pediatric patients) 30 EMS Annual Report for 2005 Contra Costa Health Services

35 V. EMS PROGRAM ACTIVITIES

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37 A. Emergency Ambulance Services Emergency ambulance services are provided Countywide under performance-based contracts in each of three exclusive operating areas. The County currently contracts with American Medical Response, San Ramon Valley Fire Protection District and Moraga-Orinda Fire Protection District. Contracts are awarded on a competitive basis, as required by law, except for Moraga-Orinda Fire, which is exempt from the competitive bid requirement under Health & Safety Code provisions. American Medical Response Moraga-Orinda Fire All of West, East, and North/Central County. Includes cities of Richmond, San Pablo, El Cerrito, Hercules, Pinole, Pittsburg, Antioch, Oakley, Brentwood, Martinez, Pleasant Hill, Lafayette, Walnut Creek, Concord, and Clayton. Area of Moraga-Orinda Fire Protection District including Town of Moraga and City of Orinda ALS/BLS ambulances 2 ALS ambulances San Ramon Valley Fire Area of San Ramon Valley Fire Protection District including cities of Danville and San Ramon. 5 ALS ambulances Contracts with all three providers require ALS level response to all life threatening or potentially life threatening emergencies. The area of the County served by American Medical Response (AMR) is divided into 5 Emergency Response Zones (ERZs). Ambulance staffing is predicated on the availability of paramedic first response in each ERZ. Ambulance response times are established based on the availability of paramedic first response in each ERZ and on access rural areas with no or poor road access may have extended response times. Ambulance staffing levels and response times are identified in the following tables: Provider Staffing Levels Ambulance Emergency Response Zones 1 st Response and Ambulance Description Level of 1 st Response Staffing Ambulance Staffing AMR ERAs 1, 2, and 5 ERZ A Territory of the city of Richmond BLS 2 paramedics ERZ B El Cerrito, Kensington, Pinole, Rodeo-Hercules, ALS 1 paramedic/1 EMT-I Crockett-Carquinez, San Pablo, El Sobrante, North Richmond, other areas of West County. ERZ C Concord, Clayton, Lafayette, Martinez, Pleasant ALS 1 paramedic/1 EMT-I Hill, other areas of Central County. ERZ D Antioch, Oakley, Pittsburg, Bay Point and ALS 1 paramedic/1 EMT-I surrounding areas of East County. ERZ E Brentwood, Byron, Bethel Island, Discovery Bay, ALS 2 paramedics and other areas of far East County. Moraga-Orinda Fire ERA 3 - Moraga-Orinda Fire Protection District ALS 1 paramedic/1 EMT-I San Ramon Valley Fire ERA 4 - San Ramon Valley Fire Protection District ALS 1 paramedic/1 EMT-I 33 EMS Annual Report for 2005 Contra Costa Health Services

38 Maximum Response Time Requirements in Minutes and Percentile Provider Code 3 Code 2 Rural Code 3 Code 2 AMR ERZ A 10:00 95% 30:00 90% 20:00 95% 45:00 90% ERZ B 11:45 90% 30:00 90% 20:00 90% 45:00 90% ERZ C 11:45 90% 30:00 90% 20:00 90% 45:00 90% ERZ D 11:45 90% 30:00 90% 20:00 90% 45:00 90% ERZ E 11: % 30:00 90% 20: % 30:00 90% Moraga Orinda Fire 10:00 95% 15:00 n/a 20:00 95% 30:00 n/a San Ramon Valley Fire 10:00 95% 15:00 n/a 20:00 95% 30:00 n/a Ambulance Transports with Average Response Times Provider Code 3 Code 3 Average Code 2 Code 2 Average AMR ERZ A 8,500 6:53 min. 1, min. ERZ B 7, min. 2, min. ERZ C 17, min. 6, ERZ D 10, min. 4, min. ERZ E 3, min. 1, min. Moraga Orinda Fire 1, min min. San Ramon Valley Fire 5,745 n/a* 70 n/a* * Full response data unavailable from San Ramon Valley Fire Protection District. During 2005, the EMS system received 70,867 requests for emergency ambulance response. Of these, 54,737 (77.2%) were considered to involve potentially life-threatening situations to which a Code 3 (red lights and siren) ambulance response was necessary. The remaining 16,130 (22.8%) ambulance responses were dispatched Code 2 (immediate response without lights and siren). The level of ambulance response - ALS (paramedic) or BLS (EMT or paramedic) - to emergency medical requests is determined by the Fire/Medical Dispatch center based on emergency medical dispatch protocols. A BLS unit is occasionally dispatched on a Code 3 dispatch if a paramedic unit is not available. Of the 54,737 Code 3 dispatches, a paramedic unit was dispatched on 54,532 (99.6%), and an EMT-I unit was dispatched on 205 (0.4%). Of the total responses, American Medical Response ran 63,406 (89.5%); San Ramon Valley Fire Protection District, 5,815 (8.2%); and Moraga-Orinda Fire Protection District, 1,646 (2.3%). Paramedic level staffing was provided on 99.6% of all Code 3 ambulance responses. Not all ambulance responses result in patient transport. Of the 65,052 emergency ambulance responses by American Medical Response and Moraga Orinda Fire Protection District during the year, 49,818 (76.6%) resulted in patient transport to an emergency receiving hospital. 7 Ambulances responding to the remaining requests were canceled either enroute or at the scene without 5 AMR must respond within 10:00 minutes to calls within non-rural designated areas of ERZ E either by ambulance or Quick Response Vehicle (QRV). 6 Priority 1 calls in rural-designated areas of Bethel Island and Discovery Bay have 16:45 minute or less response times. 34 EMS Annual Report for 2005 Contra Costa Health Services

39 the need for patient transport. Reasons for cancellation vary from poor information regarding patient severity, to the patient having been transported by other means such as private auto, to the patient refusing ambulance transport. In many instances a situation that was initially perceived to be a medical emergency has been resolved or stabilized by the time the transport ambulance arrives. Of the 49,818 patients transported by AMR and Moraga Orinda Fire, 3,361 (6.7%) were transported Code 3, lights and siren and 46,156 (92.6%) were transported Code 2. The remaining 301 (.6%) were transported by helicopter. 7 5-Year Emergency Ambulance Dispatch Summary * # % # % # % # % # % All Ambulance Dispatches 64, , , , , Code 3 (lights/siren) 48, , , , , Code 2 (no lights/siren) American Medical Response 15, , , , , , , , , , San Ramon Fire 3, , , , , Moraga-Orinda Fire 1, , , , , Transport 47, , , , n/a -- No Transport 16, , , , n/a -- Avg. Code 3 Response 7.18 minutes 7.15 minutes 7.43 minutes 8.01 minutes n/a Code 3 Responses Not Meeting Ambulance Staffing Standard n/a -- All Ambulance Dispatches by Year 7 Full response data unavailable from San Ramon Valley Fire Protection District. * Full San Ramon Valley Fire District data not available Contra Costa Health Services EMS Annual Report for

40 B. First Responder Services Most EMS responses involve dispatch of both first responder and ambulance units. Historically fire services have provided first response to medical emergencies. All firefighters are required by law to be trained in emergency first aid and most are certified as EMT-Is. Most fire services have either implemented or are in the process of implementing paramedic programs where firefighters licensed as paramedics respond on first responder units. Firefighters generally respond from the nearest fire station and are normally the first responder on the scene of a medical emergency. Eleven County-governed, independent district and municipal fire departments respond from a total of 69 fire stations within the County. Fire first responder services are now augmented in some remote areas of the County by 4 paramedic-staffed quick response vehicles (QRVs) deployed by American Medical Response. First Responder Programs Fire first responder paramedics provide a method for combining early advanced life support care with the generally shorter response times provided by first responder units. Several models of paramedic first responder service are provided in Contra Costa County. All First Responder Paramedic programs operate under base hospital medical direction as well as EMS Agency policies and procedures. Moraga-Orinda Fire Protection District: Moraga Fire Protection District has provided paramedic ambulance services since In 1988, the Moraga Fire District implemented an ALS Engine program, to back up the Moraga paramedic ambulance. An ALS Engine, staffed with at least 1 paramedic and 1 EMT-I and stocked with ALS equipment, is dispatched simultaneously with an ALS transport unit to emergency medical requests. In 1997, Moraga Fire Protection District merged with Orinda Fire Protection District to form the Moraga-Orinda Fire Protection District. By 1999 all first responder units were staffed to provide paramedic advanced life support care. San Ramon Valley Fire Protection District: The San Ramon Valley Fire Protection District has provided paramedic ambulance services since In 1997, San Ramon Valley Fire Protection District implemented a program under which minimum ambulance staffing was dropped from two paramedics to 1 paramedic and 1 EMT-I. This enabled the District to increase the number of stations with paramedic staffing and provided flexibility for responses of paramedic ambulances and paramedic engines for critical patients. A dispatch plan was developed based on Medical Priority s Emergency Medical Dispatch System to assure 2 paramedics are on scene when needed for certain categories of patients. Contra Costa County Fire Protection District: In 1997, Contra Costa County Fire Protection District implemented a pilot first responder paramedic program in the Walnut Creek area with two engines staffed with a paramedic and 2 firefighters, and a Medic Unit, a non-transport vehicle staffed with 1 paramedic. Contra Costa County Fire has continued to expand their first responder paramedic program. As of April 2006, there were 28 units. In addition, all stations were equipped with paramedic equipment to allow extra available paramedics to provide ALS service if needed. 36 EMS Annual Report for 2005 Contra Costa Health Services

41 El Cerrito Fire Department: In 2001, El Cerrito Fire Department implemented an ALS program by providing a paramedic engine to cover the Kensington and El Cerrito hills where ambulance response times are typically over 10 minutes. El Cerrito currently has 2 paramedic engines in their District, which also covers the Kensington area. Pinole Fire Department: In 2005, Pinole Fire Department implemented a first responder paramedic program by providing a part-time paramedic-staffed engine. As of April 2005, Pinole brought 1 unit up full-time and as of December 2005, brought up an additional unit part-time. Rodeo Hercules Fire Protection District: In 2004, Rodeo Hercules Fire Protection District implemented a first responder paramedic program by providing a part-time paramedic-staffed engine. As of January 2006, Rodeo Hercules had 2 full-time paramedic engines. Crockett Carquinez Fire Protection District: Crockett Carquinez Fire Protection District offers a basic life support fire first responder program. American Medical Response provides paramedic first responder services within the District with a QRV. East Contra Costa County Fire Protection District: The East Contra Costa County Fire Protection District offers a basic life support fire first responder program. American Medical Response provides paramedic first responder services within the District with 3 QRVs. Richmond Fire Department: Richmond Fire Department offers a basic life support fire first responder program. To meet the countywide standard of assuring a paramedic to provide advanced life support on-scene within 10 minutes, American Medical Response responds with 2 paramedic-staffed ambulances within a 10-minute response time standard. Paramedic Quick Response Vehicles (QRVs) In 1992, the first paramedic-staffed non-transport quick response vehicle (QRV), funded by Measure H and provided by American Medical Response (AMR), was stationed in the Byron-Discovery Bay area to provide timely paramedic response in a remote area of the County where response times could be extended. In 2004, AMR assumed responsibility for the QRV program and stationed 4 paramedicstaffed QRVs to provide a timely paramedic response in remote areas where the fire services have not implemented paramedic first responder programs. Three QRVs were QRV TOTAL Code 3 Code 2 Crockett Oakley 1, Bethel Island Byron Contra Costa Health Services EMS Annual Report for

42 stationed throughout East County (Byron/Discovery Bay, Bethel Island and Oakley areas) and 1 QRV was stationed to augment paramedic first responder services in the Crockett, Rodeo- Hercules, and Pinole areas of West County. In 2005, a total of 2,635 Code 3 responses and 513 Code 2 responses were made by QRV s in these areas. First Responder Automated External Defibrillator (AED) Program The first responder defibrillation program, established on a Countywide basis in 1992, provides rapid access to life-saving care for patients with cardiac arrest. Initially the program was implemented in fire services, but several police departments are also equipping squad cars with defibrillators. AEDs are currently being carried or are planned for police units in Antioch, Brentwood, Hercules, Kensington, Lafayette, Moraga, Orinda, Pittsburg, San Ramon, Alamo, and Blackhawk. Emergency Medical Guidelines for Law Enforcement Agencies Emergency Medical Guidelines For Law Enforcement Agencies were first developed and implemented in 1992 following approval by the County Police Chiefs' Association and the Emergency Medical Care Committee. These guidelines provide direction to law enforcement personnel when they are the first to arrive on the scene of a medical emergency. The guidelines address the medical aspects of the officer's responsibility. C. Dispatch and Communications Medical Emergency & Disaster Ambulance Radio System (MEDARS) MEDARS is the County radio system used for ambulance-to-hospital and for Sheriff's Dispatch-to-ambulance communications. This radio system includes 4 channels. XCCEMS1 is used for communications between ambulances and Sheriff s Dispatch. XCCEMS2, XCCEMS3, and XCCEMS4 are for ambulance-to-hospital communications. Message Transmission Network (MTN) MTN is a computer network designed to interconnect County's fire/medical dispatch centers, Sheriff's dispatch, and American Medical Response (AMR) dispatch. Currently, the MTN system is in use at Contra Costa Fire Dispatch and AMR Dispatch and in 2005 handled about 70% of all EMS dispatches Countywide. Richmond Police Dispatch implemented the MTN system in June By establishing a direct data link among the computer-aided dispatch systems, MTN decreases dispatch time, reduces dispatch errors, and provides system response data. MTN makes use of the All County Criminal Justice Information Network (ACCJIN), which provides an existing linkage among answering points using similar protocols (TCP/IP) to those used on the Internet. Priority Dispatching Emergency Medical Dispatch (EMD) is a process where EMS dispatchers screen calls to provide appropriate EMS first responder and ambulance response, and provide simple emergency medical instructions for the caller to initiate prior to arrival of EMS personnel. In 1993, Medical Priority's ProQA Dispatch System was piloted in the San Ramon Valley Fire Protection District s dispatch center. By 2000, all fire/medical dispatch centers provided fire/ambulance dispatch utilizing this system. The National Academy of Emergency Medical Dispatch accredits dispatch agencies that use the Medical Priority Dispatch System and meet high standards of utilization, evaluation and 38 EMS Annual Report for 2005 Contra Costa Health Services

43 education as Centers of Excellence. All 3 public safety medical dispatch centers within Contra Costa County have achieved the Center of Excellence accreditation: San Ramon Valley Fire Protection District in 1996, West County Consolidated Communications Operations Center in 2002, and Contra Costa County Fire Protection District in Fire Radios Hi-band mobile radios, programmed with existing fire service radio channels, have been installed in all paramedic units to facilitate communication among paramedics, fire dispatch centers, and fire first responders except Richmond, which has an 800-trunking radio system. ReddiNet The ReddiNet system, implemented locally in 2001, was designed as a microwave communications link between hospitals. Hospitals and EMS Agencies in Alameda and Contra Costa Counties, and in 2003, Solano County, are included in the local ReddiNet system. Since 2003, Marin, Napa, Sonoma, Mendocino, Lake and Humboldt have become part of the ReddiNet system. In Contra Costa, Sheriff s Dispatch is the coordination point, and dispatch centers for all 3 emergency ambulance providers participate. On a day-to-day basis, hospitals can receive alert notices and timely incident updates from EMS and Sheriff s dispatch, can post hospital diversion and census alert status, and can send any important message to other hospitals individually or as a group. During multicasualty incidents, ReddiNet facilitates reporting of hospital information, tracking of ambulance assignments, and patient information. During a major disaster, ReddiNet is designed to provide a reliable communication path between hospitals and the counties disaster operations centers. Periodic drills with the hospitals using ReddiNet provide practice in using this important communications tool. D. Helicopter Transport Operational Procedures for Patient Transport by Helicopter were originally developed during trauma system planning in 1985/1986. In 2002, policies addressing helicopter transport were implemented. Most local helicopter transports are for trauma patients from distant areas of Contra Costa to the John Muir Trauma Center in Walnut Creek. Doctors Hospital, San Pablo also has a helipad that may be used as an ambulance/helicopter rendezvous point. The County s current standard of care for emergency patients transported by air is by an "air ambulance" which is staffed with 2 ALS care providers. Rescue aircraft are also requested for their special resources. As an example, a California Highway patrol helicopter has been used for its hoist capability. Additionally, a formal procedure for access of military aircraft has been adopted. In 2005 there were 372 transports of local patients by helicopter, almost exclusively to trauma centers. One hundred thirty nine patients (37%) were from West County, 182 (49%) were from East County, 22 (6%) were from South County and 29 (8%) were from Central County. Local authorized air ambulance helicopter providers, CALSTAR and REACH, are dispatched on a daily rotation schedule and perform nearly all helicopter transports in the County. In 2005, CALSTAR transported 197 patients (53%); REACH 168 patients (45%); CHP 5 (1%) and other helicopter provider(s) 2 (0.5%). In addition to the local helicopter transports, 250 patients were transported by helicopter from out-of-county locations to John Muir Trauma Center. Contra Costa Health Services EMS Annual Report for

44 E. Hospital Emergency Services The California licensed acute care hospitals located in Contra Costa have 8 emergency departments that provide service 24 hours/day, 7 days/week, and serve as receiving facilities for patients transported by emergency ambulance. The staff of these emergency departments includes at least 1 physician, trained and experienced in emergency medicine, 1 or more specialized registered nurses, plus clinical and clerical support staff. Specialty physicians are generally available for consultation on patients in the emergency department on-call, from their offices or home. Contra Costa Regional Medical Center Doctors Medical Center, San Pablo John Muir Health, Walnut Creek John Muir Health, Concord Kaiser Medical Center, Richmond Kaiser Medical Center, Walnut Creek San Ramon Regional Medical Center Sutter Delta Medical Center Hospital Resource Assessments 2500 Alhambra Avenue Martinez, CA Vale Road San Pablo, CA Ygnacio Valley Road Walnut Creek, CA East Street Concord, CA So. Cutting Blvd. Richmond, CA South Main Street Walnut Creek, CA Norris Canyon Road San Ramon, CA Lone Tree Way Antioch, CA Acute Care Beds 164 Intensive Care Beds 8 Acute Care Beds 232 Intensive Care Beds 29 Acute Care Beds 321 Intensive Care Beds 35 Acute Care Beds 254 Intensive Care Beds 25 Acute Care Beds 50 Intensive Care Beds 8 Acute Care Beds 229 Intensive Care Bed 24 Acute Care Beds 123 Intensive Care Beds 12 Acute Care Beds 111 Intensive Care Beds 12 The 8 acute care hospitals in Contra Costa County perform self-assessments annually to identify critical care capabilities and other hospital resources available to their patients. Hospital data collected includes information about: Special permit services such as emergency services burn unit, cardiovascular surgery service, and/or chronic dialysis unit. Intensive care units and surgical services. Hospital specialty services such as hemodialysis, trauma, specialized hand surgery and inhospital pharmacy. Physician specialty availability such as orthopedics, neurology, internal medicine, surgery, and anesthesiology. Disaster and radiation/hazardous material exposure preparations. The EMS Agency develops and distributes a report that includes information collected from the hospitals. It is available upon request or online at 40 EMS Annual Report for 2005 Contra Costa Health Services

45 Emergency Department Diversion of Ambulances EMS policy, initially developed and implemented in 1985, permits diversion of ambulances by emergency departments of acute care receiving facilities in the County. Under ambulance diversion policy, hospitals whose emergency departments are temporarily overloaded, may direct certain ambulance patients to other nearby hospitals. The purpose of this policy is to assure that patients are transported to a hospital that is able to provide immediate emergency treatment. At the end of 1997, and into the first quarter of 1998, Contra Costa experienced an acute shortage of ED and critical care resources. This phenomenon was felt in surrounding counties and throughout much of the State. As a result of this shortage, in 1998 the hospitals in Contra Costa worked in conjunction with the Hospital Council and EMS Agency to develop a framework for hospital response to scarcity in staffing, equipment, and/or bed capacity. Each hospital has internally integrated this Hospital Census Alert System for shortages in their facility. Starting in 2001, hospitals report their census alert status on the ReddiNet system. In 2005, the ED diversion policy was amended to restrict ED diversion to a maximum of 90 minutes with a 2-hour ED open period prior to a second request for ED diversion ED diversion hrs CT diversion hrs CCRMC Doctors SP John Muir Kaiser Rich. Kaiser - WC Mt Diablo SRRMC Sutter Delta During 2005, 7 of the 8 acute care hospitals utilized full diversion for a total of 478 hours. There were no reports of problems in patient care resulting from these diversion incidents. During the same period, 6 hospitals utilized CAT Scan diversion a total of 609 hours. CAT Scan diversion permits ambulances to divert patients who may require this test to another area hospital when the hospital s CAT Scanner is down for repairs or maintenance. F. Base Hospital and Paramedic Service Programs Base Hospital Services John Muir Health, Walnut Creek provides direct (on-line) and indirect (retrospective review) medical oversight services for ambulances Countywide. John Muir Base also performs trauma triage for ambulances transporting possible major trauma victims. In 2005 there were 3,599 base hospital contacts by field personnel. Total Base Contacts 6,000 5,000 4,000 3,000 2,000 1, Contra Costa Health Services EMS Annual Report for

46 Field Treatment Protocols First responders, paramedics, EMTs, and base hospital personnel use EMS Field Treatment Guidelines to provide care to patients in the field. These guidelines, based on current research and medical need in the County, are reviewed and evaluated by the Medical Advisory Committee that makes recommendations to the EMS Medical Director for implementation. Field treatment protocols are reviewed and revised on an ongoing basis. G. Trauma System In 1986, the Board of Supervisors approved a comprehensive Trauma System Plan for the County and designated John Muir Medical Center (Walnut Creek) as the County's Level II Trauma Center, and in June of that year, ambulance personnel began transporting critical trauma patients directly to John Muir, Walnut Creek. Ambulance and base hospital personnel use triage protocols, which include evaluation of mechanisms of injury and anatomic factors as well as a physiologic trauma scoring system to identify critical trauma patients. In 2001, a revised trauma system plan was developed to meet new State trauma system planning requirements. John Muir Trauma Service has received Capitol Program designation by the American College of Surgeons, the only Level II trauma center receiving this designation in northern California. This designation means that John Muir, Walnut Creek is designated to care for the President of the United States when he is in the Contra Costa area. In Contra Costa in 2005, 2,691 patients were identified as requiring trauma triage, 917 (34%) of which were transported directly to John Muir Trauma Center. One hundred twenty one patients were transported to Children s Hospital, Oakland, and 25 to out-of-county adult trauma centers, primarily Eden Hospital, Castro Valley and Highland Hospital, Oakland. Patients in traumatic full arrest or whose airway cannot be managed are triaged to the closest basic emergency department for resuscitation. During the past 19.5 years of operation, a total of 56,976 patients have been triaged through the County trauma system. Critically injured patients who arrive at a non-trauma center hospital may be transferred to a trauma center. Eighty-one of the 147 injured patients transferred to John Muir, Walnut Creek from within Contra Costa in 2005 were retrospective major trauma victims. John Muir Trauma Center also received 333 trauma patients from surrounding counties, 900 generally by air transport. One hundred seventy 800 five of the injured out-of-county patients were 700 retrospective Major Trauma Victims. In particular, 600 John Muir Trauma Center receives a significant number of trauma victims from neighboring Solano 300 County as triaged by Solano Base Hospitals. The 200 number of patients John Muir Trauma Center receives 100 from Solano has remained constant at about 12% of - their trauma admissions. John Muir Trauma Center has seen an increase in the distance trauma patients are being transported to the Trauma Center, coming from as far away as Ukiah. MTV Non-MTV All CC field CC Transfer Out of County 42 EMS Annual Report for 2005 Contra Costa Health Services

47 5% 4% 3% 2% 1% 0% If trauma center resources are temporarily overwhelmed, the trauma center may consider "Trauma Center Bypass, directing any critical trauma patients to out-of-county trauma centers until 2.7% 2.4% 2.5% 2.2% resources are again available. In 2005 John Muir Trauma Center bypass rate was 2.2 % and was most often due to operating room overload. Eleven critical trauma patients were triaged to out-of - County trauma centers during trauma center bypass periods. Trauma System Evaluation A major aspect of the trauma system is an extensive trauma system and trauma center monitoring program. A part of the program is a unique, bi-county audit system held in conjunction with Alameda County EMS and Alameda County trauma centers, which has been in place since the inception of the County trauma system. Trauma surgeons from other California trauma systems also participate in our trauma system evaluation and monitoring process, bringing outside perspectives and the additional expertise from teaching facilities. EMS Agency and trauma center staffs in both counties are testing new procedures to update the PreTAC case review process. Trauma surgeon directors dictate certain cases into their trauma registry system, and another trauma center surgeon, through the trauma registry system, reviews this information without having to travel to a distant trauma center to undertake chart review. John Muir Trauma Center also has its own internal monitoring and evaluation systems coordinated by an RN Trauma Program Coordinator. The Coordinator meets weekly with nurses, social service, physical therapists, neuropsychology, rehabilitation, nutritional services, pastoral care and patient accounting. These rounds analyze every patient on the trauma service from a multidisciplinary perspective. Current activities include design and implementation of the Neuroscience Institute, to address short and long-term care of traumatic brain injured patients. Trauma Injury Prevention John Muir Trauma Center supports an active injury prevention program that includes a prevention program for the elderly (falls and medication use); car seat inspections; school-based presentations; participation in health fairs; and representation on a number of injury prevention organizations, target groups and committees. John Muir Injury Prevention has received National Awards of Recognition for their programs and service to the community including recognition for the development of Nurses & Cops Caring for Contra Costa Children, which provides free car seat inspections in all areas of Contra Costa throughout the year. 2.3% H. Disaster/Multicasualty Planning and Response Multicasualty Incident Plan (MCI) The MCI is a multi-agency plan setting forth roles and responsibilities of response and support agencies in the event of a large scale incident involving a large number of casualties. The plan was originally developed and approved by the Board of Supervisors following the 1976 Yuba City/Martinez school bus accident. A multidisciplinary committee began work on the most recent revision of the MCI plan in 2005 to incorporate various levels of emergency response into one plan and the most current emergency medical response information. There were no MCI plan activations in Triage Tag Contra Costa Health Services EMS Annual Report for

48 Regional Disaster Planning Grant Since 1990, the EMS Agency has received a series of disaster planning grants through the State EMS Authority. California Health and Safety Code Division 2.5, Section , provides for the designation of Regional Disaster Medical/Health Coordinators (RDMHC) and the Contra Costa County Health Officer has been the designated RDMHC for Region II the northern California coastal area (OES Coastal Region). A Regional Disaster Medical/Health Specialist (RDMHS), funded by the Regional Disaster Planning Grant, is staff to the RDMHC. In 2005 staff continued work on the medical mutual aid system region-wide including quarterly forums for medical/health emergency planners and others. The focus of the , objectives included: Selection of sites for placement of Chempack caches Participation in Strategic National Stockpile (SNS) Plan development at local level Assistance in planning and development of Annual Statewide Exercises Assistance in medical/health planning and development of Golden Guardian Exercise. Development of RDMHC/RDMHS Activation and Response Expectation Policies Development of Medical/Health Operational Area Coordinator Orientation manual Participation in SNS regional exercises Initiated work on a web-based resource tracking and MHOAC alerting/notification systems. Medical Advisory Alert The Medical Advisory Alert is a notification procedure that is implemented when an incident has occurred or a condition exists which migh tax the local medical resources. When an MAA is implemented, Sheriff's Communications alerts those agencies with responsibilities in providing administrative or other support during a multicasualty incident that the potential for such a situation exists. Community Warning System Refineries and other industrial sites which use or store potentially hazardous chemicals use the Community Warning System to issue alerts that indicate incidents have occurred. These alerts range from Level 0 alerts at the low end to Level 3 alerts at the high end. EMS staff is alerted by pager to Level 2 (an incident has occurred resulting in minimal off-site impact) and Level 3 (an incident has occurred resulting in significant off-site impact) events. Both Level 2 and 3 alerts normally result in Medical Advisory Alerts. Multi-Casualty Supply Caches First aid supplies purchased by the EMS Agency are organized into 25 multicasualty supply caches that are stored and maintained in fire stations throughout the County. Fire agencies have agreed to rapidly transport caches to incidents. Cache supplies include bandaging equipment, splinting supplies, oxygen administration supplies, and blood pressure equipment. 44 EMS Annual Report for 2005 Contra Costa Health Services

49 Health Services Emergency Preparedness Program Contra Costa Health Services places a priority on emergency preparedness, and has established an Emergency Preparedness Work Group. This group meets monthly to develop and expand upon plans for the various Health Services divisions to be able to respond together to a wide variety of emergency situations from natural disasters such as earthquakes and floods, to chemical or other toxic releases to health emergencies. The Contra Costa Health Services Emergency Management Team (EMT) consists of Health Services division directors and administrative staff necessary to provide a health medical response to medical emergencies, public health emergencies and the like within the Standardized Emergency Management System (SEMS) and National Incident Management System (NIMS). The EMT meets quarterly. In June 2005, Contra Costa Health Services conducted Code Orange, a full-scale, countywide exercise that simulated an accidental pesticide release exposing patients that converged in our medical system. In November 2005 Health Services EMTs participated in Golden Guardian 2005, a full-scale exercise involving multiple explosions, casualties, and patients exposed to hazardous materials. Participants included acute care hospitals and clinics within the County and accomplished improved integration of response of Law, Fire and Medical branches. The CCHS Department Operating Center (DOC) was activated as part of the drill, and response staff practiced where to go, how to get to the DOC, how to open and activate the DOC and assume assigned roles in the DOC as well as understand SEMS/NIMS functions. The drill also served to familiarize staff with various activation materials, and utilizing coordination tools such as IRIS, satellite phones, radios, ring-down lines to the County EOC, radios, and the RACES system. An After Action Report was developed for the follow-up of corrective actions. Incident Response Information System (IRIS) IRIS is an in-house software program developed for use by Health Services employees, to facilitate communications among its various divisions and physical sites during major disasters affecting the region or state, or during minor incidents of local significance. The program provides the potential for the creation of a 'virtual' Department Operations Center (DOC) during a large-scale event or disaster. National Bioterrorism Hospital Preparedness Program A Health Resources Services Administration (HRSA) cooperative agreement has made available local funding, $741,028 in 2005, to achieve preparedness in critical benchmarks: surge capacity, pharmaceutical caches; personal protection; decontamination; communications and information technology; education and preparedness training; and terrorism preparedness exercises. Each of the 8 acute care hospitals within Contra Costa County hosted the Hospital Emergency Incident Command System (HEICS) refresher in early 2006 for their staffs. This was a 1.5-hour HEICS refresher and Tabletop Exercise for people who would normally fill a role in the HEICS response during a facility emergency. Instructor disaster courses at 3 levels were provided as well: First Receiver Awareness, First Responder Operations, and Decontamination Team Ops. Those facility staff that successfully completed these 2-day train-the-trainer classes are designated as "Core Team" members and are prepared with instructor materials to lead their peers during future trainings at their hospitals. This training incorporated orientation to the new mass- Contra Costa Health Services EMS Annual Report for

50 decontamination tents and equipment, Personal Protective Equipment (PPE), and shelter tents purchased with HRSA Grant funds. Homeland Security (HLS) Programs State and Local Domestic Preparedness Equipment Support Program Contra Costa EMS continued preparedness activities with various Fire, Law, OES and EMS agencies to implement the Homeland Security grant that provided communications equipment, radiological detection equipment, and PPE. The funds have been used to enhance the capabilities of first response agencies that may be called upon to respond to acts of terrorism. The equipment is supplementing the existing equipment currently staged in 4 caches maintained at designated fire stations throughout the County for rapid transport and deployment to any location. A 5-person County Approval Authority consisting of the Sheriff, Health Services Director, the Contra Costa County Fire Chief, a municipal fire chief and a municipal police chief administers this HLS grant program. I. Certification Programs Paramedics Paramedics are licensed by the State of California and are accredited by the local EMS Agency to practice in each county or EMS region in which they are employed. In 2005, 229 paramedics were either accredited or reaccredited by the Contra Costa County EMS Agency to practice as paramedics within the County. EMT-Is Any local EMS Agency may certify EMT-I s within the State. Once certified, an EMT-I may function as such statewide. In 2005, 420 EMT-Is were either certified or recertified in Contra Costa County. In 2003, the County adopted the National Registry of Emergency Medical Technicians certification exam as the approved EMT-I certification exam. MICNs In 2005, 20 RNs were either authorized or re-authorized in Contra Costa to practice in the expanded MICN role within the County. J. Training Programs Local EMS Agencies are required to review and approve training programs for prehospital personnel as meeting all requirements established by State regulations. Paramedic Training Programs There is no paramedic program provider currently based within Contra Costa. EMT Training Programs The EMS Agency has approved the local EMT courses offered by Los Medanos Community College, Contra Costa County Fire, Moraga-Orinda Fire, Mt. Diablo Adult Education, Contra Costa College, West Contra Costa Adult Education, Contra Costa County ROP, Health Career College. 46 EMS Annual Report for 2005 Contra Costa Health Services

51 Los Medanos Community College offers EMT training each semester at its Pittsburg campus. Contra Costa College offers EMT training each semester at its San Pablo campus. Mt. Diablo Adult Education offers EMT training at various times throughout the year at its facility in Concord. Health Career College offers EMT training at various times throughout the year at its facility in Concord. Contra Costa County R.O.P. offers EMT training at various times throughout the year at its facility in Pleasant Hill. Fire services offer training and continuing education to their in-house personnel. MICN Training Programs A 3-day MICN training course was offered at John Muir Health, Walnut Creek in October Eight MICNs completed the course. K. Public Information Education Program Emphases of the EMS agency public information and education efforts are on EMS system access, recognition of life threatening situations, prevention of injuries, and techniques and first-aid skills that the public can utilize in emergency situations (CPR specifically). In 2005, EMS distributed 49 Automatic External Defibrillators (AEDs), including 7 donated by American Medical Response, to public agencies within the County. This project included site selection, CPR/AED training to 121 staff members from various sites and AED orientations/demonstrations for the supplemental staff. EMS is now working with American Medical Response to assist with distribution of 25 AEDs annually. Local CPR class availability is accessible through the GIVE-CPR number maintained by the Contra Costa EMS Agency. This number is advertised in the EMS Brochure, local newspapers, telephone books and CCC Cable TV. EMS has continued to provide speakers for a number of community and wellness organizations such as Junior Chamber of Commerce, the Rotary Club, acute care receiving and skilled nursing facilities, and school districts. Contra Costa EMS Brochure is available. L. Interfacility Transfer Paramedic Program In 2002 an Interfacility Transfer Paramedic Program (Critical Care Transport-Paramedic - CCT-P) was developed to provide an alternative means of transferring stable patients who require, or who may require, care within the CCT-Paramedic Scope of Practice during transfer. CCT-P units were initially used to transfer patients from acute care hospitals, or other medical facilities approved by the EMS Medical Director, to other acute care facilities. In June 2004, policies were enacted that also permitted outpatient clinics to use CCT-P units to transport patients to acute care hospitals. Contra Costa EMS authorizes and contracts with interested ambulance companies that meet the training, staffing, equipment and oversight requirements. CCT-P units are fully equipped advanced life support ambulances, staffed with a minimum of 2 qualified staff that includes at least 1 paramedic. The EMT assigned to a CCT-P unit must have completed specialized training in order to work on that unit. CCT-Ps have an expanded scope of practice, and the transferring physician specifies standing orders for a patient based on skills and Contra Costa Health Services EMS Annual Report for

52 medications included in the County CCT-P scope of practice. CCT-P programs are required to have written quality improvement plans approved by the EMS Medical Director. In December 2003 Contra Costa and Alameda Counties signed a reciprocal agreement allowing interfacility transfer paramedics to respond and transport patients throughout both Counties. The CCT-P scope of practice was expanded to include transport of patients on ventilators, 12-lead EKG capability, and conscious sedation for ventilator patients. M. Do Not-Resuscitate Program (DNR) A DNR program for patients with terminal medical problems was implemented in This program evolved in response to concern from the public over the patient's right to selfdetermination. The Do-Not-Resuscitate program allows patients, in conjunction with their physicians, to refuse resuscitative measures in the prehospital setting, even if the system is inadvertently activated. The DNR form is signed by both the patient and the patient s physician and is recognized by prehospital personnel Statewide. The DNR form provides prehospital personnel with a physician order to not resuscitate the patient. Comfort measures and care other than resuscitative measures are still provided by first responders and ambulance personnel. The EMS Agency has distributed thousands of DNR forms to individuals, hospitals, nursing homes, hospices, home health agencies, and private physicians throughout the County. N. EMS for Children Program In 1999, the EMS Agency obtained a 2-year grant to develop and implement an EMS for Children (EMSC) program for Contra Costa. During 2001, an EMSC Plan was adopted which has been integrated into the County EMS System Plan. Hospital related EMSC issues and plan updates are addressed through the EMS Facilities and Critical Care Committee. Starting in 2005, EMS has become an active participant on the Child Death Review Team (CDRT) for Contra Costa County. The purpose of the CDRT is to: Share, question, and clarify all relevant information on the circumstances of deaths Discuss the investigation Identify risk factors Recommend system improvements Identify and take action to initiate prevention opportunities O. Other EMS Programs EMS Training Consortium At the request of local fire services, the Contra Costa County EMS Training Consortium was formed in 2005 to develop and provide a countywide training standard for fire agencies and ambulance personnel. As this program develops, it will integrate EMT continuing education (including the California-required 10 basic skills), and County-mandated training and infrequent skills for paramedics into a countywide program. This will offer an enhancement to fire agency and ambulance provider EMS training. 48 EMS Annual Report for 2005 Contra Costa Health Services

53 This standardized program will use a life-sized state-of-the- art Emergency Care Simulator (ECS) to provide patient simulation training. This ECS provides real-life scenarios, anatomical believability and real response to pharmacology, which will help emergency professionals learn to recognize, treat and communicate almost any conceivable extent of trauma or illness. Skills training and practice on this lifelike model should assist participants in transferring skill proficiency from practice sessions to daily EMS responses. Disaster Medical Assistance Team (DMAT) Contra Costa EMS is the sponsor of the California Bay Area Disaster Medical Assistance Team (DMAT). The federal entity, DMAT CA-6, is established under Department of Homeland Security (DHS), Federal Emergency Management Agency (FEMA). The majority of the team members belong to both entities with the difference being CA-6 deploys on federal missions and the nonprofit entity deploys to state and local missions. Both DMAT CA-6 and the California Bay Area DMAT were formed in 1997 with support of Contra Costa, San Mateo, Alameda and San Francisco Counties. Disaster Medical Assistance Teams are comprised of trained and prepared medical and support personnel organized to provide medical/health care to disaster victims. Teams can be staged prior to high-risk events such as the Olympics, or can be deployed during or post event to provide medical services in an austere post-disaster environment. There are 28 federal DMATs considered operational nationwide, with 6 in California plus a mental health specialty team. Following is the chronology of DMAT CA 6 and California Bay Area DMAT that includes both partial and full deployments Bay Area Disaster Medical Assistance Team formed and sponsored by Contra Costa Health Services Bay Area DMAT CA6 attained Level II designation Bay Area DMAT attained Level I designation. Deployed to Ft. Dix, New Jersey, for Operation Refugees and to Washington State for World Trade Council Meetings. Members traveled to Ukraine for joint training mission DMAT CA-6 incorporated as a nonprofit organization with 501(c)(3) status. Members provided medical coverage for firefighters participating in Wildland 2000 and at Fleet Week in San Francisco California Department of Forestry (CDF) contracts with DMAT CA-6 to pilot medical response to National Fire Service events when requested. CA-6 was the first team to undertake this type of response, and is the prototype for a nationwide collaborative between DMATs and U.S. Dept of Forestry. Members deployed to provide medical coverage in Washington D.C. at the Presidential Inauguration, in Texas for tropical storm Allison, for firefighters participating in Wildland 2001, in Salt Lake City for the 2001 Olympics. Members deployed to Ground Zero, NYC/World Trade Center and to the US Postal Service Annex for employee anthrax screening Members deployed to provide medical coverage for firefighters participating in Wildland 2002, and to 4 major California wildfires as part of the CDF agreement. Members staged for response at the 2002 World Series and Fleet Week in San Francisco Members staged to provide care for the Sunnyvale Anti-War Protests. Members deployed to 5 major Southern California fires as part of the CDF agreement. Members provide medical care at Moffett Field Air Show and San Francisco Fleet Week. Contra Costa Health Services EMS Annual Report for