EMS Oversight Presentation Community and Public Health Committee San Francisco Health Commission October 19, 2010 #1 Summary of Oversight for Quality of Prehospital Care Delivery in SF EOA The CCSF and EMSA will have a Performance Based Contract to ensure high quality clinical care, provide efficient and reliable EMS services at a reasonable cost to consumers, and provide the community with an operationally and financially stable system. The EMSA intends to improve accountability and the clinical care delivery in the EMS System by requiring robust Operations, Training and Quality Improvement (QI) Plans. The following are highlights of essential performance elements: 1. Ambulance Response Time Performance, Reliability and Measurement Provider requirement to conform with Response Time Standards. DEC will provide direct access to 9-1-1 CAD information systems for the Provider and the EMSA to monitor performance staff responsible for contract management. Provider will be required to submit system status management plans that use response time data to evaluate the effectiveness of ambulance deployment plans on an ongoing basis. The provider will be required to staff and deploy a minimum number of ambulance unit hours per week. Provider will be required to submit monthly reports on response times to EMSA in a presentation format specified by the Contract Manager. Provider will participate in DEC/EMSA workgroup for evaluating failures of performance and documenting efforts to eliminate problems on an on-going basis. Penalties will be in place for exceeding response time standards, running out of ambulances, failed responses, failure to provide data, and ambulance breakdowns during transport. 2. Clinical Performance Standards Provider will implement Training and Quality Improvement Plans that demonstrate how QI interfaces with all aspects of organizational performance. Provider will be required to deploy a single software application for the electronic patient care record (epcr) and provide EMSA with direct access to all patient records and application reporting tools. Provider must establish interface for electronic access to SFFD First Responder epcr. Uniform plan for orientation to the EMS system and field training for all providers (to replace current disparate orientations programs). FTE commitment for provider staffing of QI Manager, Risk Manager, Data Manager, Training Managers, Field Training Officers, and Field Supervisors. Ambulance and staffing levels including personnel with current and appropriate levels of certification/licensure Monthly reporting of required QI Parameters, which include: - Adequacy of the primary assessment and documentation relative to the patient history, chief complaint and primary impression. 1
- Compliance with EMSA triage, treatment and transport protocols. This will include reports that evaluate the documentation of trauma, burns, STEMI, stroke and other specialty care triage criteria for over and under-triage rates. - Evaluation of high risk and infrequent skills competencies as defined in EMS policies and protocols. For example, successful intubation rates and number of attempts by entire system, by provider, by airway type and by individual. - Accuracy and completeness of epcr and all related patient care documentation. - Results from annual field provider performance evaluations. - Medical cardiac arrest survival in accordance with Utstein protocols and participation in the national Cardiac Arrest Registry to Enhance Survival. - Pain reduction. - Field procedures authorized. - Internal and/or external customer feedback (e.g., patients, family members, hospital staff, co-workers, first responder partners etc.) - Employee injuries. - Vehicle collisions. - Critical vehicle/biomedical equipment breakdowns (interfering with a response, transport or treatment). - Employee turnover. - ALS transport unavailable for dispatch to an incident. - Patient outcomes of Code 2 dispatches with Code 3 transport. The Provider QIP Committee will annually identify topics for mandatory review and reporting from but not limited to the following topics: - Refusals of care - Pediatric calls - Base Hospital medical control order requests - Repeated types of unusual occurrences - Outcomes from diversions - Triage delays - Field care issues involving specialty care patients - Efficacy of Care - Trauma Team activations - Utilization and efficacy of medications for management of chest pain, arrhythmias, respiratory distress, seizures, overdoses etc. 3. Risk Management, Patient and Employee Safety Provider will implement a comprehensive Risk Management Program consisting of processes for risk identification, avoidance, measurement and monitoring. Provider will conduct timely investigations of clinical incidents and complaints and maintain risk management data collection systems designed to track and trend potential and actual risk for patients and employees. Provider will submit monthly reports of Risk Management activities to the EMSA. Providers will have multiple programs to enhance patient and employee health and safety. These shall include driver training, safety and risk management training. 2
Providers will assure that adequate personal protective gear and equipment is available to employees and that they are properly trained in the usage of the equipment and working in hazardous environments such as rescue operations, motor vehicle accidents, etc. #2 Ambulance Depletion Issue: Typically DEC receives over 7,000 EMS Calls each month. Dispositions for Phantom Jul-10 Aug-10 Sep-10 Medic Dispatches # % # % # % AMA 2 1.9% 2 0.6% 3 1.1% CXL 2 1.9% 9 2.6% 6 2.3% FIRE CALL 4 3.9% 11 3.2% 18 6.8% GOA 2 1.9% 2 0.6% 2 0.8% MAP 1 1.0% 3 0.9% 3 1.1% NOM 4 3.9% 24 6.9% 14 5.3% OME 0 0.0% 2 0.6% 4 1.5% OTH 0 0.0% 0 0.0% 3 1.1% PDT 12 11.7% 29 8.4% 30 11.4% SPD 1 1.0% 3 0.9% 4 1.5% TH2 65 63.1% 238 68.8% 163 62.0% TH3 6 5.8% 20 5.8% 4 1.5% TMP 1 1.0% 1 0.3% 0 0.0% UTL 3 2.9% 2 0.6% 9 3.4% Total 103 346 263 Phantom ambulance totals have increased on a monthly basis from 70 in June 2009 to 261 in June 2010. Conclusions: 1. Technical error is responsible for a small percentage (6.9%) or phantom ambulance notifications. The vast majority are due to rapid spikes in call volume and lack of available vehicles to respond. 2. These spikes in unmet volume tend to occur in clusters resulting in greater than 10 notifications in 1-2 hour time spans. 3. It is difficult to isolate definitive patterns in this data. However, a significant number of notifications have occurred in the 0800 to 1200 and 1600 to 2000 time periods (all days). 4. Overall ambulance depletion in 2010 is increasing over 2009 levels. 5. Code 3 return transports to hospital and office of medical examiner cases are being monitored among these calls (see red bars above) and are a small percentage of overall calls. 3
#3 Diversion Trends Jan 2002 Sept 2010 14% Annual ED Diversion Hours (%) 2002-9/2010 for Non-Critical & Non-Speciality Care Patient Transports 14% 12% 10% 12% 10% 10% 9% 11% 9% 8% 6% 6% 6% 4% 2% 0% 2002 2003 2004 2005 2006 2007 2008 2009 As of 9/2010 Diversion Suspension Reported as Percentage of Hours Per Month that More than 4 ED's were on Diversion and EMSA Invoked Six Hour Period of Diversion Suspension Yrly Year Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Avg 2008 22% 28% 15% 15% 15% 15% 13% 10% 6% 14% 8% 9% 14% 2009 13% 8% 6% 6% 4% 6% 6% 6% 8% 14% 8% 9% 8% 2010 13% 8% 6% 6% 4% 6% 6% 2% 1% - - - 5% Ambulance diversion reform initiative: we are working with Seattle/King County Washington s EMS System to develop standard diversion policies with data collection and analysis in order to move both systems to a new diversion standard utilizing medical surge grant funds. The goal is to develop medical surge within hospitals to accommodate periods of increased ambulance traffic. One issue is decreasing ambulance turnaround times while dropping patients off at hospitals: 4
100% Ambulance ED Turn Around Times (TAT) Percentage of TAT's > 35 Mins. for 8/1-8/14/2010 (n=2340) Starts @ Time Ambulance Arrived and Ends @ Back In Service Time % > 35 Min ED TAT % < 35 Min ED TAT 80% 22% 17% 32% 26% 24% 28% 24% 20% 26% 26% 28% 23% 23% 24% % of Transports 60% 40% 20% 0% 8/1 8/2 8/3 8/4 n=151 8/5 n=143 8/6 n=165 8/7 n=157 8/8 n=190 8/9 n=170 8/10 n=184 8/11 8/12 n=151 8/13 n=159 8/14 5
#4 Response Intervals for First Response (Defibrillator-equipped vehicle, most often a Fire Engine) by ERD 6
For Sept Presidio, the 18 min is due to 4 out of 22 calls where the Incident location couldn t be easily determined. 16.0 April - September 2010 Code 3 Total Call Response Intervals for First Unit On Scene 1 by Emergency Response Districts 14.0 90th Percentile Response Interval (mins) 12.0 10.0 8.0 6.0 4.0 2.0 EMSA RESPONSE TIME REQUIREMENT = 6.5 MINS. 0.0 ERD1 ERD2 ERD3 ERD4 ERD5 ERD6 ERD7 ERD8 ERD9 ERD10 PRESIDIO Overall Apr 6.97 6.85 7.92 6.58 7.07 7.18 7.65 7.72 7.87 7.78 8.03 7.38 May 7.17 7.03 7.62 6.80 7.52 7.83 7.80 8.27 8.05 8.73 9.10 7.67 Jun 7.05 7.12 8.08 7.13 7.15 7.40 7.58 7.90 8.62 7.77 8.80 7.60 Jul 7.32 6.80 7.53 6.83 6.65 6.85 7.07 8.25 8.18 8.63 9.00 7.42 Aug 7.33 7.52 7.73 6.67 7.48 6.82 7.23 7.97 8.37 8.2 10.32 7.60 Sep 7.93 7.63 8.75 7.07 7.50 7.67 8.18 8.05 8.30 8.27 17.95 8.02 7
#5 Cardiac Arrest Survival Improvement Initiatives Goal: Increase cardiac arrest survival from witnessed ventricular fibrillation events from current 9.1% to 18% in 2 years. Partner with Heartsafe Region (AHA) and Take Heart America Initiatives to improve: 1. Chain of Survival components: Identifying Cardiac Arrest and performing CPR a. NERT, SFPD, Social Media, DPH Clinics phone messaging outreach b. Dispatcher training 2. Improving access to AED s: a. SFPD b. Legislative outreach c. Increasing supply of program directors 3. Optimize EMS resuscitations: a. Changing EMS protocols Jan 1, 2011 b. Integration of all providers into CARES 4. Optimizing hospital treatments: a. STEMI heart attack and post-cardiac arrest resuscitation center program b. Discharge instructions to include CPR for families Develop a timeline and deliverables, including measurement statistics and report results to health commission and post on website by February 2011. #6 Increasing First Responder effectiveness and limiting shift duration for EMS personnel providing medical care We continue to experience problems with first responder effectiveness when on scene prior to the arrival of ambulance personnel. This has not improved to date by institution of a first responder documentation form, and we have pursued this issue via the SFFD quality improvement system. There will be a presentation at this meeting on first responder issues by SFFD. 8