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Agenda 05/13/2013 Item #10I5/1412013 10.1. EXECUTIVE SUMMARY Recommendation that the Board of County Commissioners direct the `Medical Director Subcommittee' of the PSA investigate claims of actual and potential failed calls as they relate to protocols and training promulgated under the current county Medical Director. A full investigation is required to be conducted given the PSA's obligation to provide a quality assurance process and a duty to investigate problems as they arise and recommend solutions promptly. There are three matters that require such investigation: 1. In January, 2013 the county's Medical Director released updated protocols as final without allowing for review. The consequence was that protocols were released as official which contained life threatening standards. For example - a protocol was released with respect to pediatric rescue breathing which was incorrect, and, if administered by an EMS provider as prescribed would result in the death of the child. Protocols should not be released as official until validated by the appropriate agencies /boards. Medical accuracy is mandatory. 2. A young man passed away, allegedly because EMS failed to timely arrive at the scene. EMS claimed that no emergency tone was heard. There are complaints that the county's 800 Mega Hertz communications system is failing to set off the appropriate tones which are used to alert emergency vehicles of an incoming call. These failures are being reported as happening daily and may have contributed towards the death of one resident, and is threatening the lives of all. This matter must be immediately investigated and addressed. 3. A letter received from Physician's Regional Hospital, dated May 6, 2013 explains that the county's medical director was working "extremely closely with NCH to promulgate protocols seemingly effectuated by the threat of loss of market share to NCH." In an email dated December 20, 2012, the county's medical director advocated against certain stroke protocols because these protocols would "divert 40% of the patients currently going to NCH." The medical director was in effect seemingly making decisions about which protocols were to be adopted based on how NCH's market share would be affected if stroke patients were transported to Physician Regional's new Comprehensive Stroke Center (the only such accredited stroke center in SW Florida) rather than to NCH. Protocols must be developed on what is in the best interest of the patient, not in any way based on the market share a hospital might lose. It appears that only 12 -15% of the county's stroke victims are being transported to Physicians Regional notwithstanding the current protocol. There are two recent stroke related deaths where the patients were transported to NCH rather than the Physician's Regional stroke center begging the question as to whether these patients might have survived if transported to the stroke center. What has transpired is of the utmost seriousness. A full study into how many patients are being transported by county EMS to one hospital over another hospital is needed. Further, the timeliness and basis on which protocols are being established needs to be fully investigated. Lastly, the training of providers as to directions on where patients shall be transported under which conditions needs to be investigated. The Packet Page -214- 5/14/2013 10.1. development of protocols and training of the EMS providers are the responsibility of the county's medical director. OBJECTIVE: That the Board of County Commissioners direct the `Medical Director Subcommittee' of the PSA investigate claims of actual and potential failed calls as they relate to protocols and training promulgated under the current county Medical Director. A full investigation is required to be conducted given the PSA's obligation to provide a quality assurance process and a duty to investigate problems as they arise and recommend solutions promptly. There are three matters that require such investigation: 1. In January, 2013 the county's Medical Director released updated protocols as final without allowing for review. The consequence was that protocols were released as official which contained life threatening standards. For example - a protocol was released with respect to pediatric rescue breathing which was incorrect, and, if administered by an EMS provider as prescribed would result in the death of the child. Protocols should not be released as official until validated by the appropriate agencies/boards. Medical accuracy is mandatory. 2. A young man passed away, allegedly because EMS failed to timely arrive at the scene. EMS claimed that no emergency tone was heard. There are complaints that the county's 800 Mega Hertz communications system is failing to set off the appropriate tones which are used to alert emergency vehicles of an incoming call. These failures are being reported as happening daily and may have contributed towards the death of one resident, and is threatening the lives of all. This matter must be immediately investigated and addressed. 3. A letter received from Physician's Regional Hospital, dated May 6, 2013 explains that the county's medical director was working "extremely closely with NCH to promulgate protocols seemingly effectuated by the threat of loss of market share to NCH." In an email dated December 20, 2012, the county's medical director advocated against certain stroke protocols because these protocols would "divert 40% of the patients currently going to NCH." The medical director was in effect seemingly making decisions about which protocols were to be adopted based on how NCH's market share would be affected if stroke patients were transported to Physician Regional's new Comprehensive Stroke Center (the only such accredited stroke center in SW Florida) rather than to NCH. Protocols must be developed on what is in the best interest of the patient, not in any way based on the market share a hospital might lose. It appears that only 12 -15% of the county's stroke victims are being transported to Physicians Regional notwithstanding the current protocol. There are two recent stroke related deaths where the patients were transported to NCH rather than the Physician's Regional stroke center begging the question as to whether these patients might have survived if transported to the stroke center. What has transpired is of the utmost seriousness. A full study into how many patients are being transported by county EMS to one hospital over another hospital is needed. Further, the timeliness and basis on which protocols are being established needs to be fully investigated. Lastly, the training of providers as to directions on where patients shall be transported under which conditions needs to be investigated. The development of protocols and training of the EMS providers are the responsibility of the county's medical director. Packet Page -215- 5/14/2013 10.1. CONSIDERATIONS: The PSA has a duty to ensure quality assurance of protocols and training promulgated /provided by the county's medical director. There have been numerous instances where such protocols and training have come into question, putting lives at risk. The Medical Director Subcommittee shall be tasked with the investigation of the three matters raised in this executive summary - specifically as relating to the release of inaccurate protocols, the failing county EMS communications system, the development of protocols based on hospital market share rather than patient care, and, training with respect to transport - again based on hospital market share rather than what is in the patient's best interest. These are matters of great importance since they involve the public's health and safety. The Board of County Commissioners cannot ignore what has come to light and must take corrective action as quickly as possible. FISCAL IMPACT: None at this time. LEGAL CONSIDERATIONS: This item has been reviewed by the County Attorney. If the Board wishes to pursue this matter, then for the sole purpose of minimizing the County's litigation exposure, the County Attorney requests that the Board directs the County Attorney to work with the County Manager in structuring and coordinating this investigation with the PSA. -JAK RECOMMENDATION: That the Board of County Commissioners direct the `Medical Director Subcommittee' of the PSA investigate claims of actual and potential failed calls as they relate to protocols and training promulgated under the current county Medical Director. A full investigation is required to be conducted given the PSA's obligation to provide a quality assurance process and a duty to investigate problems as they arise and recommend solutions promptly. There are three matters that require such investigation: 1. In January, 2013 the county's Medical Director released updated protocols as final without allowing for review. The consequence was that protocols were released as official which contained life threatening standards. For example - a protocol was released with respect to pediatric rescue breathing which was incorrect, and, if administered by an EMS provider as prescribed would result in the death of the child. Protocols should not be released as official until validated by the appropriate agencies/boards. Medical accuracy is mandatory. 2. A young man passed away, allegedly because EMS failed to timely arrive at the scene. EMS claimed that no emergency tone was heard. There are complaints that the county's 800 Mega Hertz communications system is failing to set off the appropriate tones which are used to alert emergency vehicles of an incoming call. These failures are being reported as happening daily and may have contributed towards the death of one resident, and is threatening the lives of all. This matter must be immediately investigated and addressed. 3. A letter received from Physician's Regional Hospital, dated May 6, 2013 explains that the county's medical director was working "extremely closely with NCH to promulgate protocols seemingly effectuated by the threat of loss of market share to NCH." In an email dated December 20, 2012, the county's medical director advocated against certain stroke protocols because these protocols would "divert 40% of the patients currently going to NCH." The Packet Page -216- 5/14/2013 10.1. medical director was in effect seemingly making decisions about which protocols were to be adopted based on how NCH's market share would be affected if stroke patients were transported to Physician Regional's new Comprehensive Stroke Center (the only such accredited stroke center in SW Florida) rather than to NCH. Protocols must be developed on what is in the best interest of the patient, not in any way based on the market share a hospital might lose. It appears that only 12 -15% of the county's stroke victims are being transported to Physicians Regional notwithstanding the current protocol. There are two recent stroke related deaths where the patients were transported to NCH rather than the Physician's Regional stroke center begging the question as to whether these patients might have survived if transported to the stroke center. What has transpired is of the utmost seriousness. A full study into how many patients are being transported by county EMS to one hospital over another hospital is needed. Further, the timeliness and basis on which protocols are being established needs to be fully investigated. Lastly, the training of providers as to directions on where patients shall be transported under which conditions needs to be investigated. The development of protocols and training of the EMS providers are the responsibility of the county's medical director. PREPARED BY: Commissioner Georgia Hiller, Chair - District 2 Attachment - Physician's Regional Letter dated May 6, 2013 Packet Page -217- 5/14/2013 10.1. COLLIER COUNTY Board of County Commissioners Item Number: 10.10.1. Item Summary: Recommendation that the Board of County Commissioners direct the 'Medical Director Subcommittee' of the PSA investigate claims of actual and potential failed calls as they relate to protocols and training promulgated under the current county Medical Director. A full investigation is required to be conducted given the PSA's obligation to provide a quality assurance process and a duty to investigate problems as they arise and recommend solutions promptly. There are three matters that require such investigation: 1. In January, 2013 the county's Medical Director released updated protocols as final without allowing for review. The consequence was that protocols were released as official which contained life threatening standards. For example - a protocol was released with respect to pediatric rescue breathing which was incorrect, and, if administered by an EMS provider as prescribed would result in the death of the child. Protocols should not be released as official until validated by the appropriate agencies /boards. Medical accuracy is mandatory. 2. A young man passed away, allegedly because EMS failed to timely arrive at the scene. EMS claimed that no emergency tone was heard. There are complaints that the county's 800 Mega Hertz communications system is failing to set off the appropriate tones which are used to alert emergency vehicles of an incoming call. These failures are being reported as happening daily and may have contributed towards the death of one resident, and is threatening the lives of all. This matter must be immediately investigated and addressed. 3. A letter received from Physician's Regional Hospital, dated May 6, 2013 explains that the county's medical director was working "extremely closely with NCH to promulgate protocols seemingly effectuated by the threat of loss of market share to NCH." In an email dated December 20, 2012, the county's medical director advocated against certain stroke protocols because these protocols would "divert 40% of the patients currently going to NCH." The medical director was in effect seemingly making decisions about which protocols were to be adopted based on how NCH's market share would be affected if stroke patients were transported to Physician Regional's new Comprehensive Stroke Center (the only such accredited stroke center in SW Florida) rather than to NCH. Protocols must be developed on what is in the best interest of the patient, not in any way based on the market share a hospital might lose. It appears that only 12 -15% of the county's stroke victims are being transported to Physicians Regional notwithstanding the current protocol. There are two recent stroke related Packet Page -218- 5/14/2013 10.1. deaths where the patients were transported to NCH rather than the Physician's Regional stroke center begging the question as to whether these patients might have survived if transported to the stroke center. What has transpired is of the utmost seriousness. A full study into how many patients are being transported by county EMS to one hospital over another hospital is needed. Further, the timeliness and basis on which protocols are being established needs to be fully investigated. Lastly, the training of providers as to directions on where patients shall be transported under which conditions needs to be investigated. The development of protocols and training of the EMS providers are the responsibility of the county's medical director. (Commissioner Hiller) Meeting Date: 5/14/2013 Prepared By Approved By Name: OchsLeo Title: County Manager Date: 5/8/2013 10:00:14 AM Packet Page -219- 5/14/2013 10.1. PHYSICIANS REGIONAL HEALTHCARE SYSTEM May 6, 2013 Collier County Board of County Commissioners c/o The Honorable Georgia Hiller, Chairwoman 3299 Tamiami Trail East, Suite 303 Naples, FL 34112 Dear Commissioner Hiller: There has been much public discussion recently regarding the Medical Director position for Collier County. The decision about how-to proceed is one in which only the Commissioners can make, and Physicians Regional Healthcare System stands ready to support whatever decision you make. However, there have been comments made publicly which we feel need to be clarified. It is our responsibility - and one we take seriously - to provide the best care possible, as quickly as possible, to patients who have emergency conditions. To that end, we have made serving patients in an emergency condition a major priority. For example, as of May 3, 2013, the federal government's own website points out (www.hospitalcompare.hhs.aov) that patients who present to our Emergency Department are seen by a professional faster (in 35 minutes, vs. 72 minutes at NCH), receive pain medication faster for broken bones (53 minutes vs. 79 minutes at NCH), and leave without being seen at a lower rate (2% vs. 4% at NCH). This is not to say the care at NCH is not excellent, and certainly, we believe both systems prioritize care for patients in emergencies. But, given this proven commitment to quality, we would hope patients would be provided access to these services, certainly at their request, and also when our hospital is the closest one - as the county EMS protocols require. We have had circumstances where patients have complained that either — or both - of these conditions were present, and yet, the patient was not taken to Physicians Regional -Pine Ridge by EMS. We are somewhat puzzled by reading assertions in a few news stories that there have not been efforts to protect one particular hospital's business. We believe this very thing has happened, and we hope, as you consider the role of the Collier Boulevard Campus - 8300 Collier Blvd., Naples, FL 34114 - (239) 354 -6000 Pine Ridge Campus - 6101 Pine Ridge Road, Naples, FL 34119 - (239) 348 -4000 www.PhysiciansRegional.com Packet Page -220- 5/14/2013 10.1. County, that the process remains objective. We believe this is in the best interest of patient care, and that is what should guide the County's policy. Physicians Regional Healthcare System invested significant resources in technology, recruitment of clinical staff, and experienced, highly regarded NeuroVascular /Endovascular Surgeons to build the only accredited Comprehensive Stroke Center in Southwest Florida to implement the best state of the art practice protocols to care for victims of stroke. To take it one step further, our program at PRHS is included in a Joint Commission Comprehensive Stroke Center Pilot Study to help establish standards of care in hospitals in the rest of the country. Yet, in email exchanges between NCH and the County's Medical Director, it is clear the Medical Director was working extremely closely with NCH to promulgate protocols seemingly effectuated by the threat of loss of market share to NCH. Clearly, this concern was expressed in his December 20th, 2012 email when he advocated that the protocols would "divert about 40% of the patients currently going to NCH...." He said this would be a "disservice to the patients." Setting aside the disturbing email, and looking solely at the data, it is clear a distinct minority of stroke cases are being transported by EMS to Physicians Regional, notwithstanding its demonstrated capability and certification. Unless the data is wrong, only 12 -15 percent of Collier County Stroke patients are being transported by EMS to Physicians Regional, notwithstanding the protocols and the fact that Physicians Regional is the only hospital locally that can provide the continuum of care necessary for this very deadly acute condition. In fact, CC EMS has been sending just as many stroke patients from North Naples to North Collier Campus, which is not a certified stroke center. We are unclear how bringing patients as quickly as possible to the area's only certified Comprehensive Stroke Center, an emergency department where the federal government's own website points out that patients presenting get care faster, would be a disservice to patients, which the current Medical Director asserted in his email. To the contrary, it is a life- saving service for patients. It is also concerning to see the prolonged and protracted 6 -month timeline these EMS Stroke assessment protocols took to implement. We certainly agree with Packet Page -221- 5/14/2013 10.1. making sure diligence is done, but we should point out that these protocols are the same as those implemented by Miami /Dade and Broward Counties. The protocols are geared toward permitting EMS to stratify stroke victims such that those who need more advanced care are brought to the best - equipped location for the service. This is critical so as to avoid delays in care when patients must then be transferred. Clearly, bringing a patient to a location that can provide the range of services without transfer leads to better outcomes and no life - threatening delays. In our dealings with the County, we make every attempt to be responsive and forthcoming. This can be made more difficult if we believe the representative from the County may be acting as a proxy for other enterprises, which is indeed how we felt during the process of establishing the stroke program. It is our intent to always do what is best for our patients, and frankly, to collaborate with NCH and the County. We stand ready to be of service. Cordially, 6,3 �- " e rcl -e7' C. Scott Campbell Market CEO Physicians Regional Healthcare System Packet Page -222-