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Backup Documents 01/11/2011 Item # 5DPatricia L. Morgan 15D From: FlorinJennifer [JenniferFlorin @colliergov.net] Sent: Friday, December 31, 2010 8:05 AM To: ButcherTabatha; Chief Robert Metzger (bobmetzger @ggfire.com); Douglas Lee (duglee @hotmail.com); Dr. Talano (jvtalano @com cast. net); Jerry Pinto (jjprx @aol.com); Kopka, Walter; Patricia L. Morgan; Rosemary LeBailley (rn_roe @hotmail.com); Tober (rbtobermd @yahoo.com); Tucker, Samuel; Walter Kopka (wkopka @comcast.net); WatsonWayne Cc: Page, Jeff Subject: January Meeting Agenda Items Attachments: Final reportBOTTOMLINERecommendations FINAL12 30 10 (2).pdf; REPORT- FINAL- PreHospitalCare 12 30 10.pdf Good Morning and Happy New Year to you all. Per our Chairman, Dr. Talano, I have attached the final recommendations of the EMS Blue Ribbon Committee for your review. Please read through them carefully and be prepared to discuss this and make a recommendation to the BCC at our next meeting. If you have trouble opening the documents please let me know. Thank you! Administrative Assistant Collier County EMS 8075 Lely Cultural Parkway Suite 267 Naples, FL 34113 (239) 252 -3759 (239) 252 -6490 - Fax i IIM� under {-Ior' tip? maw, f. r i,90 saCtitre x.., biro mihIIr (f't "ii)'ktS If vmi do not waW ymI .rr aII ]d'd, oss ro I(::a sod 3n f''1"por?sc to a ptJ; he roco!ds re( uo-st, I #tS f"t;I Y f 1,fcA,,d 'c: nt,t..t "nis R¢ t 'cy m ; 1. 50 BOTTOM -LINE RECOMMENDATIONS FOR PREHOSPITAL EMERGENCY MEDICAL TREATMENT AND TRANSPORT (PEMTT) SERVICES PREFACE Collier County, Florida is one of the best places in America to live, work and visit. Daily, we have at least 1,294 public safety professionals (662 Sheriff's Deputies in law enforcement, 632 Fire Rescue and Emergency Medical Service Offiicers... 246 of which are Paramedics) on call to risk their lives to help, protect and serve us. The Panel producing this report, over and over again during the past year of its study, was impressed and regularly gratified by the evidence that all these professionals are dedicated, focused, and conscientious. They work hard to immediately help us during our most vulnerable moments. The data shows clear results. Our prehospital emergency medical treatment and transport (PEMTT) professionals enjoy national praise. And, we enjoy living in one of the safest and healthiest communities in America. National studies rank Collier County as the generally healthiest county in Florida. And, we have the best cardiology services in Florida. Moreover, Collier County residents have the highest life expectancy in Florida and the fourth highest life expectancy in the United States. And, we want to keep it that way. The report is dedicated to praising our "best and brightest" PEMTT professionals and recommending ways in which we can improve the system that supports them. Shifting demographics, medical advances, technological leaps ... all dictate that we craft our future by expertly managing our resources. This report recommends ways in which we all, our professionals and our citizens, together can continue to be an even healthier, safer community. Page 1 of 5 RECOMMENDATIONS 1. The Board of County Commissioners should designate and delegate authority and responsibility for all PEMTT services to a Public Safety Authority. 2. Reappoint the medical director to report to the designated Public Safety Authority. The Panel strongly suggests that the medical director work closely with the leaders of the three hospitals' emergency departments serving Collier County (NCH, PRHS, and Lee Memorial trauma departments.) 3. Establish a PEMTT Council to report to the designated Public Safety Authority, chaired by a hospital administrator. Under the guidance of the designated Public Safety Authority, the medical director, in collaboration with the directors of the emergency departments of the NCH, Lee Memorial Trauma Center and PRHS, will promulgate all PEMTT personnel training, quality initiatives, credentialing and testing. Membership on the Council to include representatives from fire districts, the public and outside independent experts. 4. Outsource all test design, administration, evaluation and dispute resolution to professionals at a local college or university to insure independence and objectivity. 5. The designated Public Safety Authority should propose administrative procedures and policy to the Board of County Commissioners after thorough vetting of such by the Council. The Board of County Commissioners should set general policy; the designated Public Safety Authority should implement and manage the system; The Board of County Commissioners should evaluate the clinical and financial efficacy of all proposed procedures and policies. 6. With guidance and advice from the PEMTT Council and delegated authority and responsibility from the Board of County Commissioners, the designated Public Safety Authority should lead development of a five -year strategic plan ... with a required three -year audit provision... to provide collegial oversight for all involved in establishing a refreshed PEMTT model for county -wide PEMTT services 7. Establish a two- tiered county-wide PEMTT model: • Tier One = Timely delivery of Basic Life Support (BLS) Services • Tier Two = Timely delivery of Advanced Life Support (ALS) Services 8. Mandate that all agencies providing ALS services also provide patient transport to hospitals. 9. Establish a mandatory Automatic Electric Defibrillator (AED) placement and training program for all staff at appropriate public locations. Effective and efficient AED execution must be countywide priority involving all facets of the public and private sectors. Page 2 of 5 50 10. Encourage discussion of functional consolidation of fire service districts in Collier County and expert reallocation of resources in response to current demographics and professional standards, utilizing the county's Productivity Committee to comprehensively study and review all costs and potential service enhancements. 11. Encourage consideration of a pilot project aimed at a functional integration of county EMS personnel into the fire service districts. To do so, the pilot districts would utilize position control administration to manage the optimal assignment of Paramedic and EMT positions and also the possible use of smaller, lighter ambulances to be used in certain non - ALS required response situations. 12. Encourage all PEMTT agencies within fire service agencies to collaborate in order to develop common response protocols. 13. Encourage all PEMTT agencies to collaborate to designate one leader to be the one voice for all PEMTT treatment and transport matters conducted BY fire services operating in Collier County. 14. Mandate that all PEMTT vehicles be equipped with standardized life saving equipment COMPATIBLE with AREA hospital emergency department equipment and supplies. Page 3 of 5 The Panel Geoffrey Moebius, Chair -Blue Ribbon Panel Community Liaison and Past CEO, Physicians Regional Healthcare System Edward A. Morton, Vice Chair -Blue Ribbon Panel Partner & Managing Director, Wasmer Schroeder & Company, Inc. Past CEO, NCH Healthcare System Patricia Barton, Community Leader Edward Boyer, Retired Healthcare System Executive Russell Budd, President, Wall Systems Inc. of Southwest Florida Joseph Gauta, M.D., Past President, Collier County Medical Society Michael V. Reagen, Ph.D., President, The Greater Naples Chamber of Commerce & Leadership Collier Foundation, Inc. EMS and Fire Chiefs, Assistant Chiefs and Firefighters Jorge Aguilera, Deputy Chief of Medical Services and Community Relations North Naples Fire Control & Rescue District Dan Bowman, Deputy Chief, Collier County Emergency Medical Services Chris Byrne, Deputy Chief, City of Marco Island Fire - Rescue District Steve McInerny, Chief, City of Naples Fire District Robert Metzger, Chief, Golden Gate Fire District Jeff Page, Chief, Collier County Emergency Medical Services Dan Summers, Executive Director, Collier County Department of Emergency Management Eric Watson, Firefighter, Big Corkscrew Fire District Wayne Watson, Deputy Chief, Collier County Emergency Medical Services Page 4 of 5 X50 Hospital Leaders Joseph Bernard, Chief Operating Officer, Physicians Regional Healthcare System — Collier Boulevard Phillip Dutcher, Chief Operating Officer, NCH Healthcare System, Inc. Chris Lee, M.D., Associate Medical Director, Collier County Emergency Medical Services Hospital Emergency Department Physicians Todd D. Bethel, M.D., Emergency Medicine, Naples Community Hospital John P. Lewis, M.D., ER Physician Director, Naples Community Hospital John W. Zelahy, M.D., Emergency Medicine /Internal Medicine Physicians Regional Hospital — Pine Ridge Road Robert Tober, M.D., Medical Director, Collier County Emergency Medical Services Florida Gulf Coast Universi Lisa Zidek, Ph.D., Associate Professor, Florida Gulf Coast University Collier County Sheriffs Office Jim Bloom, Chief of Operations, Collier County Sheriffs Office Deborah Chester, Manager of Planning & Research, Collier County Sheriffs Office Page 5 of 5 5D This report to remain CONFIDENTIAL County, until presented to Collier Board of Count'v Commissioners ar onJanuary 11, 2011 at the .. Meeting, r50 BLUE RIBBON PANEL REPORT COLLIER COUNTY, FLORIDA BOARD OF COUNTY COMMISSIONERS REGARDING PREHOSPITAL EMERGENCY MEDICAL TREATMENT PRESENTED TO COLLIER COUNTY, FLORIDA BOARD OF COUNTY COMMISSIONERS JANUARY 11, 2011 V50 TABLE OF CONTENTS Acknowledgments........................................................................................ ..............................2 ExecutiveSummary ................................................................................... ..............................1 l History......................................................................................................... .............................13 Lessons Learned: A Reality Check for System Adjustments ..................... .............................16 The Current Local Scene ................................................................ .............................17 Elements of a Refreshed Model ...................................................... .............................18 Lessons Learned from King County, Washington .......................... .............................19 Lessons Learned from Broward County, Florida ........................... .............................21 Lessons Learned from Volusia County, Fl orida ............................. .............................23 Lessons Learned from Cities of Marco Island and Naples, Florida ............................24 The Panel's Recommendations ................................................................... .............................25 Bibliography............................................................................................... .............................31 Data Analysis Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Page I of 32 X50 ACKNOWLEDGMENTS V-5 0 ACKNOWLEDGMENTS The Blue Ribbon Panel wishes to acknowledge those individuals who participated in the review and development of the proposal and recommendations being presented to the Collier County Board of Commissioners. The Panel Geoffrey Moebius, Chair -Blue Ribbon Panel Community Liaison and Past CEO, Physicians Regional Healthcare System Edward A. Morton, Vice Chair -Blue Ribbon Panel Partner & Managing Director, Wasmer Schroeder & Company, Inc. Past CEO, NCH Healthcare System Patricia Barton, Community Leader Edward Boyer, Retired Healthcare System Executive Russell Budd, President, Wall Systems Inc. of Southwest Florida Joseph Gauta, M.D., Past President, Collier County Medical Society Michael V. Reagen, Ph.D., President, The Greater Naples Chamber of Commerce & Leadership Collier Foundation, Inc. EMS and Fire Chiefs, Assistant Chiefs and Firefighters Jorge Aguilera, Deputy Chief of Medical Services and Community Relations North Naples Fire Control & Rescue District Dan Bowman, Deputy Chief, Collier County Emergency Medical Services Chris Byrne, Deputy Chief, City of Marco Island Fire - Rescue District Steve McInerny, Chief, City of Naples Fire District Robert Metzger, Chief, Golden Gate Fire District Jeff Page, Chief, Collier County Emergency Medical Services Dan Summers, Executive Director, Collier County Department of Emergency Management Eric Watson, Firefighter, Big Corkscrew Fire District Wayne Watson, Deputy Chief, Collier County Emergency Medical Services Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Page 2 of 32 f 5 Hospital Leaders Joseph Bernard, Chief Operating Officer, Physicians Regional Healthcare System — Collier Boulevard Phillip Dutcher, Chief Operating Officer, NCH Healthcare System, Inc. Chris Lee, M.D., Associate Medical Director, Collier County Emergency Medical Services Hospital Emergency Department Physicians Todd D. Bethel, M.D., Emergency Medicine, Naples Community Hospital John P. Lewis, M.D., ER Physician Director, Naples Community Hospital John W. Zelahy, M.D., Emergency Medicine /Internal Medicine Physicians Regional Hospital — Pine Ridge Road Robert Tober, M.D., Medical Director, Collier County Emergency Medical Services Florida Gulf Coast University Lisa Zidek, Ph.D., Associate Professor, Florida Gulf Coast University Collier County Sheriffs Office Jim Bloom, Chief of Operations, Collier County Sheriff s Office Deborah Chester, Manager of Planning & Research, Collier County Sheriffs Office Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEM7T) System Page 3 of 32 150 Geoffrey Moebius Chair -Blue Ribbon Panel Community Liaison and Past CEO, Physicians Regional Healthcare System Geoffrey Moebius serves as the Community Liaison for (the Physicians Regional Healthcare System) Physicians Regional Medical Center. He came to Naples to oversee the completion of Cleveland Clinic Florida Naples' new hospital and served as the hospital administrator until Health Management Associates purchased the facility on May 1, 2006. In 2006, Mr. Moebius became CEO of Physicians Regional Medical Center and served as CEO until retiring in December, 2009. Mr. Moebius has a Masters Degree in Health Specialties from Cleveland State University and a Bachelor of Science from Lake Erie College. In addition, he completed the Kaiser Permanente Executive Master Program at Stanford University during his tenure with Kaiser Foundation Health Plan, Cleveland, Ohio. Mr. Moebius' career began at Meridia Huron Hospital in Cleveland where he worked for five years as the administrative director of operations. He held leadership positions in administration with Kaiser Foundation Health Plan in Cleveland and was CEO of Deaconess Hospital of Cleveland and Saint Michael Hospital, both owned by Primary Health Systems. Prior to joining Cleveland Clinic Florida, he was the chief administrative officer at Deaconess Hospital LLC, Cleveland. He is a presently a member of the Collier Heart Walk Executive Leadership Team, Southwest Florida American Heart Association Board and serves on the board of The Greater Naples Chamber of Commerce. Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEM77) System Page 4 of 32 I�lJ Edward A. Morton Vice Chair -Blue Ribbon Panel Partner & Managing Director, Wasmer Schroeder & Company, Inc. Past CEO, NCH Healthcare System Prior to joining Wasmer Schroeder & Company, Inc., Morton held the positions of Chief Executive Officer, Chief Operating Officer and Chief Financial Officer for NCH Healthcare System. Morton received his under - graduate education at the University of Notre Dame where he received a B.S. in Public and Managerial Accounting. Morton continued at the University of Miami where he received his MBA and, most recently, his MS in Health Science from Florida Gulf Coast University. Currently, Morton's professional associations and affiliations include: Trustee, Florida Gulf Coast University; Trustee, Quest Foundation; Member, Neighborhood Clinic Advisory Committee; Immediate Past Chairman of the Leadership Collier Foundation; Chairman Emeritus, Florida Gulf Coast University Foundation; Director, NCH Health System Foundation and Trustee, Moorings Park Institute. Former Associations include: Chairman, Naples Area Chamber of Commerce; Vice Chairman, Florida Gulf Coast University Board of Trustees; Member, City of Naples Redevelopment Advisory Board; Member, Collier County Board of Economic Advisors; Member, City of Naples 41 -10 District Advisory Board; Member, Eagle Scout Selection Committee; Director, Economic Development Council; Director, Barnett Bank of Naples; Active Duty Service, Captain, United States Army 1969 -1972, and Past Chairman, Education Foundation of Collier County and Partners in Education. Academic and professional achievements include a LIFE Award winner of Edison Community College and was selected as the health representative to the General Electric Strategic Planning Program for 2005. Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEM7T) System Page 5 of 32 150 Patricia Barton Community Leader An alumni of Auburn University, Patricia Barton's involvement in the community is far reaching, currently serving on several boards including the Juvenile Assessment Center (JAC) Advisory Board, the Volunteer Collier Board, the PACE Center for Girls - Collier at Immokalee Advisory Board and the Greater Naples Leadership Board. Past Board participation includes the YMCA of Collier County, the David Lawrence Mental Health Center and Foundation Board, the Naples Community Hospital Auxiliary, Edison Community College Foundation Board and the Statewide Health & Human Services Board. Her work in Drug Abuse Prevention includes founding member of the Naples Informed Parents, founding member and Project Director of Florida Informed Parents (now Informed Families) and Founding member of the National Federation of Parents for Drug -Free Youth (NFP, now National Family Partnership). Ms. Barton has also been appointed to the Florida Substance Abuse & Mental Health Corp. Political activism includes committee member and Vice President for Naples Better Government from 2002 -2006 as well as Chair of numerous campaigns for city council, mayor, school board, constitutional officer and active in various state and federal campaigns. Ms. Barton is the recipient of numerous awards including the 2007 PACE State Award for Invest in the Future and the Pioneer Award in 2010, the 2007 Youth Haven Frances Pew Hayes Child Advocate of the Year Award as well as the 2007 AAUW Women of Achievement Award. Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Page 6 of 32 X50 Edward Boyer Retired Healthcare System Executive Boyer is a seasoned healthcare professional with more than 30 years experience. In his last position as Senior Vice President of Corporate Services for Bon Secours Health System, Boyer developed and implemented a system -wide supply chain and performance reporting system, an offshore captive insurance company and created a new direction for information technology services. Boyer was responsible for supporting the company's wide range of corporate services, including information systems services, quality improvement, material management and insurance and risk management. Prior to joining Bon Secours, he served as a consultant for several years; first as a principal in the Baltimore office of Arthur Andersen and then as a managing consultant in the Washington offices of Towers Perrin. Before this, he acted as president of Maryland Health Care System, located in Baltimore, MD., a six - hospital consortium that provided its members with a range of shared services, including strategic planning, systems engineering, purchasing and public relations. Boyer received a Bachelor of Arts degree from the University of Maryland and an M.B.A. from George Washington University. Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Page 7 of 32 V.5D Russell Budd President, Wall Systems Inc. of Southwest Florida Russell demonstrates his belief in community service by his active participation local civic associations. Junior Achievement of Southwest Florida named Russell a 2005 Laureate for his entrepreneurial leadership skills. Russell is a graduate 2005 -2006 Class of Leadership Florida. Locally, Russell has served for many years with the Greater Naples Chamber of Commerce including two years as the Chairman of the Board of Directors. He is also a graduate of Leadership Collier, Class of '94 as well as the inaugural Leadership Institute Class of 2001 and is a Past Chairman of the Leadership Foundation. Russell also completed twelve years of service on the Collier County Planning Commission, including three years as the Chairman. He is serving as a volunteer on the Selective Service Board and was a Director for the Bank of Florida- Southwest. In 1993, he was elected to the Board of Commissioners in the Golden Gate Fire Control and Rescue District and served a four - year term, acting as Chairman for three of those years. He served for six years as a member of the Board of Trustees for Seacrest Country Day School. Russell is dedicated to his family that includes his wife, Dr. Katie Paschall, a professor at Edison Community College, and their three children, Daniel, Rachael and Emily. His focus on family serves as the force behind his commitment to the preservation of the Southwest Florida environment and the improvement of our community. Russell Budd, President of Wall Systems Inc, of Southwest Florida, founded the organization in 1986. Russell received a Bachelor of Building Construction from the University of Florida in 1981. He has held a Certified General Contractor ( #CGC 021714) in the State of Florida since 1982 and is a licensed Real Estate Broker. Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Page 8 of 32 �50 Joseph Gauta, M.D. Past President, Collier County Medical Society Joseph Gauta, MD is a board certified gynecologist in Naples, FL. He has been practicing in Naples since 1998 and founded Especially for Women in 2000 and the Florida Bladder Institute in 2006. His expertise includes all aspects of obstetrics and gynecology, with special training and emphasis in urogynecology. Prior to moving to Naples, Dr Gauta finished his undergraduate studies at Siena College in Albany, NY. His medical degree was completed at Albany Medical College and finally specialty training at Tulane University in New Orleans. Dr Gauta has been actively involved in the political welfare of the patients and doctors of Florida. He is the President of the Collier County Medical Society. He was on the Board of Governors of the Florida Medical Association, currently a member of the Board of Governors of the Florida Medical Association Political Action Committee, and on the Board of Leadership Collier. He is also past- President of the Southwest Florida Physicians Association, a 600 member organization of physicians in our local PHO. Lastly, he is a Board member of Ava Healthcare, Inc, a recently launched health insurer in the state of Florida. Dr Gauta has been married to Susan for 13 years, and has three children: Spencer, Stephen and Samantha. Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Page 9 of 32 Michael V Reagen, Ph.D. President, The Greater Naples Chamber of Commerce & Leadership Collier Foundation, Inc. In June 2002, Reagen was named President of The Greater Naples Chamber of Commerce, the largest of 25 Chambers in the five county SWFL region, and, according to the Florida Association of Chamber Professionals, among the top seven of 300 chambers in Florida. He is also President of the Leadership Collier Foundation. Mike's extensive career has included key executive positions in metropolitan development, higher education and state government where he was a cabinet officer for three state Governors. Reagen is a 2003 graduate of Leadership Collier, a 2007 graduate of the Collier County Sheriffs Citizen Academy and was a member of Collier County Habitat for Humanity. He has served on Collier County's Freedom Monument Selection Committee and its Fiscal Stability Committee. He has served on the advisory Boards of Edison College, Lorenzo Walker Technical Institute, Naples /Fort Myers Town Hall, the Rookery Bay Estuarine National Research Center and Seacrest Country Day School. Mike also participated as a Panelist in the FCCMA Coaching Program Webinar on Sustainability for Economic Development and is a Member of U.S. Senator George LaMieux's Jobs Advisory Council. Active in local affairs, Mike is advisor to the Council for International Visitors, the Civic Information Center and the Naples Press Club. In 2006, he received The World Food Prize's Iowa Founders Award; in 2008 he was named one of Gulfshore Life magazine's Men of the Year, and in 2009 The Collier Education Foundation named him a `Man of Distinction'. Mike has served as a Member of the Governance Task Force of the Collier County School District; Chair, Friendship Health Center Coordination Council; and the Facilitator, Collier County Pre - Hospital Emergency Medical Services Study Group. Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Page 10 of 32 M5o EXECUTIVE SUMMARY 150 EXECUTIVE SUMMARY Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Encouraged by the Collier County Board of Commissioners (BCC), a citizen Blue Ribbon Panel (the Panel) was assembled in September 2009 to study and review the elements of the continuum of care (EMS, fire department, hospital emergency department physicians, police and community) of pre - hospital emergency medical treatment and transport (PEMTT) system in Collier County, Florida. The Panel's charge was, after evaluating issues, proposals, and current relevant literature, to recommend improving PEMTT service to assure all in Collier County are provided the highest level of medically effective and efficient care. Collier County has experienced significant population growth during the past 30 years. Its 338,000 citizens (both full time and part time) and nearly two million annual visitors have been well served during that period by the dedicated professionals within EMS, the fire departments, the sheriffs office and police departments, whose coordinated and integral response to medical emergencies deliver timely and expert basic life support (BLS) and advanced life support (ALS) services. Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Page I I of 32 t- Collier County citizens and taxpayers have never accepted average when it comes to community services and healthcare; neither have the county's public safety forces. The Panel's recommendations are meant to ensure that by working together, Collier County will continue to be one of the safest communities in the nation. In February 2010 the Panel presented preliminary thoughts to the BCC. After conducting its own review of the academic literature (see bibliography) the Panel in June recommended establishing a countywide, two - tiered PEMTT delivery model. Tier One would be charged with the delivery of timely BLS services and Tier Two with the delivery of timely ALS and transport services. At that same meeting the Panel also suggested the following: the creation of a PEMTT Council to refresh the currently standing county committee, as well as an objective review of all 911 dispatch data. The BCC responded by asking the Panel to continue its work and provided $45,000 in funding for the 911 data review. Professional support to conduct the review was provided by Florida Gulf Coast University. This report contains the results of the 911 data review, along with system recommendations. In addition, it provides a contextual comment on PEMTT history, lessons learned from other jurisdictions, and specific recommendations for consideration. Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Page 12 of 32 t5� HISTORY r50 HISTORY Hospitals and physicians have been involved with pre- hospital care at least since 1921 when Dr. Claude Beck, an M.D. at Western Reserve University, Cleveland called the fire department so he could apply a "pulmotor" (an artificial breathing apparatus) to help resuscitate victims who stopped breathing. In 1939 the Miami -Dade Fire Department provided first aid training for firefighters to treat victims. Transport was done by the funeral homes. The 1960s brought the development of the 911 system and Emergency Medical Services (EMS). A variety of pre - hospital care delivery systems exist across the 3085 counties of the United States. System makeup is largely based on the size and scope of local government; whether a rural or urban setting; funding; and medical expertise. Consistently however, first responders for pre - hospital care have been fire and sheriff departments. This is primarily due to their functional organization and duty to respond to accidents, fires and rescue situations. Transportation of victims has typically been provided by hospitals, private ambulance services, or through government ambulances managed by fire or county- managed EMS corps. America's most prestigious pre- hospital delivery systems average a seven - minute on scene arrival time. Many research findings state the ideal on -scene arrival goal as four minutes for Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Page 13 of 32 basic life support (BLS) services, especially for heart attack victims. Eight minutes is ideal for advanced life support (ALS) services. Heart attack (cardiac arrest) became a leading cause of death after the turn of the century and is a key emergency services need in Collier County. Humans have always suffered from cardiac problems, but they usually died from causes such as infectious disease, long before reaching an age where heart problems threatened their life. As the world of medicine has advanced and people are living longer, heart disease has become a serious health issue. Beck (1894 - 1971), a pioneer of heart surgery; focused on operations to improve circulation in damaged heart muscles and developed ways to revive heart attack victims, including the defibrillator and CPR. In 1947 Beck successfully defibrillated his first patient, a 14- year -old boy whose heart went into fibrillation after an operation. The defibrillator used on this patient was made by James Rand, a friend of Beck. Nine years later (1956) Paul Zoll used a more powerful unit to perform the first closed -chest defibrillation. In Belfast, ambulance - transported physicians first achieved pre- hospital defibrillation in 1966. Defibrillation by EMTs (Emergency Medical Technicians) without the presence of physicians was first performed in Oregon in 1969. Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Page 14 of 32 r50 Today, all should reasonably understand that the use of Automated External Defibrillators (AEDs) is a community responsibility. AEDs and people properly trained in their use should be situated in easily accessible public places. There are 1,587 AEDs registered in Collier County. That is a higher number per capita than King County (Seattle, Washington), which is among the most prominent pre - hospital care providers in America. The King County Dispatch Center is the repository for information on all registered Public Access Defibrillators (PADs) or AEDs. When a call is received regarding a possible cardiac event the caller is told the location of the closest PAD /AED. In Florida, Broward County has mandated AEDs be available in all restaurants with specified occupancies, as well as in airports and seaports. Mandatory staff training is provided by the companies that sell the AEDs. This Panel recommends Collier County consider establishing a similar program. Collier County should also, in establishing this plan, coordinate community AED services and create training for sheriff and county services staff. Additionally, the county along with the sheriff's office should implement an automated tracking system to identify AED locations, usage time and other pertinent data. The Collier county Sheriff's Office should continue to pursue the necessary legislative changes to implement the above recommendations. Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Page 15 of 32 r5o LESSONS LEARNED: A REALITY CHECK FOR SYSTEM ADJUSTMENTS 5 D H LESSONS LEARNED: A REALITY CHECK FOR SYSTEM ADJUSTMENTS The Panel reviewed multiple white papers, community structures, state and local blue prints for developing integrated pre- hospital care systems (see bibliography). Several counties have exceptional programs evidencing best practices which the Panel recommends Collier County carefully consider as follows: King County (Seattle), Washington; Broward County, Florida; Volusia County, Florida, and the Cities of Marco Island and Naples, Florida: King County is known for medical leadership and structure, expertise in pre- hospital cardiac care, cost - effective use of resources, and regionalized fire and EMS services. Under the leadership and command of the Broward County Sheriff, Broward County has developed a functionally impressive organizational structure, medical leadership, and EMS and fire cooperation. Volusia County, like Collier County, has multiple fire districts and a county -wide EMS. Consequently it has service coordination, leadership challenges, potential cost, and structural issues it is attempting to address. The City Fire and Rescue Departments of Marco Island and Naples have good interagency experiences working closely with Collier County EMS that may be replicated. Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Page 16 of 32 . 50 - 1 THE CURRENT LOCAL SCENE All involved in Collier County's system are dedicated, loyal to their professions, community- spirited and hard working. All, however, are effaced by the currently conflicted dysfunctional rhetoric that springs from national system- change -angst which has become extraordinarily personal. Although outside this Panel's focus, it is obvious that the functions of fire services in Collier County should consider consolidation and that resources, given modern needs, be professionally reallocated. Fire Services PEMTT should work to share common protocols for responding to pre - hospital medical treatment and transport calls. Fire Services PEMTT leaders should at the very least collaborate on establishing one voice, one leader, for all PEMTT matters. Collier County's EMS is centrally run, uniformly well trained, dedicated, and loyal to its distinguished medical director, Dr. Robert Tober. All involved in Collier County appreciate the historical and present professional contributions of Dr. Tober. All praise and recognize his competence. The current PEMTT system in Collier County, however, is now racked by the regular exchange of personal, ideologically -based arguments that need to cease. Private professional discussions, of course, should be encouraged; public attacks should end immediately. All energy, passion and professionalism should be re- channeled into resetting current operations into a new delivery model. Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Page 17 of 32 5D M ELEMENTS OF A REFRESHED MODEL The start of a refreshed PEMTT model needs to focus on who arrives on scene quickest with the highest level of training and expertise in order to begin treatment that will quickly prepare the patient for transport. This is the crux of the issue that led to the Panel's recommendation of a two- tiered BLS and ALS model. All citizens want the best emergency services. It is common sense to have a paramedic with EMT support first on scene for those cases that require a high level of service (ALS). A number of factors complicate immediate support response: lengthy distances; extended and /or protracted response times to hospital; density of an aging population and other demographics; high -rise residential towers challenging access and other extenuating circumstances. Clearly, the number of medics and equipment on scene should be determined by the acuity of the incident versus the complications noted above. Low acuity may range from no transportation required to an ambulance or other transportation. High acuity episodes (heart attack /stroke or traumas for example) may need to include additional manpower and multiple pieces of equipment. This should be determined by centralized PEMTT management based on geography, community expectations, population demographics, available staffing resources and treatment protocols set by the medical director. Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Page 18 of 32 i5D 4, LESSONS LEARNED FROM KING COUNTY The Panel is impressed with the King County program which was started in 1969 by physicians Drs. Leonard Cobb (cardiologist) and Michael Copass (Emergency Director Harborview Medical Center) and Seattle Fire Chief Gordon Vickery. The focus was to provide the highest level of pre - hospital care to the community with highly trained paramedics and EMTs. Collier County (338,000 residents) presently has 259 trained paramedics within EMS (113) and fire departments (146). King County (population 1.9 million) has a total of approximately 250 paramedics. Michele Plorde, Director for King County ( PEMTT), says initial and ongoing field - based training of an elite, select group of paramedics is critical to maintenance of a highly proficient PEMTTcare service. King County standards exceed Washington State's training requirements by two times, requiring 2,500 hours of training to become a paramedic. King County coordinates all initial and ongoing training for EMTs and paramedics from Fire and EMS, medical direction, strategic planning, placement of units and individual fire department services with ALS and BLS protocols, promulgated by King County's Medical Director. The King County EMS Advisory Committee model is worthy of Collier County's consideration. The Advisory Committee membership appears to be inclusive and could be a model for Collier County. A PEMTT Council for Collier County could consist of the following entities: medical director; hospital emergency department directors; hospitals administrative staff; the sheriff or Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Page 19 of 32 50 designee; EMS and fire department; and community leaders who help with communication and planning. This PEMTT Council could be ably and professionally facilitated by the designated public safety authority with directly delegated authority and responsibility from the Board of County Commissioners. It should meet to address, for example, paramedic related issues; clinical issues such as cardiac stroke programs; community education; the county -wide AED program; and education for all first responders. The King County medical director conducts a quarterly meeting with the system's six medical directors, EMS director, and other administrative staff (all involved in coordination of the medical protocols for personnel training, QI and QA, credentialing, and reviewing of medical pre - hospital care). As a model for Collier County, the translation would include the opportunity for a Collier County medical director to meet with hospital emergency room directors to discuss medical related services including expanding hospital involvement in training and educational seminars. Similar to King County, cardiac survival rates should be a base starting point for monitoring and reporting. Additionally, stroke and trauma survival rates should be reviewed. Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Page 20 of 32 50 Pq LESSONS LEARNED FROM BROWARD COUNTY, FLORIDA Broward County, Florida has a unique PEMTT management system, aspects of which might well serve Collier County. Broward County started reviewing its interagency PEMTT issues in 1992. The review resulted in transference of all Fire and EMS PEMTT services to the management of the sheriff in 2003. All municipalities combined Fire and EMS. All Fire and EMS personnel are considered equal with medics in both EMS and fire. This integration was considered a critically necessary improvement in the pre - hospital care system. Since all Broward County PEMTT personnel report through the sheriffs office there is a chain of command that uniformly manages all local PEMTT issues. All fire and EMS vehicles are equipped with standardized life saving equipment consistent with Broward hospitals emergency departments' equipment and supplies. There are 31 municipalities within Broward County. Professional flexibility in accordance with different city needs is vital. For example, while the Fort Lauderdale Fire /EMS Service is now exploring BLS transport, it does not send fire engines to transport situations. Broward County's medical director also serves as the medical director for Ft. Lauderdale and works collegially with the 31 municipalities, 21 of which provide independent safety services. Some also have medical directors who set, based on Florida's minimum requirements, local protocols. All medical directors within Broward County meet monthly in collaboration with the sheriffs office. Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospual Emergency Medical Treatment & Transport (PEMTT) System Page 21 of 32 Broward County's Advisory Committee facilitates the resolution of issues between the county's medical director and the independent municipality fire districts and other agencies, including training. Training in Broward County occurs through a variety of venues utilizing the hospitals as well as the scheduling of fire paramedics on ambulances for vacation /staffing shortage days. Broward County believes collaborative experience -based field training is critical to keeping up technical proficiencies. Note that in both Broward and King counties some hospitals, not all, help provide medical direction. The directors of the emergency departments within the separate jurisdictions work collaboratively with the county medical director. Their input is critical for all PEMTT personnel training and community programs. All hospitals flag cases for review and share data on trauma cases. Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Page 22 of 32 50 50 LESSONS LEARNED FROM VOLUSIA COUNTY, FLORIDA Volusia County, Florida recently conducted a study worthy of note. Volusia has experienced issues similar to those now challenging Collier County, including increasing costs associated with fire and EMS services. The Halifax Area Civic League submitted to the county in July 2010 a report titled, "Possibilities of Fire and Rescue Service Consolidation in Volusia County." As a frame of reference there are 16 incorporated cities or towns in the county. Combined with unincorporated Volusia County, the population is approximately 507,000. There are 13 separate governmental fire /rescue services. The study's recommendation is to merge the fire and rescue services, which can easily be accomplished through inter -local agreements. Through attrition, overall savings would be roughly $5.7 million per year. Collier County Commissioners may wish to consult with their peers in Volusia County. Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Page 23 of 32 so �f LESSONS LEARNED FROM CITIES OF MARCO ISLAND AND NAPLES FLORIDA The collaboration between Marco Island and Naples Fire Departments and Collier County EMS seems to yield positive results. The three agencies have progressively worked well together in education, community involvement, AED use, American Heart Association basic life support programs, and a host of safety programs. The collaboration has fire engine paramedics (ALS trained staff) which take into account the aspects of both cities. Expanding this collaboration to other areas of Collier County should be considered wherever feasible. Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Page 24 of 32 elf THE PANEL'S RECOMMENDATIONS 50 THE PANEL'S RECOMMENDATIONS The Panel believes the Board of County Commissioners should investigate the potential economic savings and clinical enhancements associated with coordinating and regionalizing all PEMTT services under a unified public safety concept. In turn, the medical director should report to the designated public safety authority. Because of the multiple layers of organizational structures within the fire departments and EMS in Collier County there is no local county -wide managed authority to address system management complaints or issues. The benefits of better integration are obvious: 1. All pre- hospital care services would be under one management structure. Standardization can be achieved of units, supplies, management and personnel, and potential cost savings with direct and indirect administrative and non - service related personnel in pre- hospital care services and other safety related services. 2. Simplification and standardization of dispatch codes and protocols can be realized. Plus, the elimination of district boundaries and possible improvement of response times can only assist with public service. 3. The PEMTT Council could support the contiguous coordination and, where reasonable, possible integration of County and City of Naples 911 Dispatch Centers, including community AED program. This would help ensure standardization of 911 codes and protocols across Collier County and ensure that all potential fire and EMS first responders covered under a mutual aid services agreement are initially notified by the dispatch center. Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEAITT) System Page 25 of 32 The lack of consistent, centralized, positive management for EMS, fire, hospitals and emergency department physicians also allows for disagreements in process and functional issues to reach outside organizations before any resolution can be obtained. Placing all PEMTT services eventually under a well- managed and highly professional public safety authority could have many positive, service - enhancement results for all Collier citizens. The Panel did not focus on the consolidation of fire services in Collier County. However, the Panel does recommend that Collier County comprehensively study PEMTT organizational collaboration similar to that done by the Civic League Study in Volusia County in June 2010. To that end: The PEMTT should study the cost implications of fire and EMS services throughout the county and potential savings, direct and indirect, of regionalizing such services under one management structure. To start, the PEMTT Council should review recommendations of the 2007 EMS Strategic Report and ensure recommendations have been implemented or justify why they have not. Provided the study supports increased collaboration under a unified PEMTT management (coordinated public safety concept), the Panel suggests the following steps toward developing a regionalized pre - hospital care system: County EMS personnel could be integrated within the Fire Departments. Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Page 26 of 32 50 1. If the aforementioned steps of regionalizing and consolidating services for pre - hospital care demonstrate cost savings and increased cooperation between fire and EMS, the Panel suggests initiation of a pilot program with a fire district for the functional integration of emergency ALS medical services including emergency ALS transportation services. This program will be monitored by the PEMTT Council and fire district representatives to ensure quality, training, cost management, expertise and service. 2. EMS services would be managed by the fire district, including among other things, personnel and equipment. The fire district would integrate existing EMS equipment and staff. The district would report quarterly to the PEMTT Council on specific measurement criteria developed by the designated public safety authority, the medical director and fire district. The Panel recommends that any such reorganization of PEMTT services in Collier County should be part of a five -year strategic plan that takes into account the men and women who have provided excellent service to Collier County in the past, as well as consideration of the referendum ballot in November 2010. The five -year strategic plan should consider reviewing and reasonably implementing the Marco Island paramedic staffing of fire engines and ambulances across Collier County. The use of ALS engines to support the ambulance service with concurrent calls and back up on high priority medical runs will help on -scene as first responders and may reduce call time for medical personnel to ensure that the highest level of medical personnel respond to emergencies. County Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEM7T) System Page 27 of 32 50 safety services could initiate an educational program to improve basic information from citizens calling into 911 such as location and symptoms of victim, as well as an educational program to inform drivers to move out of the path of ambulances, fire and police vehicles. The five -year strategic plan ought to also incorporate provisions for a system audit every three years which would focus on analyses of core business models that could be integrated and regionalized where possible to reduce or avoid costs to taxpayers. This would allow Collier County to develop a more cost- and resource - efficient response to low acuity patients and in the future explore use of contract ambulance or transport services for low acuity or out -of- county transport (similar to Broward and King County models). The Panel suggests the Board of County Commissioners offer to initiate this process with certain fire districts which can and will work with the currently constituted Office of the Medical Director to ensure that there is no degradation in training, expertise and quality within the provision of pre - hospital care to the citizens and visitors within Collier County. A positive step would entail the use of ALS fire engines and the emergency transportation services within these fire districts. The fire districts would develop a management process for position control that would professionally manage the number of paramedics and EMT positions within the district to ensure quality and expertise through field training. The fire districts could also evaluate the possible opportunity for the use of smaller, lighter ambulances, such as Ford F- Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Page 28 of 32 X50 350 and F -450 vehicles to be used in certain transportation situations that do not require ALS services. The fire districts would, of course, agree to follow the recommendations of the newly designated public safety authority, working with the reassigned yet currently constituted Office of the Medical Director and the revamped PEMTT Advisory /Council. A hospital administrator should chair the PEMTT Advisory Council to assure that all proper processes are initiated and completed and that emergency department directors of the NCH Healthcare System, The Lee County Memorial Hospital Trauma Center and the Physicians Regional Healthcare System are all robustly involved. The Panel is biased that the new PEMTT Advisory Council, ably and professionally facilitated by the designated public safety authority, should be chaired by a hospital administrator. The Panel also strongly believes that one medical leader for the county, working with hospital medical emergency department leaders, can provide a higher standard of care for the county with overall superior service. The designated public safety authority, with appropriate guidance and advice from the PEMTT Council and obviously in accordance with law and germane professional standards, should develop procedures to address grievances between fire and EMS on a local basis prior to grievances being sent to the state. Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Page 29 of 32 50 This new model should improve communications, improve fire districts' management of their dispatched equipment and prompt significantly more involvement from Collier County hospitals in training and coordination of all county safety services. The Panel also strongly suggests that all personnel training, quality initiatives and assurance, credentialing and testing be centrally overseen and coordinated through the PEMTT Council, facilitated by the designated public safety authority with the cooperation of the medical director in collaboration with the directors of the emergency departments of Collier County hospitals to ensure standards are maintained at a consistently high level. The Panel recommends that all testing services be contracted to testing professionals at a local college or university which can maintain the integrity and professional demeanor that is expected of safety forces. Members of the Panel appreciate the opportunity afforded to them by the Board of County Commissioners to study the PEMTT System, The Panel stands ready to respond to any future questions. Respectfully submitted, Geoffrey Moebius, Chair Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEAdTT) System Page 30 of 32 50 BIBLIOGRAPHY so Bibliography Carney, C.J. (1999). Pre - Hospital Care — A UK Perspective. British Medical Bulletin (Volume 55, Issue 4, pp. 757 -76). Oxford University Press. City of Houston, Texas Fire Department. Assistant Chief William Barry. Retrieved from: http: / /www.houstontx.gov /fire /. Emergency Services Consulting, Inc. (2007). Collier County Florida, EMS System Master Plan 2007. 4. Cohen, H. (2010, July). Possibilities of Fire and Rescue Services Consolidation in Volusia County. Submitted to Halifax Area Civic League. Goodwin, J. (2010, August). Best Practices in Emergency Services: Integration: The New Frontier? Retrieved from: http: / /www.emerizencybestl2ractices .corn /Currentlssue /tabid /225 /ctl /ArchiveV iew /mi d /573 /month /8 /Year /2010 /Default.aspx. 6. Gueugniaud, P.Y., David, J.S., Chanzy, H., Dubien, P.Y. et. al. (2008, July 3). Vasopressin and Epinephrine vs. Epinephrine Alone in Cardiopulmonary Resuscitation. The New England Journal of Medicine 359, 21 -30. 7. Henry, G. (2010). ACLS: Close the Drug Box. Emergency Physicians Monthly. Retrieved January 20, 2010 from: http : / /www.epmonthly.com /index.php? option= comcontent &task = view &id = 643 &Itemid =91 Herhold, S. (2010, September). Herhold: Why Emergency Medical Costs Spiral out of Control. Mercury News. National Association State EMS Officials. (2008, July). State Emergency Medical Services Systems: A Model, 10. Nielsen T. (2009, November). Exploring Closest Unit Response to Fire and Medical Emergencies in Spokane County. Spokane County Fire Protection District Eight. Spokane, WA. H. Office of Pre - Hospital Care — University Emergency Medical Services, Wyoming - Erie New York, Office of Pre - Hospital Care, Buffalo NY. Retrieved from: http://www.opcems.org/. 12. Olson, L. (2000). San Mateo County Pre - Hospital Advanced Life Support Services. Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Page 31 of 32 50 13. Pratt, F./MD, Pepe P. /MD, Katz S./MD, FACEP, EMT -P, Persse, D. /MD, EMT -P, FACEP. (2007). Pre - Hospital 9 -1 -1 Emergency Medical Response: The Role of the United States Fire Service in Delivery and Coordination. 14. Public Health Seattle and King County. (2009, November). Medic One /Emergency Medical Services, 2008 -2013; Strategic Plan Revised November 2009. Retrieved from: http://www.kingcounty.gov/. 15. Public Health Seattle and King County. (2010, September). Public Health- Seattle & King County Division of Emergency Medical Services 2010 Annual Report. Retrieved from: http: / /www.kingcounty.gov /. 16. Public Health Seattle and King County. (2010, September). Saving Lives: An Innovative and Efficient King County Emergency Medical Services. Retrieved from: http: / /www.kin county .gov /healthservices/health /news /2010/10090301 aspx 17. Sampson, D. (2008, April). Regionalizing Fire Services and Breaking Home Rule. 18, Schaitberger H. Emergency Medical Services, A Guidebookfor Fire -based Systems (4`h Edition). 19, Seattle Fire Department- Emergency Response Totals 2005 -2009. Retrieved from: http: / /www.seattle.gov. 20. Stiell, I.G., Nesbitt, L.P., Pickett, W., Munkley, D., et al. (2008). The OPALS Major Trauma Study: Impact ofAdvanced Life Support on Survival and Morbidity. Canadian Medical Association Journal, 178 (9), 1141 -1150. 21. West, G. (2007, April). Integrating Emergency Medical Services in the Fire Department, Fire /EMS First Responders: It's Just a Matter of Time. 22. Wikipedia. (2008) Seattle Fire Departments 23, Wolcott, M.D., Foelker, T. (2009). Evaluating the Impact: Fire services Provision of Advanced Life Support. A report to Volusia County, Florida. Blue Ribbon Panel Report for Collier County, Florida Board of County Commissioners regarding Prehospital Emergency Medical Treatment & Transport (PEMTT) System Page 32 of 32 50 �► DATA ANALYSIS ,5� EVALUATION OF DATA REGARDING EMERGENCY RESPONSE IN COLLIER COUNTY As Presented to: Collier County, Florida Board of County Commissioners January 11, 2011 Data Compiled and Reviewed By: The Collier County Sheriff's Office Data Review and Approval Completed By: Dr. Lisa Zidek, Associate Professor Academic Program Director U.A. Whitaker School of Engineering Florida Gulf Coast University PRE - HOSPITAL CALLS FOR SERVICE: RESPONSE TIMES AND LOCATIONS As Presented to: Collier County, Florida Board of County Commissioners January 11, 2011 Prepared By: The Collier County Sheriff's Office 3301 Tamiami Trail East, Bldg J Naples, Florida 50 PRE - HOSPITAL CALLS FOR SERVICE: RESPONSE TIMES AND LOCATIONS DECEMBER 2010 Data and Methodology Data were pulled from Computer Aided Dispatch (CAD) for a one -year time period Quly 2009 through June 2010) in order to identify response time to medical - related calls for service. The final sample of data includes calls for service that had a coded response or transport to a hospital, and were identified as highest priority in CAD (1 or 2). This was done to capture the most serious calls; as such, this selection assumes incidents falling into these criteria, requiring travel or response to a hospital at some point during the call, represent serious medical- related calls. Only reactive, citizen - generated calls for service were included in order to more accurately identify response to a can (compared to proactive calls for service recorded in CAD). Finally, to eliminate extreme values and outliers, calls with a response time longer than 30 minutes were removed.' The final number of calls for service selected is 17,604. EMS /Fire calls account for 94 percent. Collier County Sheriff's Office (SO) had 1,038 calls meeting these criteria and Marco Island Police (MPD) had 21 calls. The final number (17,604) of calls includes duplicates due to the structure of the CAD. Each time an agency is dispatched, a unique call is created. Therefore, if EMS /Fire and SO are both dispatched to a call, this will result in two unique calls for service in the CAD data. In addition, it is important to note that based on this methodology, the nature of calls for sheriff's office /police is very different than ENIS /Fire. General descriptions of call types by agency illustrate this point. The majority (92 percent) for Fire /EMS are described, in general, as cardiac or medical calls.' For the SO, the same medical call categories represent only 13 percent of selected calls. For Fire /EMS, vehicle accidents represent 6.2 percent, and crime /disorder - related represent 1.6 percent of calls.' The highest incident type category for the SO is suicidal or mentally -ill person (30 percent); another 23 percent are traffic accidents and 32 percent of calls are crime or disorder - related. Because Fire /ENIS is involved in all medical calls requiring transport to a hospital, these data are included in analysis below. This is done to avoid including duplicate calls, which can produce misleading results. In addition to the duplicate call issue, the numbers for SO, and particularly for NIP, are small for a one -year period, which makes it difficult to determine patterns and trends. Finally, as discussed above, the nature of law enforcement calls selected with these criteria are much different for police agencies than Fire /EMS. I This only removed a very small percentage (0.9) and is necessary due to the structure of CAD data; for instance, on occasion calls do not get closed properly, or are closed at a later time due to system updates or other reasons. When this happens the time field cannot be altered; therefore, the time entered can misrepresent actual response. 2 Medical category includes cardiac call, medical alarm, medical call, and person down. 3 Crime /disorder category includes assault/ battery, criminal mischief, robbery, burglary, trespassing, disturbance, suspicious incidents, etc. EMS /Fire Pre - Hospital Calls For Service — Collier County Sheriff s Office — December 2010 — Page 1 50 Descriptive Statistics - Fire /EMS Calls Call requms;y by weekday - Saturday and Sunday had fewer calls than weekdays. Monday had the highest number of calls during the week, the largest difference in calls by day of week was 278 calls. LWI free uenQ:.� month -January shows the highest frequency by month; however, by daily average the highest frequency is February. Overall, most calls occurred December through March. zom� i r^ 1500 r 1 t a mq .YE J i 1 Y U iffiB 4971 V 11� N, �0' 1, AM W Mt AV % >VN, M AM set tit I& C;. Monthly Trend by Number and Averaize Calls per Day. Tul 2009 - Tun 2010 1700 - 1653 54,8 60.0 Jan 1653 hm 02.i Feb 1529 9.2 54.6 Mar 1612 9.7 52.0 Apr 1329 8.0 44.3 May 1336 8.1 43.1 Jun 1175 7.1 39.2 Jul 1189 7.2 38.4 Aug 1168 7.1 37.7 Sep 1264 7.6 42.1 Oct 1398 8.4 45.1 Nov 1374 8.3 45.8 Dec 1518 9.2 49.0 1200 f 1'i E 1 1 e5:1 t zom� i r^ 1500 r 1 t a mq .YE J i 1 Y U iffiB 4971 V 11� N, �0' 1, AM W Mt AV % >VN, M AM set tit I& C;. Monthly Trend by Number and Averaize Calls per Day. Tul 2009 - Tun 2010 1700 - 1653 54,8 60.0 1600 - 48.0 52.7 .1 & 9 4-518 .. - . � 45. 50.0 43.1 42.1 1600 W9 ;tc� 38.4 37.7 151C 40.0 139£5 1400 1374 30.0 1300 1328 1264 1200 f 1'i E 1 1 e5:1 t 20.0 'I -t lf6 1100 requency- 40-Avg /Day 10,0 1000 Jan Feb Mer Apr Mtay Jun Jul Aug Sep 00t Nov Dec EMS /Fire Pre - Hospital Calls For Service - Collier County Sheriff's Office - December 2010 - Page 2 50.', Call frequency y week - the number of calls ranged from 398 in week 10 (early March) to week 28 (mid July) with 228 calls; this represents a maximum difference of 170 calls by week. However, in order to determine patterns throughout the year, such as call volume by week and month, it is preferable to use more than one year's worth of data points. Call frequency by hour - Call frequency was higher during daytime hours; 71 percent of the calls occurred from 8:00 a.m. to 8:00 p.m. 0 431 2.6 12 969 5.9 1 343 2.1 13 954 5.8 2 386 23 14 946 5.7 3 362 2.2 15 926 5.6 4 307 1.9 16 867 5.2 5 319 1.9 17 848 5.1 6 410 2.5 18 811 4.9 7 566 3.4 19 843 5.1 8 785 4.7 20 709 4.3 9 994 6.0 21 600 3.6 10 1003 6.1 22 5"5 3.5 11 1084 6.6 23 507 3.1 EMS, /Fire Pre - Hospital Calls For Service — Collier Count;- Sheriff's Office — December 2010 — Page 3 511 '1 Call frequency by timc. of_by_and day of week — the below chart shows patterns by day of week and time of day. The darker shades on the grid lines represent higher values. On average, the highest frequency of calls occurred earlier in the week during the midday hours. HMS, 'Fire Pre - Hospital Calls For Service — Collier County Sheriff's Office — December 2010 — Page 4 50 Times Overall response time is defined by -when a call is created to when Wire or ENIS first arrived on scene (create -to- arrival). This can be separated into two time categories: when the call was created to when it was dispatched to an agency (create -to- dispatch) and when a call was dispatched to when an agency arrived on scene (dispatch -to- arrival). For these data, the overall create-to-arrival response time was on average 8.5 minutes. The median response time was 8.2 minutes, indicating that 50 percent of the calls had EMS /Fire on scene in 8.2 minutes or less. The create -to- dispatch time averaged 2.0 minutes, with a median of 1.9 minutes. The dispatch -to- arrival averaged 6.5 minutes, with a median time of 6.1 minutes. FMS/Fire Pre - Hospital Calls For Service — Collier County Sherifps Office — December 2010 — Page 5 50 .1 Average Response Timr b --Tay of —1 There were no differences in average create- to- arri-s-al response time by day of week. N 9.0 .E 8,6 6.6 8 8.5 8.6 b.S i Sun Abn Tue Weekday Set Average Response Times by Month By month, there were small differences in response times (ranging from 8.3 to 8.7 minutes). However, as discussed above, to determine patterns by month, more than one year's data is preferable. EMS /Fire Pre - Hospital Calls For Service — Collier County Sheriffs Office — December 2010 — Page 6 at Average Response Time y'lim� These data show differences in average response time by hour, with shorter response times occurring during the daytime hours. The range from create -to- arrival response time by hour is 8.1 to 10.3, a difference of 2.2 minutes. The dispatch -to- arrival response time showed a similar pattern of shorter response times during the daytime hours; the range was from 6.0 to 8.3 minutes on average. The create -to- dispatch response time did not show a similar pattern (average times ranged from 1.9 to 2.1) by time of day. EMS /Fire Pre - Hospital Calls For Service — Collier County Sheriffs Office — December 2010 — Page 50 2, O v . w c 3E f- d 1 9 Time by Hour 3 4 5 6 7 8 9 14 11 12 13 14 15 16 17 18 19 20 21 22 23 hour Averw Dispatch-to-Arrive Response Time by Hour 10.0 9.5 9.0 8.5 a.z7 Q 8,4 7.e1 791 7 Q .ep 7M 7 a p 7.5 7-66 7.72 7.0 e.oa a.rs 6.88 m 8. e.71 6. 608 Q13 s.OB 8-16 Q19 628 627 &22 6.29 6. app e.ti 5.5 6.0 4. 4. 0 1 2 3 4 6 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 hour EbiSi Fire Pie - Hospital Calls For Service — Collier County Sheriff s Office -- December 2010 — Page 8 so AverAge e and T' of LY The following chart shows the pattern of average create- to-arrival response time by hour and day of week. The darker shades represent higher response times, in this case from around midnight through 7.00 a.m. The average response times of 10 -11 minutes occurred more often from Monday through W ednesday during the early morning hours. Average Response Time for Vehicle Accidents Vehicle accidents represent a small portion of these calls (6.2 percent); however, due to the different nature of these types of calls, response time and location information are included in this report. Vehicle accidents, based on the data selection criteria, were all identified as priority one calls; for other medical calls, 56 percent were priority one and 44 percent were coded as priority two. Response times for vehicle accidents were shorter, on average by almost two minutes, than other medical- related calls. The average response time was 6.7 minutes for vehicle accidents and 8.6 minutes for other medical- related calls. Type of CaU N - Mean 5 10 23 1 30 75 90 95 Vehicle Accident 1,019 6.7 2.6 3.5 4.6 5.8 7.6 20.3 14.4 Other Medical 15,526 8.6 4.5 5.3 6.7 8.3 10.1 12.1 13.4 EMS /Fire Pre - Hospital Calls For Service — Collier County Shetif?s Office — December 2010 — Page 9 5D �� Averag esponse T'mP Y Area CAD data captures areas identified by Fire districts /stations; the following chart shows the average response time for identified areas. North Naples Fire Department (NNFD) accounts for 33 percent of these calls; followed by East Naples Fire Department (ENFD) with 29 percent and Golden Gate Fire Department (GGFD) vii 1i 13 percent. W 1094 BCFD ICFD 2% 0% Big Corkscrew / BCF1 2 °ro GGFD gip Fast Naples / ENFD I `!<q 29% 139, 29% Immokalee / IFD 1242 8% North Naples / NNFD 5411 33% 1 % 1 �� _ Marco Island / MFD 794 5% Ochopee / OFD 133 1 .„o M FD Golden Care / GGFD 2090 13% 5% Isle of Capri / ICFD 82 r'i?v ,f :,Tames NI1+ L 1(,60 IQ°io 8% f�JFD 32% EMS /Fire Pre - Hospital Calls For Service — Collier County Sheriffs Office — December 2010 — Page 10 50, Location of Calls Density Methods Used Nearest Neighbor I lierarchical Clustering (NN) was used to identify groups of incidents that are spatially close. This is a hierarchical clustering routine that groups points together based on certain criteria,' The clustering is repeated until all points are groups or the clustering criteria. fails (based on threshold distance, minimum points per cluster, and standard deviations for ellipses, for instance). The results are ellipses used to identify groups of points spatially close to each other. In addition kernel density spatial analysis was used, which estimates density over a continuous service; this method shows hou density varies and is distributed over space. In this case, areas of high concentration of calls v ill stand out on the density maps. This is useful for visualizing aggregated crime patterns in and across defined boundary areas, and for obtaining a general picture of the overall spatial distribution of calls for service. In both cases, these areas that appear as hot spots represent locations with a greater than average number of calls for service. Limitations Density and hot spot spatial analysis is very useful, particularly to identify places with higher concentration of activity in cases with large numbers such as these calls for service. However, it is also important to outline limitations with these procedures. The NN technique can be somewhat arbitrary due to the minimum points rule. For instance, the user is required to define a meaningful cluster size Although the results are based on empirical groupings, this is not a statistical way for defining regularity (although such patterns are a human way to define patterns and trends)? Two different users may interpret the size of a hot spot differently in addition to other parameter variability. For instance, in one geographical jurisdiction, 40 incidents may be considered high activity, while in another area, this may not be unusual and different parameters would be set to identify a hot spot in this location. As such, output will be different depending on the geographical level, the number of the data involved and the parameters set by the user. Kernel density calculations face similar limitations; the technique is dependent on an arbitrarily- defined interval size. The advantages to spatial analysis can be overcome by running statistical tests when possible, and by using more than one hot spot or density calculation. In this case, in addition to the significance testing, both kernel density and NN spatial analysis techniques were used to add confidence to findings. Overview of Maps included The following pages show maps of EMS zones, Fire districts and station locations. Pin maps and density maps countywide and by geographical areas within the county are included. Many of these maps include layers of kernel density and nearest neighbor ellipses to show locations with higher than average calls. Call frequency and average response times identified within nearest neighbor /high activity groups are provided in addition to specific locations, mostly medical and senior living facilities, which represent a high numbers of calls. A map of vehicle accident locations, identifying locations (intersections) of calls is included. Finally, maps showing calls relative to straight line distances from Fire and EMS stations are included. 4 Discussion of spatial analysis methods used in this report, including advantages and limitations of nearest neighbor and kernel density techniques, are from various National Institute of Justice mapping publications; for instance, an overview of hot spots and techniques can be found in the NIJ report Mapping Crime: Understanding Hot Spots available at www.ojp.usdoj.gov/riij 5 Discussion of limitations on NN and kernel density techniques from the National Institute ofJustice mapping publications, particularly as outlined in NIJ- sponsored CrimeStat publications from Ned Levine & Associates ERISj Fire Pre- Hospital Calls For Service — Collier Count, Sheriff's Office — December 2010 — Page 11 50 'i EMS /Fire Pre - Hospital Calls For Service — Collier County Sheriff's Office — December 2010 — Page 13 This pin map identifies the high-priority, pre -hospital call locations countywide. Locatiohs of fire and a%4S stations are included. Collier County High Priority Hospital GFS Jul 2009 - Jun 2010 FOR 846 E t Legend Cm, Fire stations A EMS locations • FinaENIS CPS &eats R4 It CM 0 O EMS/Fire Pre-Hospital Calls For Service — Collier County Sheriffs Off ZIA Q ,ce —December 2010 — Page 14 50 rt -7 4F dL R4 It CM 0 O EMS/Fire Pre-Hospital Calls For Service — Collier County Sheriffs Off ZIA Q ,ce —December 2010 — Page 14 50 The following map shows density countywide, with the darker shades representing more calls. First - order nearest neighbor clusters, calculated with a minimum of 200 points per cluster, are represented by the blue ellipses on the map. The lighter dots on the map represent locations of calls. EMS /Fire Pre - Hospital Calls For Service — Collier County Sheriff s Office — December 2010 — Page 15 The nearest neighbor first -order ellipses identified 16 groups of spatially close calls countywide that met the minimum criteria of 200 points per cluster. Combined, these ellipses represent 37 percent of the calls. Overall, the average 8.5- minute response time for calls in these locations was the same as the countywide average create - to-arrival response time. ", High FWwly Me*" Von Ta 5er4ce Nw tt Neoba 611pr" JW 2008 - A. 2010 n EMS/Fire Pre - Hospital Calls For Service — Collier County Sheriff s Office — December 2010 — Page 16 1 335 9.4 2 313 10.2 3 419 9.0 4 208 9.1 5 602 9.6 6 453 8.1 7 322 5.9 8 615 8.0 9 508 8.2 10 422 8.7 11 278 7.4 12 404 10.2 13 389 8.1 14 236 9.6 15 201 6.4 16 1 441 1 7 -() ", High FWwly Me*" Von Ta 5er4ce Nw tt Neoba 611pr" JW 2008 - A. 2010 n EMS/Fire Pre - Hospital Calls For Service — Collier County Sheriff s Office — December 2010 — Page 16 i. 50 The following map shows the highest concentration of calls along the coast /western part of Collier County. The nearest neighbor ellipses identify clusters of calls with a minimum of 200 calls; the shaded areas on the density scale represent higher concentration of calls in that particular location. The maps include the point layer to show locations of calls for service across the county. r •'� * High Priority Hospitai Calls for Service Dearest Neighbor and Kemel Dens @y t Jul 2009 - Jun 2010 a EMS /Fire Pre - Hospital Calls For Service — Collier County Sheriff's Office — December 2010 — Page 17 ad • , t� jT ' , t,.t . DEr EALY, RD M .. . a j' -DEN OVE BLVD W • ' ' '•+ �'? t a L PIN RIDOE•RD ., Legend ` �• , FreIEMS CFS '/ NN Apses IA t - meior streets groom t' Subciviaor>s ,� t GolfCourses L LOW High EMS /Fire Pre - Hospital Calls For Service — Collier County Sheriff's Office — December 2010 — Page 17 50 This map identifies locations of places identified as halving a high frequency of calls (the number of calls range from approximately 70 to 200 calls); these tend to be medical - relaxed or senior living facilities. I)aMa Lawreme Center V�. n 1 b Legend CS A S O P. Q MIME RIDGE RD Muafts Park Chateau " w NN ellipses REEK BLVC © Hospital -- nejor streets rJ z yAG Ili DAIS BL�'J 1brracins Carom , 51reeiS Lakeslae PMkon Rellati ' tuvemmat Complex A I)aMa Lawreme Center V�. EMS /Fire Pre- Hospital Calls For Service — Collier County Sheriff's Office — December 2010 — Page 18 �, '� Haeage HeStlh CAB Legend P. RD 0 High Call Freq w NN ellipses n © Hospital -- nejor streets rJ z yAG Ili DAIS BL�'J 1brracins Carom , 51reeiS +_Cm tuvemmat Complex Manua Health SepAre Marimaie at Ley Palms Mien Courts Manorcare at Lay Palma 9 T9 V+Illough at Naples -... High EMS /Fire Pre- Hospital Calls For Service — Collier County Sheriff's Office — December 2010 — Page 18 This map shows call point locations and density of calls in the North Naples area; the number of calls in the identified NN ellipses are labeled on the map. Fire and EMS station locations are included. 0 0" n l • 1• Legend • FkaEMS M: ®NN WPM • . + EMS IOCat0ne Fire 9'" 9 +•• Q Hasp% rrgjur 9beeb 5eeu sutaviswo 30MOWSe9 � Law 1—� t..�� r • y Y .rY .1 •+ � M Y 4Y:Y. fi +w . •y . Y. • Y • t W FINIS/Fire Pre - Hospital Calls For Service — Collier County Sheriff's Office — December 2010 — Page 19 This map shows call point locations and density of calls in the last Naples area; the number of calls in the identified NN ellipses are labeled on the map. Fire and FMS station locations are included. EMS /Fire Pre - Hospital Calls For Service — Collier County Sheriff's Office — December 2010 — Page 20 .x P 'QE RIDGE RD • ` f � • Y • .o • L Y •+ •• • 1VhE =3��• , �.� 47 • Y Yi K • • Y S ti • . rx • FIBEW OR ;� . • �' e . ; K o ti NN Opus s } • 'K � �• ..z ENE bcallWR • 4 � - z "+ , . ;; •' • 3 • • S FIB 5•. WW . • tii '• 1 M HuapKBI • ' , ' - r�wMbaete ' : •` • RAD: 9 RD Y Bloe� �* • NNO615 • ' . OoICOlrsw M UW • • •' , • • T • u Q•. • �• Dp�153L"qp! • • a • • i East Naples Area ' Y • •� High Priority Hospital CF3 • : , ` . Jul 2009 - Jun 2010 Y EMS /Fire Pre - Hospital Calls For Service — Collier County Sheriff's Office — December 2010 — Page 20 50 This map shows call point locations and density of calls in the East Naples /Golden Gate City area; the number of calls in the identified NN ellipses are labeled on the map. Fire and EMS station locations are included. EMS,Tire Pre- Hospital Calls For Service — Collier County Sheriff's Office — December 2010 — Page 21 ' ' �• ••% 1 •• , ' • ti r• • .•• .. NN=236 p r •4 ', • ,• , • ♦ •. GOLDEN�3 'vim •. %�., �_� /��j��• • • G z • RADIO RD • • .�- - "--- -'—^•� ;tl ' ,' t •,•� •• .. A t •t •• +•' .. NiV ' '' • 389 •' East Naples ! G ,City Area �.� ., 1 ,• - • • r , High Pnonty H CFS 1 • (� '1 IWI. Jul 2009 - JL x•2010 • • Lownd ± "• •• •r •• Z • ' ti ROEMS CFS NR emipm •� ` 1 • •.,. 4, • •Y .. , EMS lucsbm • . • • •, r •' •t •. • • 17N*404 • d 0 H03ptW • •,• f • � r — major *eta r • • .• r ' �'eeb . _ i a _ q: a . svr� +�Iy .! w 9V>wWfslam ��.�� LOW fiN=2 8 High Y • M EMS,Tire Pre- Hospital Calls For Service — Collier County Sheriff's Office — December 2010 — Page 21 This map shows call point locations and density of calls in the Inunokalee area; the number of calls in the identified NN ellipses are labeled on the map. Fire and EMS station locations are included. Legerld • FreEW CPS 1.D w dlpm 0 FIB A8UM6 M -- mijor 5"M EMS /Fire Pre - Hospital Calls For Service — Collier County Sheriff's Office — December 2010 — Page 22 50 This map shows call point locations and density of calls in Marco Island, Fire and EMS station locations are included. L z� U ' Woo Island ` Igh Pnonty Hospital CFS Jul 2009 - Jun 2010 Legend • FlreEMS CFS EMS locations Cry Fhe stBM M Haspbd — mgorstreeq atree� Slbdv(sims GdICOt76B0 Density of marco 0xxv am 6. —.J 4' �y ti. % SAN Mna „ • e. y n 19 ' EWFire Pre - Hospital Calls For Service — Collier County Sheriff's Office — December 2010 — Page 23 This map shows call locations, including density and NN clusters (a minirnum of 25 calls in each group), of vehicle accident locations. Countywide, there were 1,019 vehicle accident calls meeting the data selection criteria and accounts for 6.2 percent of the total calls used in this report. L *"n< i� NN a nw M M' H9 EMS /Fire Pre- Hospital Calls For Service — Collier County Sheriffs Office — December 2010 — Page 24 50 Calls v-*hin one mile of Fire and EIN1S station locations• There were 6,349 calls located within one mile of an EbIS station and 8,145 calls located xthin one mile of a fire station. Combined, this number represents 9,269 calls located within one mile of either a fire or EMS station; this accounts for 56 percent of the total calls. The average create-to-arrival response time for calls within one mile of Fire and /or EMS stations was 7.8 minutes, with a median response time of 7.4 minutes. The average create -to- dispatch time was 2.0 minutes and the average dispatch-to-arrival response time was 5.8 minutes. Calls more than one mile from Fire and EMS station locations: "There were 7,276 calls located outside of a one -mile radius from an EMS or Fire station. The average create -to- arrival response time for these calls was 9.4 minutes. The average create -to- dispatch response time was 2.0 minutes and the average dispatch -to- arrival response time was on average 7.4 minutes. EMS /Fire Pre- Hospital Calls For Service — Collier County Sheriff s Office — December 2010 — Page 25 5D This map shows the straight line distance from EMS stations to the CFS activity; each concentric circle represents one mile out from the EMS station. EMS zone boundaries, call location points and density layers are included on the map. EMS!Fire Pre - Hospital Calb For Service — Collier County Sheriffs Office — December 2010 — Page 26 50 This map shows the straight line distance from Fire stations to the CFS activity; each concentric circle represents one mile out from the Fire stations. Fire district boundaries, call location points and density la,vers are included on the map. EMS /Fire Pre- Hospital Calls For Service —Collier County Sheriff's Office — December 2010— Page 27 v� U so H cn Q n J ce Q W V F Z H ce m W J 0. `00 V m CL 0 s .�C L 0 3 U a L R fl. H C1 d d7 (. 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