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Minutes 09/25/2009 R September 25,2009 MINUTES OF THE MEETING OF THE COLLIER COUNTY EMERGENCY MEDICAL SERVICES POLICY ADVISORY BOARD Naples, Florida, September 25,2009 LET IT BE REMEMBERED that the Collier County Emergency Medical Services Policy Advisory Board, having conducted business herein, met on this date at 4:00 PM in REGULAR SESSION at the Administrative Building "F," 3rd floor, Collier County Government Complex, Naples, Florida, with the following Members present: CHAIRMAN: Vice Chair: James Talano, M.D. Chief Robert Metzger Chief Walter Kopka Linda Mitchell Steve Shafor ALSO PRESENT: Jeffery A. Klatzkow, County Attorney Dr. Robert Tober, Collier County Medical Director Wayne Watson, Deputy Chief, Bureau of Emergency Services Michael Sheffield, Assistant to County Manager COLLIER COUNTY EMERGENCY MEDICAL SERVICES POLICY ADVISORY BOARD AGENDA MEETING TO BE HELD: COLLIER COUNTY BCC BOARD ROOM W. Harmon Turner Building, Bldg. F Collier County Government Center, 3rd Floor Naples, FL 34112 DATE: SEPTEMBER 25, 2009 TIME: 4:00 P.M. - 5:00 P.M. Call to Order Pledge of Allegiance Establish Quorum Agenda Additions/Deletions Adoption of Agenda Minutes from Previous Meeting Addition s/Oeletions/Corrections Adoption of Minutes April 17th Minutes May 22nd Minutes Old Business Adoption of Bylaws Election of Chairman & Vice-Chairman Review Term Expirations New Business a) Improvements of Rapid Sequence Intubation within the flight program b) Review of Dr. Gordon Ewy 's Circulation Editorial for May 2009 re: CPR c) Passive Oxygen Insufflation d) Review of the importance of proper documentation and state requirements for data reporting e) Review of OPALS StudylNew England Journal of Medicine Public Comment Board Member Discussion Establish Next Meeting Date Suggest Friday January 22nd. Adjournment September 25,2009 CALL TO ORDER PLEDGE OF ALLEGIANCE ESTABLISH QUORUM The Meeting was called to order at 4:01 PM by Commissioner Donna Fiala and a quorum was established. The Pledge of Allegiance was recited. AGENDA Additional/Deletions Adoption of Agenda Chief Robert Metzger proposed: . To add a review of Ordinance #2009-01 . To hear Item E under "New Business," Review of OPALS Study, as the first item in that category Linda Mitchell moved to adopt the Agenda as amended. Second by Steve Shafor. Carried unanimously, 4-0. ADDED TOPIC: Review of Ordinance #2009-01 Chief Metzger called the Committee's attention to the second WHEREAS clause of the Ordinance: ".. the purpose of this Advisory Board is to review and advise the Board of County Commissions on all issues concerning emergency medical services within Collier County. . ." He also referred to Item #2 under Section Two: Functions, Powers and Duties of the Advisory Board: "To hear all disputes arising out of the ALS Engine lnterlocal Agreements between Collier County and the various Fire Districts, and make written recommendation to the Board of County Commissioners for resolution of such disputes." and to Item #4: "To review and make written recommendation to the Board of County Commissioners of all changes to established protocol and practices recommended by the Medical Director's Quality Assurance Committee." Commissioner Fiala explained if a member of the public wanted to discuss an item on the Agenda, a Speaker Slip must be completed and presented to the County Attorney. Speakers will be allowed three minutes. 2 September 25,2009 MINUTES FROM PREVIOUS MEETING AdditionslDeletions/Corrections Adoption of Minutes April 1 ih Minutes May 22nd Minutes Linda Mitchell moved to approve the Minutes as submitted. Second by Chief Metzger. Chief Metzger stated the Minutes of the former Emergency Medical Services Advisory Committee ("EM SAC") had been very detailed. He expressed his dissatisfaction with the two sets of Minutes previously presented as "extraordinarily brief." Chief Walter Kopka reminded the Members the meetings are recorded, videotaped, and available for individual review and/or verbatim transcription. He stated summary Minutes were sufficient. (Dr. James Talano arrived at 4: 11 PM.) Chief Metzger's concern was that the Board of County Commissioners would not be able to understand the significance of an issue discussed during a meeting if the Minutes were not detailed. Commissioner Fiala mentioned a Committee Member could email the Commissioners, if necessary, to review the recording for a specific issue. Chief Kopka stated Roberts Rules of Order permits Meeting Minutes to be amended at the next meeting prior to voting on approval of the content. Motion carried unanimously, 5-0. OLD BUSINESS Adoption of Bylaws There was consensus for the Chairman and Vice-Chairman to continue to hold office through 2010. Chief Metzger referred to Article IV: Officers and objected to the inclusion of the phrase, 'from the membership recommended by the Collier County Medical Society, " which he stated restricted the positions of Chairman and Vice Chairman to only three of the five Board members. Chief Metzger moved to strike the phrase, "from the membership recommended by the Collier County Medical Society," from the first sentence of 'Article IV: Officers' of the Bylaws for the Emergency Medical Services Policy Advisory Board. Discussion ensued concerning the intent and interpretation of the phrase. County Attorney K1atzkow stated Board members elect their own Officers from their membership rather than accept a recommendation from an outside entity. Second by Linda Mitchell. Motion carried, 3-"Yes"/2-"No." Opposed by Dr. James Talano and Chief Walter Kopka. 3 September 25,2009 Election of Chairman & Vice-Chairman Chief Metzger nominated Steve Shafor to serve as Chairman. Mr. Shafor declined. Chief Walter Kopka nominated Dr. James Talano to serve as Chairman. The nomination was accepted. Second by Steve Shafor. As there were no other nominations from thefloor, the motion carried, 4-"Yes"/I- "Abstention." Dr. Talano abstained. Steve Shafor nominated Chief Robert Metzger to serve as Vice-Chairman. The nomination was accepted. Second by Chairman Talano. As there were no other nominations from thefloor, the motion carried, 4-"Yes"/I- "Absention." Chief Metzger abstained. Review of Term Expirations Commissioner Fiala noted two members will serve for two years and the remaining members will serve for four years. It was suggested the members volunteer for specific terms. . Steve Shafor and Linda Mitchell volunteered to accept the two-year terms. . Dr. Talano, Chief Metzger and Chief Kopka will serve for four years. County Attorney K1atzkow stated the Board of County Commissioners assigned the terms of office when the members were appointed. He will review the Board's Resolution. He confirmed terms will begin with their first meeting. Chairman Talano stated since the officers were elected at this meeting, it will be considered their "first" meeting. Chief Kopka nominated Linda Mitchell and Steve Shafor to serve two-year terms with the remaining members serving four-year terms. Second by Vice-Chairman Metzger. Carried unanimously, 5-0. NEW BUSINESS e) Review of OPALS Study/New England Journal of Medicine Dr. Robert Tober, Collier County Medical Director, gave a slide presentation and outlined the following: . The Study encompassed seventeen cities . Study Subject: the impact of various modalities at interceptions of cardiac arrest patients o The provision of rapid Basic Life Support ("BLS") is the primary determining factor in the outcome of cardiac arrest patients' survival . Study Results cited: "... There was no improvement in the rate of survival with the use of Advanced Life Support ("ALS") in any subgroup. " Dr. Tober concurred with the Study's results as it mirrored the same experience noted in Collier County statistics for cardiac arrest/sudden deaths. 4 September 25,2009 . Are-orientation of the County's Cardiac Arrest Protocols was initiated in 2004 for all providers to give essentially Compression-only CPR. . The use of Compression CPR encouraged the public to also apply the same CPR in an emergency while avoiding mouth-to-mouth contact. He cited MedScape 's published findings, "The largest determinate of survival to hospital discharge was how early and how continuous the cardiac compressions were ... " Dr. Tober stated the revised Protocol has been in use for the past five years and is one of the reasons why Collier County has had an impact on the survival rate of cardiac arrest patients. Chairman Talano asked if the Study results will change how cardiac patients are approached. Dr. Tober stated the County's response rate to all types of emergency calls is approximately 8 to 9 minutes. He is developing a recommendation for better utilization of all emergency personnel within Collier County to bring the BLS response time to a goal of four minutes. Questions: . What is the percentage of patients already undergoing BLS when the County's emergency personnel arrive? Dr. Tober estimated approximately 10 to 20 percent. A video was produced and aired on the County's cable channel encouraging the general public to only perform Compression CPR. He further stated the County's system, including flight medics, is oriented to faster response times. . What was the number of Certified Paramedics employed by the County three months ago versus the number presently employed? Dr. Tober stated there are approximately 45 less ALS-engine Certified Paramedics. He noted the OPALS study results were not dependent on the number of Certified Paramedics but on whomever first provided BLS, i.e., a member of the public, a police officer, a fireman, or an EMT. . The OPALS study was conducted in 2004 within Canada. Was Canada operating in 2004 under different standards of CPR and BLS than are used presently? Dr. Tober stated most of the country still operates under the standards utilized during the OPALS Study, i.e., standard American Heart Association CPR. He stated most of the cardiac arrest survivals in Collier County were due to BLS intervention within the first five minutes. He further stated there is agreement [within the medical community] that the new approaches to cardiac arrest are more successful and more effective than the methods used in 2004 and are a BLS function. 5 September 25,2009 . The OPALS Study also concluded, in cardiac arrest, the typical ALS field procedures are not making a difference in out-of-hospital patient survival rates. Has the impact of improved BLS been studied in conjunction with ALS procedures? Dr. Tober stated Collier County has been tracking data for approximately 10 to 12 years and the majority of the "saves" resulted from BLS. He further stated ALS is not being changed or withdrawn from the field. . When did the American Heart Association begin to teach "Chest Compression-only CPR" to the public? Dr. Tober stated the AHA has not completely moved to Compression-only CPR, but has a "permissive attitude" allowing Compression-only CPR if a provider (public) was opposed to giving mouth-to-mouth CPR. Dr. Tober discussed the concept of "gasping" which many patients have exhibited during cardiac arrest (usually referred to "pre-death respiration"). He stated a recent study conducted in Arizona which cited "gasping" as evidence of central nervous system brain life. Discussion ensued regarding survival rate data and factors such as seasonal influx along with data collection/tabulation Dr. Tober noted the difficulty of finding a patient who meets the criteria: (1) witnessed cardiac arrest; (2) application of good CPR, and (3) good gasping. He stated an advantage of the Compression-only CPR is that it is much easier to teach the procedures than the American Heart Association standard CPR. Public Speaker: James Cunningham, Operations Assistant Chief, North Naples Fire Control and Rescue District, agreed with Dr. Tober that BLS is extremely important and ifBLS is not begun prior to ALS, the outcome for the patient may not be positive. He asked Dr. Tober if statistics were available for the percentage cardiac arrest calls. The answer was one percent of the total call volume. In follow-up to another question, he noted there have been documented cases where ALS engines arrived on scene and performed ALS procedures prior to EMS arrival where patients survived due to the actions taken in the field. Dr. Tober outlined changes made in Rapid Sequence Intubation System, including the cuff used by Flight Medics. The new cuff helps to reduce the incidence of ventilator-acquired pneumonia. The difference is not in size, but in the design of the cuff. He mentioned the "Glidescope video intubation device," a new intubation device, will be tested. A loaner has been requested for use in the helicopter, and described the difficulty of intubation in the restricted confines of a helicopter. He stated the goal is to reduce the on-scene time to 10 minutes before flight to a trauma center. He also stated the County must comply with both State and Federal standards regarding acquisition of data for analysis. The software currently used by Collier County is no longer available and he is searching for a program that is EMStar compliant. He noted mobile computers are yet available on all ambulances to provide real time reports. Voice activated systems are not reliable enough to be used in the field. 6 September 25,2009 Commissioner Fiala asked if the Members had been briefed on the restrictions of the Sunshine Law. Attorney K1atzkow verified a presentation of the Sunshine Law and restrictions had been presented to the Members. Commissioner Fiala stated the Board of County Commissioners had voted on term limits for Committee members which were opposite of the members' preferences. Chief Kopka moved to approve sending a recommendation to the Board of County Commissioners concerning the agreed-upon term limits for the EMS Policy Advisory Board members. Second by Vice-Chairman Metzger. Carried unanimously, 5-0. Commissioner Fiala noted the next meeting for the Advisory Board is scheduled for January 2010. She suggested the members consider adjusting the schedule to allow for more meetings. Vice-Chairman Metzger moved to adjust the meeting schedule to hold Advisory Board meetings every two months. Second by Chief Kopka. Carried unanimously, 5-0. ** Chairman Talano announced the next Board meeting will be held in November. Attorney K1atzkow stated Staff will consult the schedule to ascertain when the BCC Chambers will be available and the members will be notified. ***** There being no further business for the good of the County, the Meeting concluded by order of the Chair at 5:15 PM. COLLIER COUNTY EMERGENCY MEDICAL SERVICES POLICY ADVISORY BOARD James Talano, M.D., Chairman The Minutes were approved by the Board/Committee Chair on as presented or as amended 7