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EMS Policy Minutes 01/15/2010 R January 15, 2010 MINUTES OF THE MEETING OF THE COLLIER COUNTY EMERGENCY MEDICAL SERVICES POLICY ADVISORY BOARD Naples, Florida, January 15,2010 LET IT BE REMEMBERED that the Collier County Emergency Medical Services Policy Advisory Board, having conducted business herein, met on this date at 3:30 PM in REGULAR SESSION at the Neighborhood Health Clinic, 12 Goodlette Road N., Naples, Florida, with the following Members present: CHAIRMAN: Vice Chair: James Talano, M.D. (Excused) Chief Robert Metzger Chief Walter Kopka Linda Mitchell, RN Steve Shafor (Excused) ALSO PRESENT: Dr. Robert Tober, Collier County Medical Director Jeff Page, Chief, Bureau of Emergency Services Jennifer Florin, Administrative Assistant, EMS Dan Bowman, Deputy Chief, Bureau of Emergency Services COLLIER COUNTY EMERGENCY MEDICAL SERVICES POLICY ADVISORY BOARD AGENDA MEETING TO BE HELD: Neighborhood Health Clinic 120 Goodlette Road North, 2nd floor meeting room Naples, Florida DATE: January 15, 2010 TIME: 3:30 P.M. Call to Order Pledge of Allegiance Establish Quorum Agenda Additions/Deletions Adoption of Agenda Minutes from Previous Meeting AdditionslDeletions/Corrections Adoption of Minutes November 20th Minutes Old Business Adoption of Bylaws New Business a) JEMS Back to Basics BLS care article b) JEMS Toronto ALSIBLS model c) JAMA IV Meds vs No IV Meds OOHCA d) SALT device and intubation Public Comment Board Member Discussion Establish Next Meeting Date Adjournment January 15, 2010 Call to Order Pledge of Allegiance Establish Quorum The Meeting was called to order at 3:35 P.M. by Vice Chairman Robert Metzger and a quorum was established. The Pledge of Allegiance was recited. Commissioner Fred Coyle attended. Agenda Additional/Deletions Adoption of Agenda Linda Mitchell moved to adopt the Agenda as submitted. Second by Walter Kopka. Carried unanimously, 3-0. Minutes from Previous Meeting Additions/De leti ons/ Corrections Adoption of Minutes November 20, 2009 Walter Kopka moved to approve the Minutes from the November 20, 2009 Meeting as submitted. Second by Linda Mitchell. Carried unanimously, 3-0. Old Business Adoption of Bylaws Jennifer Florin, Administrative Assistant - Bureau of Emergency Services, confirmed the Advisory Board members had not submitted any changes to the Bylaws since the last meeting. Walter Kopka moved to approve the Bylaws as submitted. Second by Linda Mitchell. Carried unanimously, 3-0. New Business a) JEMS - "Back to the Basics - The Lost Art of BLS Care" (article), December, 2009 Dr. Tober gave a PowerPoint presentation and outlined the points contained in the article: the previous standard for emergency medical personnel was Basic Life Support training with Advanced Life Support-trained personnel as the exception. He stated there was a tendency to move too quickly to ALS-intervention before BLS procedures are completed, and his goal was to shift the focus back to a strong foundation ofBLS training and to improve response time to approximately four minutes. His concern is the deterioration of ALS skills due to the increasing number of paramedics because some paramedics do not receives an opportunity to practice skills on a frequent basis, while BLS skills should be practiccd on a regular basis since BLS response should be the first on scene. 2 January 15, 2010 Linda Mitchell asked if a paramedic and an EMT were both on a scene, would both administer ALS instead ofBLS care. Dr. Tober replied when there is ajoint team working, the efforts have been coordinated. He referenced the East and North Naples Fire Districts which hired a large number of paramedics who have jumped to ALS skills without a coordinated BLS intervention. He cited from the JEMS article: "As more and more fire departments realize that their futures are staked on the ability to position themselves as frontline EMS providers, paramedic 'saturation' is likely to continue. It's therefore incumbent on those in the field to acknowledge the problems that can result from absent or inadequate BLS care and incorporate into their paradigm and on-scene procedures a strong commitment to appreciating and implementing the principles under- lying the admonition, 'BLS comes before ALS. " He stated a greater effort is needed to teach the community how to administer CPR until EMS arrives and suggested to resume broadcasting the five-minute instruction tape on the County's cable channel. Vice Chairman Metzger welcomed Commissioner Coyle to the Advisory Board. He also asked if other studies, in addition to the OPAL Study, were available that compared similar populations in systems that ran BLS versus ALS, based solely on cardiac runs. Dr. Tober stated the first five minutes to ten minutes of an emergency medical situation impacts patient livelihood and almost any patient can be stabilized by enhanced CPR. He further stated he was not aware of any article specifically suggesting that a "saturation" of paramedics has positively affected the health and wellbeing of a community. Vice Chairman Metzger asked what was done, after reviewing the run reports from North Naples and East Naples, to identify and correct the situation with the Fire Districts. Dr. Tober stated the deviations from established protocol were reviewed with the Departments' training officers. Vice Chairman Metzger asked if the medical response data compiled by Collier County had been kept in the same format for the past ten years Chief Jeff Page stated the format was revised, as requested by the Fire Chiefs, and is more inclusive. Vice Chairman Metzger asked if data was collected for "Signal 7 Declarations" and further asked Staff to supply the data for cardiac arrest runs that were worked and not worked in order to understand how the runs have evolved over time and how to attribute the improvements. Chief Page will provide the data at the next Advisory Board meeting. b) JEMS - "Toronto Tests New ALS/BLS Model" - August, 2009 The author stated, "... many others accepted the all-ALS theory that was based on ~voa never know what could go wrong' on a call. Research now shows that we don't need ALS on all calls. In fact. only about 5% of calls need ALS. " 3 January 15, 2010 Dr. Tober stated similar data was reviewed to evaluate Collier County's protocols. He noted low blood sugar can kill quickly and is considered to be a life-threatening issue. The use of glucometers in Collier's system is considered to be a BLS skill. He suggested an EKG hook-up and LV. initiation, when prophylactic, could also be a BLS skill. Vice Chairman Metzger questioned whether taking an ALS unit out of service for a BLS transport was the best use of the resource. He asked if the focus was to expand the BLS footprint, should better ways to utilize ALS transport for serious incidents be explored, and find alternative methods for BLS transport. Dr. Tober stated he was not aware that ALS response was suffering. The focus is to shrink BLS response times. Discussion ensued concerning other options such as: . Utilizing private providers for non-emergency transports . Subsequent loss ofrevenue . The need to keep the system as cost effective as possible . How to maximize resources. Also discussed: . comparing data to agree on a definition of what constitutes an ALS call . current revenue stream - 50% is call-generated and 50% from Ad Valorem taxes . Operation "Zone Coverage" c) JAMA: "I.V. Meds VS. No LV. Meds" - OOHCA, November, 2009 Dr. Tober outlined the article: Context: Intravenous access and drug administration are included in Advanced Cardiac Life Support (ACLS) guidelines despite a lack of evidence to improve outcomes. Objective: To determine whether removing intravenous drug administration from an ACLS protocol would improve survival to hospital discharge after out-of-hospital cardiac arrest. Main Outcome Measures: The primary outcome was survival to hospital discharge. Conclusion: Compared with patients who received ACLS without intravenous drug administration following out-of-hospital cardiac arrest, patients with intravenous access and drug administration had higher rates of short-term survival with no statistically significant improvement in survival to hospital discharge, quality of CPR, or long-term survival. Dr. Tober stated most of the individuals sent home from hospital in Collier County received CPR and treatment within four to five minutes from onset of the emergency call. d) S.A.L.T. Device and Intubation Dr. Tober explained how the device is used, that it was developed by the Army Corps of Engineers and had 99% success rate when used in Afghanistan. He stated it was not necessary to stop CPR in order to intubate using the device, and allows for blind insertion, unlike a laryngoscope. 4 January 15, 2010 Copies of articles from Emergency Physicians Monthly, dated January 12, 2010, and The Washington Post, dated December 4, 2008, were distributed to the members for review. Public Comment None Board Member Discussion . Vice Chairman Metzger questioned whether the Advisory Board was tasked to examine any outstanding system issues related to QI A ("Quality Assurance") or concerns raised by the public in its capacity to interact with Collier EMS. There was a discussion concerning the charge from the Board of County Commissioners outlined in the Ordinance which created the Advisory Board. Reference: Section Two, "Functions, Powers and Duties," Ordinance #2009-01, states: "The Advisory Board shall have the following duties: 1. To review and advise the Board of County Commissioners of all issues concerning pre-hospital emergency medical services within Collier County. 2. To hear all disputes arising out of the ALS Engine Interlocal Agreements between Collier County and the various Fire Districts, and make written recommendations to the Board of County Commissioners jor resolution of such disputes. 3. To work to improve and enhance pre-hospital emergency medical care within Collier County. 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. 5. To make its special knowledge and expertise available to the Board of County Commissioners upon written request by the Board of County Commissioners. " Commissioner Coyle stated the intent of the Board of County Commissioners was for the Advisory Board to serve as a coordinating committee and sounding board for any changes to protocol, organizational responsibilities, or anything else concerning the administration of emergency medical services within Collier County. It is the responsibility of the Board of County Commissioners to make final decisions concerning the issues examined by the Advisory Board and its recommendations to the BCC. He stated the BCC is interested in the goal of improving response times and welcome a clear definition of the steps to be taken to achieve the goal. New technology, such as S.A.L.T., is also of interest to the BCC as well as a definition of BLS skills. The Advisory Board is to make recommendations regarding the course of action to be taken by the Board of County Commissioners. Chief Kopka stated the articles presented should help to lead the Advisory Board in a direction, such as an emphasis on improving initial BLS training. 5 January 15,2010 Dr. Tober stated EMS is developing a more aggressive first aid training program for the Collier County Sheriffs Office and teach basic CPR to bus drivers and employees of the County's Department of Parks and Recreation. He stated another issue is to examine how the Fire Departments can help distribute its vehicles for faster BLS response times. . Linda Mitchell asked if the members were aware of any articles concerning the hand-off of care in hospitals. Next Meeting Date April 23, 2010 from 3:30 to 5:00 PM at the Neighborhood Health Clinic located at 12 Goodlette Road N., Naples, Florida. ***** There being no further business for the good of the County, the Meeting concluded by order of the Vice Chair at 4:45 PM. COLLIER COUNTY EMERGENCY MEDICAL SERVICES POLICY ADVISORY BOARD Robert Metzger, Vice Chairman The Minutes were approved by the Board/Committee Chair on as presented , or as amended 6