EMS Policy Minutes 01/21/2011January 21, 2011
MINUTES OF THE MEETING OF THE COLLIER COUNTY
EMERGENCY MEDICAL SERVICES
POLICY ADVISORY BOARD
Naples, Florida, January 21, 2011
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: James Talano, M.D.
Vice Chair: Chief Walter Kopka
Rosemary LeBailly, RN
Chief Robert Metzger
Jerry Pinto
ALSO PRESENT:
Commissioner Georgia Hiller, District 2
Dr. Robert Tober, Collier County Medical Director
Jennifer Florin, EMS Administrative Assistant,
Jeff Page, Chief, Bureau of Emergency Services, Staff Liaison
Wayne Watson, Deputy Chief, Bureau of Emergency Services
Dan Bowman, Deputy Chief, Bureau of Emergency Services
Jorge Aguilera, Deputy Chief Medical Services /Community Relations
COLLIER COUNTY EMERGENCY MEDICAL SERVICES
POLICY ADVISORY BOARD
AGENDA
MEETING TO BE HELD:
NEIGHBORHOOD HEALTH CLINIC
121 Goodlette Road N.
Naples, FL 34102
Second Floor Education Room
DATE:
January 21, 2011
TIME:
3:30 p.m.
1. CALL TO ORDER AND PLEDGE OF ALLEGIANCE
2. AGENDA AND MINUTES
A. Approval of Today's Agenda
B. Approval of Minutes from the September 17, 2010 Policy Advisory Board Meeting
3. OLD BUSINESS
A. Review of Blue Ribbon Committee Report
4. NEW BUSINESS
A. Election of a Chairman and Vice Chairman
B. Establishment of a schedule for 2011 meetings
5. STAFF REPORTS
A. Review of COPCN application from North Naples Fire
B. Review of COPCN renewal from NCH
6. PUBLIC COMMENT
7. BOARD MEMBER DISCUSSION
8. ESTABLISH NEXT MEETING DATE
9. ADJOURNMENT
January 21, 2011
1. Call to Order and Pledge of Allegiance:
Vice Chairman Metzger called the meeting to order at 3:35 P.M. and a quorum was
established.
The Pledge of Allegiance was recited.
Commissioner Fred Coyle was present earlier but left to avoid a violation of the Sunshine
Laws due to the presence of Commissioner Georgia Hiller.
2. Agenda and Minutes:
A. Approval of Today's Agenda
Chief Walter Kopka moved to approve the agenda as submitted. Second by Jerry Pinto.
Carried unanimously, 4 — 0.
B. Approval of Minutes from September 17, 2010 Meeting:
Changes:
• On Page 4, last paragraph, substitute EMD Supervisors ( "Emergency Medical
Dispatch ") for "Fire District Chiefs" in the first sentence.
Chief Walter Kopka moved to approve the minutes as amender. Second by Jerry Pinto.
Carried unanimously, 3 — 0. Note: Vice Chairman Metzger did not vote since he was
not present at the September meeting.
3. Old Business:
A. Review of Blue Ribbon Committee Report
Vice Chairman Metzger stated staff added the topic to the agenda and asked if there
was a specific item to be reviewed.
(Dr. Talano arrived at 3:40 P.M.)
Chairman Talano thanked the Blue Ribbon Committee for their efforts to study the
existing problems and for visiting other areas around the country to establish a basis of
comparison.
Vice Chairman Metzger concurred that committee presented a "solid report."
It was noted two members of the advisory board did not have an opportunity to review
the document and the topic will be added to the next agenda for action.
4. New Business:
A. Election of Chairman and Vice Chairman for the 2011 Term
Chief Walter Kopka nominated Dr. James Talano to serve as Chairman. Second by
Vice Chairman Metzger.
There were no other nominations from the floor. The Motion carried,
4- "Yes " /1- "Abstention. "Dr. Talano abstained.
Vice Chairman Metzger nominated Chief Walter Kopka to serve as Vice- Chairman.
Second by Chairman Talano.
There were no other nominations from the floor. The Motion carried,
January 21, 2011
4- "Yes "W- "Abstention." ChiefKopka abstained.
B. Establish Schedule for 2011 Meeting
The Advisory Board Members adopted the following schedule:
• March 25, 2011
• June 10, 2011
• August 19, 2011
• October 7, 2011
• November — to be determined
The meetings will be held at the Neighborhood Health Clinic, 121 Goodlette Road North,
commencing at 3:30 PM, unless otherwise notified.
It was noted the terms for Rosemary LeBailly, RN, and .Terry Pinto will expire in
September, 2011.
Chief Robert Metzger moved to accept the meeting schedule as above - referenced
Second by Vice - Chairman Kopka. Carried unanimously, 5 — 0.
5. Staff Reports:
A. Review of COPCN ( "Certificate of Public Convenience and Necessity ") Application
from North Naples Fire District
Chief Jeff Page stated the application had been provided to the Board and Naples
Community Hospital was also submitting an application for renewal.
He explained the 2007 advisory board established the policy for COPCN applications to
be reviewed by subsequent Boards. He noted the NCH application consisted of two
letters, dated November 15, 2010 and January 7, 2011, addressed to Dan Summers,
Director — Bureau of Emergency Services.
(Copies of the documents were provided to the Board.)
Deputy Chief Jorge Aguilera, Medical Services — North Naples, stated he would
answer any questions from the Board.
Chairman Talano inquired about any changes from the September 2009 application.
Deputy Chief Aguilera stated there were no changes. The application was heard by the
Board of County Commissioners in October 2010, but failed to be approved. It was
placed back on the agenda by unanimous consent of the BCC for reconsideration. The
BCC will meet on Tuesday, January 25, 2011 to reconsider the application.
Chairman Talano questioned reviewing the application since the recommendations of
the Blue Ribbon Committee had not been incorporated into the application.
Chief Robert Metzger asked if the application had been reviewed by the previous EMS
Policy Advisory Board.
Deputy Chief Aguilera stated it had not.
Chief Metzger questioned why the Policy Advisory Board was being asked to review the
application when the Board had not reviewed it upon initial presentation.
January 21, 2011
Vice Chairman Kopka referenced the policy outlined in Ordinance 2009 -01 which
stated the Policy Advisory Board is to review any pre - hospital emergency medical care.
The Ordinance states:
"The Advisory Board is created to assist the Board of County
Commissioners with all issues affecting pre- hospital emergency
medical services within all of Collier County. "
Section Two of the Ordinance, entitled "Functions, Powers and Duties," 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. "
He stated reviewing the COPCN by the Advisory Board falls under the directive since the
goal of the application is to change the current EMS policy in North Naples.
Chief Page pointed out the last meeting of the Advisory Board was held in September
2010 and the application was submitted in October.
Chairman Talano reiterated the Blue Ribbon Committee's recommendation has not
been reviewed by the Advisory Board or incorporated into the COPCN Application. He
stated the Advisory Board should review the report before considering the application.
Vice Chairman Kopka stated he was not sure if fragmenting the services was the goal of
the Blue Ribbon Committee and cited some of the recommendations in the report:
"Mandate that all agencies providing ALS (`Advanced Life Support')
also provide patient transport to hospitals;
The Blue Ribbon Committee considered functional consolidation
of Fire Services in Collier County and re- allocation of resources in
response to demographics and professional standards;
... encourage all Fire Services to collaborate in order to develop
Common Response Protocols ... "
He further stated there was much more in the report that did not "dove- tail" with
approving the COPCN for North Naples.
Chairman Talano concurred and pointed out that transportation issues were not
addressed in the COPCN. He stated the COPCN's Protocols were not clear enough.
Chief Metzger noted the Blue Ribbon Committee's Report referenced a three -year
time line for phased -in implementation of their recommendations. The process is to be
determined by the various stakeholders and subject- matter experts. The application made
by North Naples is for a system enhancement to take place in the near future.
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January 21, 2011
The Chief continued the application could be integrated into the overall recommendation
made by the Blue Ribbon Committee. He stated the ideal is a new, progressive, common
service and to postpone consideration for North Naples may not serve the best interests of
their residents, especially if North Naples' capability can be improved.
Discussion ensued and the following points were raised:
• Did North Naples COPCN Application support the conclusion that there would be
an improvement in the delivery of care to the residents?
• The report recommends system changes that may never happen.
• The Blue Ribbon Committee is trying to work toward a functional consolidation
of the system and for continuing the current two -tier model.
• The Blue Ribbon Committee's report should be thoroughly vetted to determine
the feasibility of the recommendations.
• Since North Naples is willing to enhance their ability to respond to patients, it
could have some positive impact to the overall system — potentially by allowing
other ALS resources to be diverted to other areas of the County.
• "Enhancement" is a presumption. A number of paramedics in North Naples have
less clinical experience.
• The two - tiered system supports early BLS ( "Basic Life Support") intervention as
the key to saving patients' lives.
• The academic literature points to prompt BLS with conservative ALS by a limited
cadre of paramedics.
Dr. Robert Tober stated the recommendations of the Blue Ribbon Committee should be
analyzed and a determination made concerning the type of authority to be created before
separating out one independent state of ALS activity when there is nothing to support
such action.
Vice Chairman Kopka again cited from the Committee's Report: The Panel also
strongly believes in one medical leader for the County. "
He stated his definition of "fragmenting the service" is having a different Medical
Director in a particular district with different protocols, procedures and levels of care.
Chief Metzger agreed that Dr. Tober's position regarding cardiac care was correct but
there were other medical conditions that benefited from early ALS intervention. He cited
Canadian studies which identified airway obstructions, anaphylaxis, and other types of
medical emergencies respond to the immediacy of ALS procedures and have a positive
impact.
Dr. Tober noted the engines and the BLS equipment carried by the engines include
airway emergency equipment and "Epi- Pens." He further stated the majority of the
Canadian studies that examined cardiac and trauma found no more morbidity benefit
from ALS procedures, and the procedures should be limited and those resources diverted
to early /prompt BLS.
He had not found any medical literature to support extending ALS privileges to those who
do not regularly practice the skills have been shown to be a benefit.
January 21, 2011
Dr. Tober continued:
• Enough airway equipment has been distributed to the engines to intervene — they
carry King Tubes and Subcutaneous Epinephrine.
• During the past six months, North Naples calls had been analyzed and in
approximately 6,000 calls, only 4% required technical ALS procedures and half of
that number consisted of connecting the patient to a cardiac monitor.
• One option under consideration is to train a small number of paramedics from North
Naples to a higher level to create a small cadre of ALS Early Response should there
be a delay.
• All of the BLS engines have everything that is needed.
Chief Aguilera noted only a summary was provided. He requested that the Board review
the entire application before any recommendations were made. The Canadian system is
much different than the U.S. — the certifications, qualifications, and classifications are
drastically different.
Chairman Talano stated to take action without comparing both reports was premature.
Public Comment:
Commissioner Hiller noted the Board of County Commissioners has not adopted the
recommendations of the Blue Ribbon Committee, but merely accepted the report. The
BCC decided to schedule a Workshop to determine if a Public Safety Authority should be
created and its structure. The recommendations of the report will be deliberated and
decided by the Public Safety Authority.
She expressed concern over the details of the report which she described as "vague."
She was also concerned that Dr. Tober intended to de- certify some paramedics.
Dr. Tober explained EMS is the "Court of Last Resort" and must transport. His concerr
was trying not to overly spread the distribution of drugs into inexperienced hands.
Approximately fifty paramedics are loaned to the Fire Districts and, after a two to three
month rotation they must go back to ambulances to reinforce their skill levels (at their
request). He stated there are only so many opportunities to practice clinical skills and he
was trying to cut back on the unnecessary expansion of paramedics.
Deputy Chief Dan Bowman stated the Blue Ribbon Committee discussed a number of the
same issues expressed by the Advisory Board but its conclusions have not been clarified.
The details need to be more completely described. He continued the application may be
justified by the Blue Ribbon Committee and there may be elements for North Naples to
include. He further stated the EMS Board is in a position to encourage whether the COPCN
should be considered and he suggested waiting until a final product has been produced.
A question was asked concerning the sunset of the COPCN.
Chief Page noted a COPCN is renewed annually. If a COPCN (non - transport) is granted,
North Naples will take over the responsibility. The number of EMS units in North Naples
theoretically could be reduced by approximately 40% and could be relocated to rural areas or
further reduce the number of units provided to the County for a tax savings.
He suggested if a COPCN is granted, it should contain transport to allow the County to
Re- disburse the units. There are a number of factors to be considered by the BCC. He will
January 21, 2011
meet with Chief Stoltz and Dan Summers at the conclusion of the BCC meeting
Chief Metzger stated the COPCN could be phased in, first without and then with transport,
as a way to move the system forward. A potential benefit could be the redistribution of
assets.
Chief Page stated North Naples has the capability of providing ALS engine transport and
could have the same agreements as East Naples and Marco Island.
Chairman Tolano stated to have a non - transport agreement was not good medical policy
and he would not support it.
Vice Chairman Kopka stated the current request is for ALS non - transport.
Vice Chairman Kopko moved to recommend not approving the North Naples COPCN
application and to forward the recommendation to the Board of County Commissioners.
Second by Rosemary LeBailly.
Ms. LeBailly stated all members of the Advisory Board should be fully informed.
Chief Metzger stated his concerns:
• Two members have not had the opportunity to read the Blue Ribbon Report in its
entirety, and
• The EMS Policy Advisory Board has not has an opportunity to review the COPCN
Application in it's entirety.
He suggested tabling any action until the members have had the opportunity to review the
documents.
Dr. Tober pointed out to table the motion is to take no action, and no recommendation
will be made to the Board of County Commissioners who will vote on the application at
the next meeting. He suggested sending a recommendation to the BCC to delay their
vote for at least one month.
Chief Metzger noted if North Naples does not have consideration within a specific
timeframe, their process will begin again. He contended for the Advisory Board to take a
position without being adequately informed is not responsible and misleading.
Chairman Tolano questioned Chief Metzger's opinion. He stated if the BCC has more
information to make a decision than the Policy Advisory Board, then advice from the
Policy Advisory Board would be of no consequence.
Dr. Tober questioned whether there would be any "harm" in recommending that BCC
delay making a decision for one month.
Vice Chairman Kopko restated his motion: He moved that the Policy Advisory Board
recommend to the Board of County Commissioners to not approve the North Naples
COPCN Application at this time. Second by Rosemary LeBailly.
Motion carried, 3 — "Yes71— "No71— "Abstention." Chief Metzger was opposed and
Mr. Pinto abstained.
Rosemary LeBailly stated the goal is to make an informed decision — it should not be a
battlefield. There must be a way to present the motion to make sure it is the logical,
informed way to do the right thing and is best for all.
Chairman Tolano suggested the Policy Advisory Board could recommend to the Board
of County Commissioners to delay the decision until more study is done -- integrate the
January 21, 2011
recommendations made by the Blue Ribbon Committee as compared to the full document
from North Naples.
Rosemary LeBailly stated the door was not being closed on the North Naples COPCN
Application. She voted "no" as the only way to hold off until everyone could be
informed.
Chief Metzger stated "further study" will take a very long time
Chairman Tolano disagreed, noting the Advisory Board could make a recommendation
to the Board of County Commissioners next month. He stated the report has been out for
only a short period of time.
It was suggested an explanation for why the Board of County Commissioners voted
against approving the application when it was first presented was their comment that the
Blue Ribbon Report was not available at that time.
Deputy Chief Aguilera stated Chairman Coyle directed the COPCN to be brought to the
Advisory Board after it had been reviewed by County staff, was heard, and denied by the
BCC. The application will be brought back for a second hearing by the BCC for
reconsideration. He confirmed the process has been followed.
Chairman Talano acknowledged that while "the process" has been followed, he stressed
that, as a scientist, he could not make a decision before reviewing both documents
completely.
The status of the Motion ("carried") was confirmed.
Public Comment:
Commissioner Hiller stated the Board of County Commissioners will be exploring
whether or not to create a Public Safety Authority, and to what degree it will have the
ability to make public policy decisions. If established, the Public Safety Authority will
determine what the protocols or strategy will be, and the decision will not necessarily be
based solely on the recommendations of the Blue Ribbon Committee's Report. All
options will be considered. She reiterated the Board of County Commissioners has not
adopted the recommendations of the Blue Ribbon Committee as binding. "To compare
whatever North Naples is applying-for to the report is not an exercise that will lead to
anything."
Chairman Talano pointed out the Advisory Board was asked to make a decision on
what was actually happening in terms of the report. To approve it without knowledge is
like "putting the cart before the horse."
Commissioner Hiller continued the comment that the service to be provided would be
less than what is currently provided is not a true statement because once someone
assumes the duty as a Medical Director, to provide a certain level of service, the level of
service has to be provided — there is a duty, a responsibility, and a standard of care. To
suggest by North Naples having a Medical Director would compromise the level of
service received by North Naples residents would not be a true statement.
Dr. Tober noted, that when North Naples had drugs for two years, there were serious
errors in medical care. He had to determine what would be more harmful to the
January 21, 2011
community. He made the decision to withdraw ALS from that group of paramedics,
many of whom were inexperienced, rather than continue it. His decision was carefully
deliberated and he concluded there would have been a greater danger to the community if
he had not decided to withdraw the ability to dispense medicines. He continued the
assumption of whether North Naples will or will not improve care is up for debate.
Commissioner Hiller countered any Medical Director who assumes responsibility has
liability for the decisions made with respect to protocols, training, supervision, what
drugs should or should not be allowed to be disbursed. The [proposed] Medical Director
for North Naples would assume the legal liability. It would be his duty to ensure the
North Naples paramedics were properly trained and their actions in the field meet the
protocols he determined were necessary to meet the standard of care.
Dr. Tober reiterated he was the Medical Director for North Naples and he decided to
withdraw medicines from North Naples because it was not complicit with training and
quality management.
Commissioner Hiller stated when North Naples has its own Medical Director, it will be
that individual's responsibility to make those types of decisions.
Dr. Tober asked how her statement related to what she had said — that it would be
"automatic" when North Naples has ALS skills, it will be an improved system. The
system was not improved when North Naples reported to him.
Commissioner Hiller claimed when North Naples has ALS paramedics under a Medical
Director whose concentration is directed to the training, supervision and management of
only those paramedics, the level of concentration will hopefully allow ... at a minimum,
it will be equal to what is provided for the rest of the County because that is what the law
requires.
Dr. Tober stated the law requires that we do our best to oversee — it does not require that
the paramedics perform at a certain level of perfection. There is a training office that
spends considerable time reviewing calls and cases to determine how the paramedics are
functioning. You oversee the system by reviewing how the runs come down.
Chairman Talano concluded the time for public comment.
B. Review of COPCN Renewal from NCH
Chief Page stated the letters submitted constituted the renewal application but did not
contain information regarding insurance records and proposed charges for patient care.
He outlined a problem for Mr. Summers to consider:
• NCH currently has only one unit available for transport.
• Service is supposed to be available, by Statute, on a24/7 basis but NCH has not
complied.
• There have been instances when service was shut down for an evening and NCH
requested the County provide transport.
January 21, 2011
• In the past year, the County has covered 190 transports for NCH from the Marco
facility.
• Transports coming from Marco have also been problematic because NCH has
utilized the Marco Medic Unit to handle transports between facilities.
• In some cases, HMA's facility on Collier Boulevard has been bypassed. It was
pointed out to Marco and they have complied.
• Marco sent a letter to Dan Summers stating it will add a second unit in February
to facilitate Marco -area transports but apparently this claim has been made before
and never materialized.
• There have been staffing issues with Marco.
Chief Page stated Chief Murphy on Marco Island provided information and concerns
since he helps staff the Marco unit with two paramedic /firefighters. The situation
has become burdensome.
He stated additional documents has been requested before Mr. Summer can make his
recommendation.
The Chief noted his report was presented as an "FYI" for the Board since the issue may
become contentious. He was not sure when the application will be presented to the
Board of County Commissioners.
Dr. Tober stated there was a situation again on Saturday with a NCH transport that did
not want to take the patient to Physician's Regional on Collier even though it was the
closest appropriate hospital for the call.
Chief Page stated a call was received from NCH during the meeting claiming their
unit had a two -hour back -up and requesting EMS transport a stable patient. When
informed EMS would only transport emergency patients, a second call was placed by
NCH declaring an emergency situation. It is the same situation with Marco Island.
Vice Chairman Kopka asked if NCH was currently in compliance with its current
COPCN and the response was "no."
Chief Page outlined a challenge for North Naples if the COPCN is granted:
• The current COPCN language requires all paramedics to be certified by the
Medical Director and some in North Naples are not.
• Another issue is the paramedics are required to ride on a transport unit for at least
one month on an annual basis — North Naples has not complied.
• He noted NCH has also not complied with the requirement.
Dan Summers requested Chief Page present the update to the Board because Mr.
Summers was unavailable due to surgery.
Chief Metzger questioned how long NCH had a COPCN and who handled their inter -
facility transports prior.
The response was three years and EMS provided the service.
Chief Metzger asked why NCH received a COPCN for inter - facility transports.
Chief Page stated NCH claimed it would save approximately SIM if allowed to do so
and it had the ability to transport outside Collier County because EMS would not.
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January 21, 2011
Chief Metzger asked what would be the result if NCH's application to renew its COPCN
was not approved and the response was that EMS would take over the service. He noted
EMS does currently transport outside the County if it is an emergency situation. EMS
currently transports for HMA to Lee County.
Dr. Tober stated there have been problems moving stable patients from Marco Island — if
the wait time for the hospital is four- hours, for example, a call is placed to him to upgrade
it to emergency status. When EMS ambulances are pulled from Marco, it is a significant
step backwards for coverage in Marco. He stated it would be easier to take it over
completely.
6. Public Comment:
(as noted in Item #5 -A
7. Board Member Discussion:
• Commissioner Coyle was present before the meeting began. He is the liaison assigned by
the BCC to attend the Policy Advisory Board's meeting.
o It was unfortunate that Commissioner Coyle was put in a position where he had to
leave.
o When asked to remain, Commissioner Coyle replied he did not want to risk a
violation of the Sunshine Laws as the reason for leaving.
• It was noted it would not have been appropriate for Commissioner Coyle to hear
Commissioner Hiller's comments not permissible since the subject will be
presented to the BCC for a decision.
• It was suggested future meeting notices contain language that one or more
Commissioners may be in attendance.
A request was made for Jennifer Florin, Administrative Assistant, to draft a letter for
Chairman Talano's signature advising the BCC of the Policy Board's recommendation
concerning the North Naples COPCN Application.
Chairman Talano moved for approval to request the Staff Liaison draft a
letter to the BCC for his signature and the letter reflect the Advisory Board's vote.
Second by Vice Chairman Kopko. Carried unanimously, 5 — 0.
• Jennifer Florin noted the North Naples COPCN application was approximately 500 pages
and would make hard copies available for the members.
8. Next Meeting Date: March 25, 2011 at 3:30 P.M.
There being no further business for the good of the County, the Meeting concluded by
order of the Chair at 5:22 PM.
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January 21, 2011
COLLIER COUNTY EMERGENCY MEDICAL
SERVICES POLICY ADVISORY BOARD
Jam s T lano, M.D., Chairman
The Minutes were 15 roved by the Board/Committee Chair on �kj) , 2011,
as presented , or as amended
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