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EMS Policy Minutes 04/15/2011 April 15, 2011 ,-... Im@mllwm~ I ~ .. c.' - JlJ,..J 1 ; lUi i MINUlES OF THE COLLIER COUNTY EMERGENCY ~DICAL SERVICES POLICY ADVISORY B().AR;Q.............. MEETING April 15, 2011 Naples, Florida 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 Neighborhood Health Clinic, 12 Goodlette Road N., Naples, Florida, with the following Members present: ~ Fiala Hiller Hennin Coyle Coletta CHAIRMAN: Vice Chair: James Talano, M.D. Chief Walter Kopka Rosemary LeBailly, RN (Excused) Chief Robert Metzger Jerry Pinto ,-. ALSO PRESENT: Dr. Robert Tober, Collier County Medical Director Jeff Page, Chief, Bureau of Emergency Services - Staff Liaison Jennifer Florin, EMS Administrative Assistant Maria Hernandez, EMS Administrative Assistant Wayne Watson, Deputy Chief, Bureau of Emergency Services Dan Bowman, Deputy Chief, Bureau of Emergency Services Jorge Aguilera, Deputy Chief, Medical Services/Community Relations Misc. Corres: Orly Sto11s, Chief, North Naples Fire Control & Rescue District Date: q\\~\ \ \ Item #: \ Lo:X: "J... 'fA \ \ 1 ..~Xy April 15, 2011 ,-... , 1. Call to Order and Pledge of Allegiance: Vice Chairman Kopka called the meeting to order at 4:03 PM and a quorum was established. The Pledge of Allegiance was recited. ~ 2. Agenda and Minutes: A. Approval of Today's Agenda Chief Robert Metzger asked what had transpired since the last regularly scheduled meeting that necessitated calling today's special meeting. It was his understanding the topic on the Agenda was tabled until the legal issues were resolved. Chief Jeff Page responded while there may never be agreement between the parties, it was determined the issue would be taken to the Board of County Commissioners for a decision. Each party will have an opportunity to present their case before the Board. Chief Metzger asked what information was received that resulted in the meeting being called. He stated he was not aware of any new information. Vice Chairman Kopka stated changes were made to the original Ordinance and the meeting was convened to address/discuss the changes and to make recommendations to the Board, as discussed during the previous meeting. Chief Metzger noted questions were raised during the previous meeting concerning whether or not some portions ofthe Ordinance were consistent with Florida Statutes. He asked if the qut:(stions were resolved and if Chief Page had received information from EMS' attorney. Chief Page stated he spoke with the County Attorney and was informed by County Manager Leo Oehs that the issue would be placed on the Agenda for BCe's 2nd meeting in May. He further stated he agreed to accept the proposed language concerning the Statute issue, and would read the language into the record. The other changes in the document were agreed to during the previous Policy Advisory Board meeting (March 25, 2011), and he would read those changes into the record. He noted the County Attorney's office stated no additional changes would be made and the document was to be brought before the Board of County Commissioners. Vice Chairman Kopka called for a Motion on the Agenda. Chief Metzger nwved to approve the Agenda as submitted Second by Jerry Pinto. Carried unaninwusly, 3 - O. 3. Old Business: A. Review of COPCN ("Certificate of Public Convenience and Necessity") Ordinance and Recommendations to Board of County Commissioners ("BCC") (A copy of the Ordinance in draft format was distributed to the Members.) Chief Jeff Page referred to Page 2, Paragraph "A," stating he had been in contact with Deputy Chief Jorge Aguilera. ~ Suggested changes: . Remove the phrase: "applicable Florida Statutes and Florida Administrative Code, Section 64-E," . Insert the phrase: "the Collier County Medical Director's protocol." 2 ,-... ~ ~ April 15, 2011 Chief Metzger noted the references to Florida Statutes and the Florida Administrative Code were deleted and asked why it was done. He stated his preference was to keep the statutory citations as well incorporate the suggested language. (Chairman James Talano arrived at 4:09 PM) Vice Chairman Kopka stated the reference was to Advanced Life Support for local protocols. Chief Metzger stated local protocol must comply with Florida Statutes which sets the mlrumum. Chief Page noted variances can be requested from the State. Chief Metzger stated retaining the references could avoid a potential issue if a local protocol was contrary to, or less than, Florida Statutes. Deputy Chief Jorge Aguilera agreed with Chief Metzger and stated because it is a legal document, the definition of "ALS" should stay consistent with the statutory language that already defines it. The statutory reference should be retained because the Statutes always trump local language. He expressed concern that the draft did not contain the most recent recommendations discussed by the attorneys (JeffKlatzkow, Jennifer White, and Laura Donaldson). Chief Page confirmed the language was removed to address the Collier County Medical Director's Protocol because, in the document, the Protocol means ALS. He stated the document could be drafted to include any definition. Dr. Robert Tober suggested the document could be rephrased to state "as definedfirst by the Collier County Medical Director's protocol and, secondarily, by Florida Statutes and the Florida Administrative Code. " Chief Metzger noted the document cited State Statutes in other places. He suggested the Statute's definition could be expanded as follows: "applicable Florida Statutes and Florida Administrative Code, Section 64-E, and the Collier County Medical Director's protocol. " Dr. Tober stated he would not object as long as there was nothing in the Statutes and the Code to contradict the definitions of the protocol. Vice Chairman Kopka turned the meeting over to Chairman Talano. Deputy Chief Aguilera noted the correct Section of the Florida Administrative Code is 64-" J". He stated the Section could also change from year to year. Suggested changes: "Advanced Life Support (ALS) shall mean procedures conducted as defined in applicable Florida Statutes and Florida Administrative Code, and the Collier County Medical Director's protocol." Consensus: The changes to Paragraph "A" on Page 2 were accepted. Chief Metzger suggested amending the definition of "Rescue Service" on Page 2 under Paragraph "J." 3 April 15, 2011 ,-... Dr. Tober proposed adding (non-ALS) to follow "Rescue Service." Suggested changed: "Rescue Service" will be changed to "Rescue Service (non-ALS)" on Page 2, Paragraph "J," and on Page 3, under Section Four, Paragraph "A" of the draft. Consensus: The changes were accepted. ~ Chief Metzger referred to Section Twelve on Page 6. He suggested Section "A" should state that a Class 1 transport may or may not elect to transport patients. The Section does not discuss whether there must be the capacity to transport. If the intent of the Section is to state that transport capacity is mandatory for Class 1, it should be described. Dr. Tober stated the determining factor is whether or not the patient needs transport. Chief Page noted a service would not be in Class 1 without transport capability. He questioned how could a service elect to transport if it did not have transport capability. Deputy Chief Wayne Watson maintained the intent of the Section was patient-specific because a transport agency is not mandated to take every patient who calls for service to hospital. It is the reason for the separate Classes and an agency that will not transport would be segregated to Class 3. Chief Page stated ALS Engines that apply for a COPCN do not want to meet the same ride requirements as in Class 1. The reason for the separation of Classes is to make it easier to maintain compliance. Dr. Tober suggested adding: " may or may not elect to transport patients based on medical severity. " Chief Metzger stated the wording does not compel the need to create Class 3. Suggested changes: . The title shall read: "Class 1: ALS Transport with Transport Capabilities" . "An EMS Operator with the capability of rendering on-the-scene pre-hospital ALS services with transport capability. They mayor may not elect to transport patients based on medical necessity." Consensus: The changes to Paragraph "A" were accepted. Chief Page read the language proposed by the North Naples' attorney under paragraph 3 on Page 10: "3. Class 3 certificate holders shall contract with the County for $ (to be negotiated) per year for administrative services offered by the Office of the Medical Director, including the creation and update of medical protocol and other general support. The amount paid per year shall automatically increase by the Consumer Price Index, but any increase shall not exceed five percent (5%) per year." ~ He noted Paragraph 4 was added: "4. The Medical Director for the Class-3 certificate holder shall work cooperatively with the County's Office of the Medical Director to ensure 4 Apri115, 2011 .-. continuity of care. The Medical Director for the Class-3 certificate holder shall not delegate or relinquish any responsibilities identified in Section 401.265, Florida Statutes, and associated Florida Administrative Code rules." Chief Page stated the language is similar to King's County and ensures the Medical Director for a COPCN Applicant will abide by Dr. Tober's protocol. Deputy Chief Aguilera stated the intent is to ensure the language meets the statutory requirements and is enforceable. He cautioned the attorneys may not have fmalized the language. Consensus: (to be determined by the attorneys for the County and the parties) Chief Metzger referred to the last sentence of Paragraph "B," under Section 8, on Page 1 O. He suggested the operator must be licensed to transport but the transporter is not the only one able to assess and treat patient. Dr. Tober suggested keeping the first sentence as is, i.e, "Every call for service shall be answered promptly." ~ Suggested changes: . "ALS Engines shall appropriately assess, treat, and package the patient(s)." . "The patient(s) shall then be loaded and transported by an operator that is licensed to transport without being subject to unreasonable delays." . The remainder of Paragraph B remains the same. Consensus: The changes were approved. Deputy Chief Aguilera referred to Paragraph "A" on Page 10 concerning "Twenty-Four Hour Service" and cited the double-permit requirements, i.e., a vehicle permit issued by the State and a permit issued by the Board, as duplicative. He noted the County's permitting process does not allow for updating in the event a vehicle is changed or removed from service and questioned the need for the duplication. Florida Statutes does not identify a County-issued vehicle permit as necessary. Chief Page stated when a COPCN application is submitted to the County, the apparatus must be listed and identified. Deputy Chief Aguilera stated he was referring to the permitting process, not the COPCN application process. He reiterated there was no statutory support for the double-permit requirement. The purpose of the reviewing/revising the draft is to simplify it and eliminate redundancies. Chief Page referred to Paragraph G on Page 12 and noted the language had been revised at the last Policy Board meeting as follows: ~ "At minimum, the paramedic must work in that capacity not less than one full month's work shift annually, or in the case of non-transport ALS providers, if ALS services are provided prior to EMS transport arrival, 5 April 15, 2011 .-. or if the patient's condition requires that additional level of expertise, the ALS non-transport provider will accompany the patient on the ALS transport from scene to hospital " Chief Metzger questioned the intent of the language. He stated his understanding was if an ALS First Responder arrives on the scene and initiates ALS patient care, they shall accompany that patient with the ambulance to the hospital - which is appropriate. He continued if ALS care is not initiated by the First Responder and is subsequently started by the EMS Responders who arrive in the transport unit, there is no obligation on the part of the ALS First Responder paramedic to ride to the hospital unless it is medically necessary. Dr. Tober stated unless the EMS paramedic asks for an additional pair of hands. Chief Metzger agreed that the EMS' request must be respected. Chief Page stated two issues were being discussed: (1) continuity of care, and (2) the revised language is to replace the ride time component of ten shifts. Chief Metzger noted it was discussed at the previous Policy Board meeting, but the language read by Chief Page was not discussed. ~ Chief Page referred to the second sentence in Paragraph G ("Certification") which states, "Each paramedic must work with a Collier County EMS ambulance for a sufficient length of time for the ambulance service medical director to properly judge his capability." ~ He stated North Naples does not want to do the ten shifts and they agreed to the terms in the revised sentence as noted in the Minutes for the March 25th Policy Board meeting, and it was almost a word-far-word quote from Laura Donaldson. He asked if North Naples doesn't agree, will it be required to observe any ride time requirements. Chief Metzger stated he is a stickler for grammar and sentence structure; he could not infer what Chief Page stated from what was written. He suggested restructuring the sentence. Additionally, he is opposed to the language because he believes it would unnecessarily remove ALS capability from the field. Chief Metzger clarified if an ALS First Responder paramedic begins patient care, he must follow through and ride to the hospital. rfhe hasn't and if the actual ALS care was rendered by the EMS paramedic, and if the medical situation does not require an additional pair of hands, the First Responder should remain in the field with his apparatus. It was noted the patient's condition must require the additional level of expertise. Chief Page stated the goal was to provide a "very clean" document to eliminate confusion in the field. The EMS paramedic is to have the ability to ask for assistance or ride in, if necessary, from the ALS paramedic. He further stated if the option to ride in is only when it is "critical," who determines when a situation is critical. Chief Metzger reiterated the transporting medic should determine ifhe needs assistance; he confirmed he could not support requiring the First Responder to ride in on every call. The First Responder should ride in only if another set of ALS-skilled hands is medically necessary. 6 Apri115,2011 ,-... Vice Chairman Kopka quoted from the minutes of the January 25,2011 meeting of the Board of County Commissioners concerning the COPCN request: Richard Yovanovich, Esq: "The risk management question, either I didn't make it clear, but from a risk management standpoint, our paramedic - if they started ALS service - was always going to follow through with the patient from the initial contact all the way through to the hospital. They were going to ride in the ambulance in the back with the patient." Deputy Chief Aguilera: "As Richard said, one of the things in this "Continuity of Care" issue - what we intend to do - have offered multiple times - is that any time one of our paramedics is on the scene fIrst and starts Advanced Life Support and/or if the patient's condition, illness, or injury requires an additional set of expert hands, we will pull our paramedic and transport to the hospital with Collier County EMS." ~ Deputy Chief Aguilera: "We are committed that if we start ALS services prior to EMS or if the patient's condition meets the additional expertise, we will for "Continuity of Care" go to the hospital with the patient." Commissioner Henning: "Will there be any negative effects to the existing hospital? And, Jorge, you said you would provide paramedics to ride on the ambulance to the hospital?" Deputy Chief Aguilera: "Correct. We currently, when we do it, will either make arrangements for one of the Battalion Chiefs or one of our engines to go pick up the paramedic. " ~ Chief Metzger stated the one point of contention is what defmes - or how to address - the "medically necessary" requirement for the paramedic from the ALS First Responder to ride in with the ambulance. Dr. Tober replied the ambulance paramedic requests another set of hands. Vice Chairman Kopka said there has never been an issue in the past. The difference currently is if they start ALS they will also provide the medic to transport to the hospital. Chief Metzger concurred. He outlined a possible scenario: ALS care is not started by the ALS First Responder (Le., the Fire Department); he institutes BLS. EMS arrives and institutes ALS care. If the patient's condition is so critical that it requires another pair of ALS-skilled hands, and the medic asks for help, the Fire Department paramedic has to ride in. 7 April 15, 2011 - He continued that Chief Page has stated if ALS care or if procedures that are considered to be ALS are started, the Fire Department medic should be required to ride in. Dr. Tober asked if a Fire Department medic is on scene fIrst and begins BLS care, and EMS arrives - would EMS still take that Fire Department paramedic to the hospital if extra hands were not needed. (The general response was "no. '') Chief Page stated two different issues were being addressed and asked how the ride time component should be addressed. Chief Metzger objected, stating the ride time component was being wrapped into the issue. His goal, as an Operating Chief, is to keep ALS resources in the field unless a patient's condition requires the ALS provider ride in to the hospital. Dr. Tober stated the ride time is unknown because the system is new and has never been operated before. He noted it can be tracked. He further stated everyone else who carries drugs does have mandatory ride time, so North Naples is operating as an exception to the rule. He reiterated if ALS is started, the Fire Department medic will go in the back of the ambulance. If BLS is started by the Fire Department, the medic will not be required to accompany the patient unless requested to do so by the EMS medic. Chief Metzger concurred. ~ Vice Chairman Kopka presented a scenario for purposes of clarifIcation: ABC Fire Department arrives on the scene; the patient has chest pains; an N is started and nitro is given - this is ALS care and the Fire Department medic will accompany the patient to the hospital. ("Agreed. '') In the second scenario, the medic needs help to intubate a patient and requested a second set of hands - the Fire Department will provide its medic to assist. ("Agreed. ") Deputy Chief Aguilera stated Marco Island will establish a similar program, "Utilization of District Personnel during Patient Transport." "Procedures: Specific to the individual call types or situations listed below, a Firefighter/Paramedic will be assigned to assist in the back of the Medic Unit while enroute or responding to the hospital: a b. c. d. e. f. g. -- h. Cardiac/traumatic arrest Trauma Alert to include paramedic judgment Code-Save-a-Heart / Audicor Code-Save-a- Brain Code-Save-a-Breath (CHF) / Audicor Any Alert LOC with the potential for Respiratory or Hemo-Dynamic collapse Behavior emergencies which pose a potential risk to emergency personnel Any patient type with the potential for respiratory, hemo-dynamic collapse and/or life threatening dysrhythmias - 8 April 15, 2011 - 1. Serious poisoning and.lor overdoses J. Any acutely ill pediatric patient with the potential for compromise k. Any time a District credential paramedic begins ALS care, as defined in the Common Medical Protocol, prior to the arrival of a Collier County EMS Paramedic I. CC EMS Company Officer judgment It is important to note that the Collier County EMS paramedic has the ultimate responsibility on deciding the number and type resources necessary for the appropriate and safe transport to the hospital." Deputy Chief Aguilera continued "the street" usually decides when an extra pair of hands is needed - no one has been afraid or too intimidated to act - and it has worked well. We need to go a better job tracking it and providing the information. He stated Chief Stolts is ready to sign the policy statement. Chief Stolts noted the key is to keep two Advanced Life Support units from being gone on one call. Vice Chairman Kopka nwved to accept the changes to the draft as outlined above. Second by Jerry Pinto. ~ Chief Metzger asked if a draft copy of the proposed changes to the Ordinance would be available before the document was presented to the Board of County Commissioners. Carried unanimously, 4 - O. 4. New Business: Chief Page asked Deputy Chief Aguilera and Chief Stolts to lead the discussion of other issues and provided the following background: . City of Naples responds to all calls Alpha with lights on and sirens . North Naples responds to some Alpha calls but not all and, typically, not to nursing homes if it is anything less than a Delta call . There is no uniformity of response within the County · Goal: To develop a basic response protocol to be followed on a County-wide basis ~ Dr. Tober noted one of the issues is that Emergency Medical Dispatch uses a menu of pre- programmed questions. The goal of the questions is to categorize the type of call and the results are sporadic -- sometimes it works well and other times, it doesn't. He suggested the safest thing is to dispatch Fire and EMS simultaneously. "Roll them out the door and have them moving hot." He stated it can take as long as three minutes before an ambulance is dispatched. The type of call can be revised after Dispatch has the questions answered, and the information routed to the units. He further stated another problem is the hand-off between the City's and the County's dispatch systems, especially if the phones are not answered promptly. He concluded the dispatchers are beginning to send units out together. 9 April 15, 2011 ,-... Vice Chairman Kopka asked when a 911 medical call is dispatched, is there a reason why ALS would not be dispatched. He cited an example, Engine 40 and Squad 40 are both in the station, but the Engine (which is BLS) took the call for abdominal pain and not the Squad. He noted historically, the ALS unit has been dispatched first. ~ Deputy Chief Aguilera stated it may have been a special situation. He further stated as they expand and put ALS on the vehicles, more Alpha type calls will be answered. Choief Stolts contended to send ALS units to a sprained ankle call would not be the best use of resources when a BLS unit would probably be sufficient. He noted the time of two minutes or more to dispatch a unit is an issue that must be improved. . In North Naples, there are 17 assisted living facilities and nursing homes which have been assessed . North Naples knows which facilities have nursing staff on 24-hour duty . Each District should be allowed to decide if they will send an ALS unit to an Alpha- level call Chief Page noted the COPCN states that North Naples will respond to all calls and he wondered how it was able to choose which calls to answer. Chief Stolts stated information provided by the State requires that if they are notified of call, they must respond. He further stated he informed the Sheriff s Office that North Naples will not respond to Alpha calls and the CAD has been programmed to not dispatch those calls. Dr. Tober stated his office was criticized because no one is showing up to Alpha calls. Chief Stolts agreed it was not a good situation and stated they have decided to respond to some Alpha calls. There was further discussion on the types of calls and units coming out of zone. It was agreed the procedures needs to be "straightened out." A system that minimizes responses is not safe. Dr. Tober stated his vehicles all contain radios. Chief Metzger noted that several studies have indicated there is no appreciable response time running with lights/sires and running without. He suggested one solution might be to dispatch Fire and EMS units "cold" (simultaneously) but then up/down grade as necessary. The data has shown that an alternative approach is safe and effective. Dr. Tober stated the goal is a universal buy-in to the procedure. Chief Stolts concurred all Districts might "do the same thing" if given an opportunity to discuss the procedure. 5. Staff Reports: (None) 6. Public Comment: (see above - Deputy Chief Jorge Aguilera and Chief Orly Stolts) 7. Board Member Comments: ~ (None) 10 April 15, 2011 ,-... 8. Next Meeting Date: June 10,2011 at 3:30 PM There being no further business for the good of the County, the Meeting concluded by order of the Chair at 5:20 PM. COLLIER COUNTY EMERGENCY MEDICAL SERVICES POliCY ADVISORY BOARD J 10' The Minutes were ~roved by the Board/Committee Chair on . . C.l vLt.. "as submitted"~, OR "as amended" U ,2011, .-. .-. 11