EMS Policy Minutes 06/10/2011
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June 10,2011
MINU1ES OF TIlE COLLIER COUNTY
E1v1ERGENCY MEDICAL SERVICES POLICY ADVISORY BOARD
:MEETING
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Hiller - :p./
Henning =" H
Coyle v
Coletta - Vi
June 10,2011
Naples, Florida
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By:......"................
LET IT BE RElvlEMBERED that the Collier County Emergency Medical Services
Policy AdvisOlY 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 follO'wing Members present:
Chair:
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
J eft' Page, Chief, Bureau of Emergency Services - Staff Liaison
Maria Hernandez, EMS Administrative Assistant
Wayne \Vatson, Deputy Chief, Bureau of Emergency Services
Dan Bowman, Deputy Chief, Bureau of Emergency Services
Misc. Corres: Jorge Aguilera, Deputy Chief, Medical Services/Community
Relations
Date: \ 0\ " , \ " \ Orly Stolts, Chief, North Naples Fire Control & Rescue District
Item 1:\ \.D:S:: "'A ~
Copies to:
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1. Call to Order and Pledge of Allegiance:
Chairman Talano called the meeting to order at 3:37 PM and a quonun was established.
The Pledge of Allegiance was recited.
2. Agenda and Minutes:
A. Approyal of Toda),ls Agenda
Vice Chairman Kopka nwved to approve tlte Agenda as submitted. Second by Chief
Metzger. Carried unanimously, 3 - O.
B. ApproyalofMinutes: March 25,2011
Change:
. On Page 7, (Chief Metzger's motion - 3,-d line), the correct page referenced in the
motion was Page 12.
Vice Chairman Kopka moved to approve the Minutes of the March 25, 2001 meeting as
amended. Second by Chief Metzger. Carried unanimously, 3 - O.
C. ApproyalofMinutes: April 15, 2011
Vice Chairman Kopka moved to approve the Minutes of the April 15, 2011 meeting as
submitted. Second by Chief Metzger. Carried unanimously, 3 - O.
3. Old Business:
A. COPCN ("Certificate of Public Convenience and Necessityl') Ordinance Review
and Recommendations to Board of County Commissioners ("BCC")
(A copy of the I5-page Ordinance in draft format was distributed to the Members.)
Chief Jeff Page noted the co~y of the Ordinance contained the revisions that had been
agreed to during the April 15 meeting. He met v.~th Chief Stolts and Deputy Chief
Jorge Aguilera and noted the attorney for North Naples may have additional language to
incorporate.
(A two-page document containing a draft of Sections 7 and 8 o/the Ordinance was
distributed by Deputy Chief Aguilera to the Members.)
Deputy Chief Jorge Aguilera stated the two-page document contained the changes
requested by the North Naples attorney. He noted one change on Page 2 of the document
was the removal of language from Paragraph "G" (Certification) which became
Paragraph "I" (Continuum of Care). The reason for the change was to clarify the
language.
Chief Page consulted with the County Attorney's Office regarding the changes and the
creation of Paragraph "1." He stated while the language was similar, the County
Attorney's Office preferred to retain the language contained in Paragraph "I" under
Paragraph "G" because it referred to the issue of ride time.
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Deputy Chief Aguilera stated the North Naples paramedics would not be riding for
certification purposes. The paramedics ride when it is appropriate for patient care - to
provide the appropriate level of sen'ice for critical patients. He stated North Naples is
not being certified by Collier County Medical Director. He further stated North Naples is
committed to provide continuity of patient care, not for certification.
He continued creating Paragraph "I" had no impact on the intent of the document.
Chairman Talano agreed that Continuum of Care was not a certification issue.
Deputy Chief Aguilera concluded North Naples wanted to make clear that its
commitment has remained the same.
Chief Page stated his impression was the County Attorney's Office would not change its
position.
Deputy Chief Aguilera stated the premise behind the Certification paragraph was to be
certified by the County Medical Director. North Naples' position is it is not their intent-
their paramedics ride to provide continuity of patient care.
Chief Page suggested changing the title of Paragraph "G" from Certification to
Continuum of Care.
Deputy Chief Aguilera cautioned if the title change were made, it would necessitate
changing the remainder of the Ordinance. He stated the intent was there are Class-l and
Class-2 providers that have specific ride time requirements. For a Class-3 provider, there
is a specific Continuum of Care provision made \-\lith the Board. He stated the class of
providers has always been segregated. For a Class-3 provider, the issue is Continuum of
Care and not certification.
Chief Page suggested an alternative: Change Paragraph to "Certification/Continuum of
Care. "
Chief Metzger stated the two-page document constitutes the proposal of the attorney for
NOlth Naples. He agreed the issue of Continuum of Care is specific to Class- 3 providers
only.
Deputy Chief Aguilera noted Paragraph "G" clearly pertains to Class-l and Class-2
providers. Creating Paragraph "I" was a "cleaner" option than just changing the title and
keeping the language "jumbled in" together.
Chief Page stated the County Attorney's Office has a reservation concerning the change
due to the removal of language from the ride time element. It is opposed to the removal.
He further stated changing the title of Paragraph "G" from Cel1ification to
Certification/Continuum of Care satisfies both patties' issues.
Dr. Robert Tober provided background information: \Vhen he was the only Medical
Director over the paramedics, part of his certification criteria included ride time. There
are now two Medical Directors and the North Naples Medical Director does not require
that. The only issue at stake is whether> and when, the paramedics V\~ll ride on to the
hospital with EMS.
Deputy Chief Aguilera stated North Naples does have an internal credentialing process
which requires riding in to the hospital. The changes are from an Ordinance perspective.
Inside the department is different from the Ordinance. From an Ordinance perspective,
the commitment of North Naples to the Board was to assure the continuity of patient care.
NOlth Naples has specifications concerning riding to the hospital.
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He concluded the North Naples' requirements are not linked to the Ordinance.
Chief Page again suggested if the Continuum of Care is important, simply change the
title of Paragraph "G."
Deputy Chief Aguilera suggested writing the Continuum of Care as the Standard and
keep the requirements for credentialing and certification as an internal document. Since
the requirements for credentialinglcertification could change \\~th each new medical
director, it became an internal dOClU11ent which would make it easier to revise. The
Ordinance clarifies the intent of what will be done. The certification piece would become
an internal; department-related policy.
He continued, for example, if Golden Gate wanted to become a Class-3 provider and
contract with Dr. Tober for credentialing, his intemal credentialing procedure requires
ride time - as does the North Naples Medical Director.
Chief Page countered if a Medical Director is hired who does not require ride time, it
\\~ll not be a requirement.
Deputy Chief Aguilera restated that continuity of care would still be required, as
specified in the Paragraph. He continued ride time is still required under continuity of
care, but what is alleviated are specifics concerning the number of hours or shifts per
month, etc.
Chief Metzger asked if ride time was a component required by Florida Statutes.
Chief Page stated a paramedic cannot just ride on an engine and become certified.
Chief Metzger asked how much latitude would an indi,'idual Medical Director have
relating to the amount of ride time a State-certified paramedic must invest in any given
year.
It was noted "zero to unlimited - there is a lot of latitude."
Chief Metzger suggested since it is the responsibility of the Medical Director, why not
let individual Medical Directors detemune the amount. If it is not required by the State,
he questioned whether the language was necessary in the Ordinance.
Deputy Chief Aguilera stated North Naples' position is the continuity of care is
important. If a medic starts ALS, it is important that he/she accompany the patient to the
hospital.
Chief Metzger stated he agreed with the concept of Continuum of Care. He noted there
are systems that will pass patient care from one paramedic to another. He fwther stated
Medical Directors have complete latitude via State Statutes and questioned why it should
be made more restrictive on a local level.
Chief Page noted the Board of County Commissioner - through the Ordinance - would
control whether or not ride time will be required. If the parties agree that ride time is not
necessary or appropriate, the requirement can be removed.
Chief Metzger stated the Board could decide to allow the Medical Director to detelmine
how much ride time, if any, was appropriate and the Ordinance would permit subsequent
medical directors to make their own decision.
Chief Page noted if the flexibility were available, a Fire Chief could "doctor shop" to
hire a Medical Director who would do whatever the Chief wanted.
(Jerry Pinto arrived at 3: 50 PM)
Chief Metzger acknowledged the possibility, but stated the Medical Director should be
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the "go-to guy" for a Fire Chief and consulted concerning how to provide the. best care
for residents in the area.
Dr. Tober remarked that not all Fire Chiefs share his opinion.
Chief Metzger stated while keeping a restrictive provision in the Ordinance may not be
problematic for the County's Medical Director, it would be better to remove the
restriction from the Ordinance and compel the medical directors to assume that
responsibility.
Chief Page noted \...ithout the requirement, there would be no safeguard for the public
that there would ever be any ride time - it is a "safety net" to ensure there is a component
for ride time. He suggested an option is to modify the amount of time specified.
Chief Metzger asked what the basis was for the specific requirement in the Ordinance.
Chief Page cited the example of the CitY of Memphis, which requires twelve hours on an
engine and twelve hours in an ambulance for every paramedic fire fighter. The Ordinance
requires a paramedic to ride less than one shift per month.
Dr. Tober stated the requirement resulted from the EMS's experience ",1th EMTs who
had ridden for six months to one year before they continued onto paramedic training.
He cited an example of a physician who is required to complete another 2 to 3 years of
clinical rotation after graduating from medical school and completing one year of
intemship - the pmpose was to obtain constant exposure to a variety of patients.
He further stated EMS ride time was cut to the bare minimum to maintain the integrity of
the system. He noted the focus of ride time for North Naples is the issue of Continuum
of Care because the North Naples Medical Director has a different opinion of what is
necessary for the paramedics under him.
He concluded in North Naples, bare minimum ride time is not a predicate for certification
as it is for EMS.
Deputy Chief Aguilera reiterated North Naples paramedics have a requirement.
Dr. Tober noted the North Naples requirement is distinct from the EMS requirement.
Deputy Chief Aguilera stated the EMS requirement is predicated on time on a truck
while North Naples is predicated on the number of times the paramedic touches the
patient while in the truck.
He clarified the requirement for ride time in North Naples was "internal" and was a
commitment made to the Board of County Commissioners. North Naples' focus is to
ride to provide continuity of care for the patient.
Chief Page reiterated his suggestion to re-insert the language that was previously
stricken: "... or the individual Medical Director of the licensed agency" in Paragraph
"G."
Vice Chairman Kopka supported the ride rime component and stated having different
medical directors could result in fragmented service with different levels of care The
purpose of the Ordinance is to establish a standard and ensure the same level of care
regardless of where a person resides in the County.
Chairman Talano noted when physicians are trained in their specific specialties the
training is based on their experience and physician-patient contact. There are standard
protocols - as minimum requirements - that every resident must fulfill. If not, the
physician will not be able to carry out the duties of the particular residency or specialty.
Chief Metzger stated a paramedic doing ride time receives no value from it unless he/she
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is treating patients, and the needed patient contact time is accomplished through the
Continuum of Care.
Dr. Tober agreed ifthere was Continuum of Care. He cautioned if the nature ofthe
initial contact was to "tag and release" to the EMS paramedic in a situation where ALS
was not initiated, there would be very little ongoing patient care.
(ChiefOrly Stolts arrived at 4:05 PM)
Chief Metzger referred to the last sentence in Paragraph uG", asked if it was new
language and requested clarification because it was open to interpretation.
Deputy Chief Aguilera stated he would obtain clarification.
Chief Page noted "Class-I" did not necessarily refer only to Collier County EMS -
another provider could come into the area.
Chief Metzger agreed the sentence was confusing as to whether it applied to the entire
paragraph or just the previous sentence. He again stated he would obtain clarification.
Vice Chairman Kopka refelTed the Members to Page I of the document.
Discussion ensued.
Chief Page refen-ed. to Page 10 ofthe Ordinance draft (#3 and #4).
Regarding the subject of equipment, it was stated the purpose ofthe language was to
coordinate the type of equipment utilized. It was mentioned Florida Statutes allows each
Medical Director of each agency to develop his/her own equipment list.
Chief Stolts noted North Naples upgraded its monitors recently even though it may be a
year before' Collier EMS decides to also upgrade. He agreed the same equipment should
be used by each service.
Chief Page stated that to leave options open will not lead to agreement.
Deputy Chief Aguilera agreed that, in the future, opinions would come fi'om the Office
of the Medical Director. He stated the NOlth Naples attomeyexpressed concern about
what would happen if there were disagreements and that was the reason why the language
was not more specific.
Chief Page suggested it would be very helpful if North Naples' attorney attended the
next Policy Advisory Board meeting.
Chief Stolts stated he brought the agreed changes to their attorney for review and the
document represented her concerns. He did not think the intent was changed.
Chairman Talano stated that the Board members, having reviewed the handout, had
objections to her clarifications. He asked Chief Stolts had the authority to make changes.
It was noted the document provided to Board of County Commissioners was different
from what was provided to the Members. It was agreed that the members would only
work from the document provided by Chief Page which contained the changes approved
by the Po~icy Advisory Board at the April meeting.
Thefollowing revisions to Section 7, Paragraph ({3" were suggested:
. Third Line: Remove the semi-colon following the word "protocol"
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.. Add the revised last sentence, i.e., "The Office of the Medical Director shall not
be presumed to be the medical directorfor a Class-3 Operatorfor pwposes of
this Ordinance 01' Florida Statutes. ..
Chief Page "vill meet with Deputy Chief Aguilera and Chief Stolts to review the revised
Ordinance and incorporate suggested changes prior to the next Policy Advisory Board
Meeting. It was again suggested that the attorney for North Naples attend the meeting.
Under Section 8, Paragraph ((F," the following revisions were suggested:
. Retain the previously removed language and re-insert it at the end of the fIrst
sentence: "or the individual Medical Director of the licensed agency. ..
New Topic: (Local) DefInition of ALS
Dr. Tober stated he spoke with Deputy Chief Aguilera and as well as to Deputy Chief
Wayne Watson and Deputy Chief Dan Bowman concerning moving two skills to an
Intermediate Paramedic category, i.e., starting a TKO W, or a 3-lead cardiac monitor.
He continued starting either one ofthose skills would not automatically bind a North
Naples paramedic to ride to the hospital. He cautioned the only exception would be if a
patient's condition were so severe that the EMS paramedic requested assistance from the
Fire Department paramedic to ride in.
He continued the change might cut into ride time and patient contact.
Chief Page suggested not implementing changes until completion ofa trial period to
establish the extent of North Naples' current ride time.
Vice Chairman Kopka expressed concern about the change in policy and supported
keeping the old policy in place stating "... if they stalt an IV - they ride; if they give
medication - they ride ... let's not change that."
Chief Page stated his preference was for each paramedic to work ten shifts. He
continued the issue of ride time should not be separated from the Continuum of Care
paragraph.
Chief Stolts reiterated if a paramedic hooked up three-leads to a monitor, and saw
nothing that appeared to be a problem, the two ALS units in that zone would still be taken
out of service.
Dr. Tober noted it could be argued that if a three-lead monitor was hooked up and
nothing was determined, why carry it any further. The other side of the argument was if
starting an IV or the three-lead alone did not require a paramedic to ride to the hospital,
how many times in a 3-month period would North Naples paramedics ride in with a
patient. He stated there is very little actual, ongoing Continuum of Care patient contact.
D~puty Chief Aguilera stated the EMS issue was different from the Continuum of Care
issue; North Naples position is that if the patient needs and ALS care is started, the
paramedic will accompany the patient to the hospital. "That is Continuum of Care - that
is for the patient's benefIt."
He countered starting a three-lead monitor was simply an assessment tool and an
administering an IIV could be nothing more than prophylactic - they were just good
patient care opportunities. "This has nothing to do with augmenting the level of care -- it
is simply about ride time."
He said the Board of County Commissioners ruled on the proposal to augment the level
of care and North Naples committed to it.
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Dr. Tober noted two issues were vying for the paramedic's attention, and one was to
take a common sense approach - to not tie up more units than necessary to take what
appears to be a patient to the hospital.
Deputy Chief Aguilera suggested the definitions contained in the Ordinance should be
examined and clarified. He specifically asked to review the definitions and language.
Chief Metzger noted the COPCN license is renewed annually. Data will be generated by
North Naples ability to provide service and if there is a concern of either the North
Naples Medical Director or the County's Medical Director, then the shOltcomings in
patient care will be addressed. There will be time to investigate.
Chief Metzger made thefollowing motion: uFor Nortlt Naples to take the original
Ordinance draft provided by Chief Page and insert any changes to that language which
they propose to be considered and return it to the Policy Advisory Board for
consideration as soon as possible. JJ
Second by VICe Chairman Kopka.
Chief Stolts suggested meeting 'with Chief Page to discuss the changes and he would
contact the North Naples attorney.
Chief Page suggested emailing the Board to review the changes prio! to the next
meeting.
It was noted to avoid any conflict with the Sunshine Law, suggested changes will be
emailed to Maria Hernandez to distribute to the Board and all interested parties.
Motion carried, 4 - O.
4. New Business:
(None)
5. Staff Reports:
(None)
6. Public Comment:
(see above - Deputy Chief Jorge Aguilera and Chief Orly Stolts)
7. Board Member Comments:
(None) .
. 8. Next Meeting Date: August 19,2011 at 3:30 PM
Note: There may be another meeting scheduled prior to August depending upon when the
changes to the Ordinance draft are completed.
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There being no further business for the good of the County, the Meeting concluded by
order of the Chair at 4:50 PM
COLLIER COUNTY EMERGENCY MEDICAL
SERVICES POLICY ADVISORY BOARD
James Ta
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(\ . \ \(1'~
The Minutes were approved by the Board/Committee Chair on ~q U1s\.:J , 2011,
"as submitted"~, OR "as amended" LJ d
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