EMS Policy Minutes 11/04/2011 November 4,2011
MINUTES OF THE COLLIER COUNTY
EMERGENCY MEDICAL SERVICES POLICY ADVISORY BOARD-9
MEETING Ry7
Hiller
l� Q Fiala 0 31E W
Henning —r' }- November 4, 2011
Coyle r Naples, Florida
Colette �G _
BY:
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:
Chair: James Talano,M.D.
Vice Chair: Chief Walter Kopka
Rosemary LeBailly, RN
Misc.Corres: Chief Robert Metzger
Date: 31►31 ►z
Jerry Pinto
Item it ►L.1? 2\A \
Copies to:
ALSO PRESENT:
Commissioner Fred Coyle, Collier County Board of County Commissioners
Dr. Robert Tober, Collier County Medical Director
Maria Franco, 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
Tabitha Butcher,Battalion Chief
1
November 4,2011
1. CALL TO ORDER:
Chairman James Talano called the meeting to order at 3:40 PM.
A quorum was established. Five members were present.
2. AGENDA AND MINUTES:
A. Approval of Today's Agenda
Chief Robert Metzger moved to approve the Agenda as submitted. Second by Jerry Pinto.
Carried unanimously, 5—0.
B. Approval of Minutes: August 19,2011
Chief Robert Metzger moved to approve the Minutes of the August 19,2011 meeting as
submitted. Second by Rosemary LeBailly. Carried unanimously,3--0.
(Note:
• Jerry Pinto could not vote because he did not attend the August meeting.
• Assistant Chief Kopka could not vote because he resigned as a member of the
Board.
• Battalion Chief Butcher could not vote because she was not a member of the Board
at the August meeting.)
3. OLD BUSINESS:
(None)
4. NEW BUSINESS:
A. Establish Schedule for 2012 Meetings
The Policy Advisory Board approved and adopted the following schedule:
• January 20,2012
• March 23,2012
• May 18,2012
• July 13,2012
• September 21,2012
• November 9,2012
The meetings will be held in the Conference Room at the Neighborhood Health Clinic,
121 Goodlette Road North,commencing at 3:30 PM,unless otherwise notified.
Chairman Talano noted:
• Assistant Chief Walter Kopka resigned from the Policy Advisory Board to serve
as Interim Chief of EMS due to the retirement of Chief Jeff Paige.
• Battalion Chief Tabitha Butcher was appointed by EMS as the EMS
representative to the Policy Advisory Board.
Chairman Talano called for nominations for Vice Chair:
Battalion Chief Butcher nominated Chief Metzger to serve as Vice Chain Second by
Jerry Pinto. Carried unanimously, 4—0. Chief Metzger abstained from voting.
2
November 4,2011
B. Discussion: Ambitran's COPCN("Certificate of Public Convenience and Necessity")
Application
Interim Chief Walter Kopka provided background information
• Ambitran submitted an Application to obtain a Class-2 COPCN in September.
• The Application was reviewed by Staff and forwarded to the BCC.
• The Naples Daily News published articles concerning billing issues between EMS
and the Hospitals.
• Ambitran applied to fill a specific niche: to provide inter-facility medical transfer
services within and outside Collier County
• The Board of County Commissioners approved the application on September 27,
2011 and granted Ambitran a Class 2 Inter-Hospital Certificate.
Chief Kopka noted a Billing Resolution,adopted by the BCC in 2008,provided that the
hospitals would be billed by EMS on a monthly basis for transports from their facilities.
The system functioned as intended,i.e.,the hospitals were invoiced and paid the invoices,
until approximately July 2010 when the hospitals stopped payments.
He stated:
• EMS allocated an additional ambulance for the inter-hospital transports,and paid
the Staff and Crew necessary to provide the service
• Meetings were held with Staff from both hospitals but the hospitals refused to pay
the invoices
• Due to the news coverage,Ambitran became aware of the problems and applied
to provide the service
The Chief continued:
• EMS is not geared to handle inter-facility transports—it is dedicated to providing
"911"emergency service.
• Ambulances that provide transport services are configured and equipped
differently than rescue services vehicles.
• The inter-facility transport staff is trained differently and paid at a different rate
than First Responders.
• Ambitran is dedicated solely to providing inter-facility transport.
• It is in EMS' best interest to allow Ambitran to provide the transport service.
• After Ambitran submitted its application,NCH sent an email to EMS stating it
would no longer provide inter-hospital transport.
He explained a COPCN is not necessary to provide out-of-County transport,i.e.,any
ambulance company can pick up a patient from Collier County and transport to a facility
in another County because the service is not regulated by the BCC.
• Ambitran works in Tampa,in Charlotte and Lee Counties,and has a contract
with the VA to transport clinic patients from St. Petersburg to Lee County.
• [Positive] References were obtained from Lee and Charlotte Counties,as well as
from Physician's Regional Hospital.
3
November 4,2011
Vice Chairman Metzger asked why the COPCN Application was placed on the Board
of County Commissioners' agenda before it was vetted by the Policy Advisory Board.
Chief Kopka stated County Manager and Staff determined that EMS had been carrying
the loss and to continue to pay for the inter-facility transports would place an unfair
burden on the County's taxpayers. The goal was to resolve the issue as quickly as
possible.
Battalion Chief Butcher asked if Ambitran would be used for emergency transports.
Chief Kopka stated both Dr. Tober and the hospitals will determine whether or not
Ambitran could service an emergency call if necessary. He noted the Ordinance
references only"inter-hospital transports"because the definition of"emergency"differs
from case to case.
Dr.Robert Tober explained he has been called by cardiologists for an"emergency"
transport of patient to the cath lab who is in stable condition. In that situation,Ambitran
could transport the patient instead of using an EMS vehicle. [The cardiologist wanted his
patient at the lab as quickly as possible and he considered it to be an"emergency."]
Chief Kopka stated while EMS may never totally extricate itself from transport,its
position would be as"back up"to Ambitran. Ambitran will handle its billing. There are
complicated Medicare rules and regulations to be followed unless the hospital has an
agreement with a provider. The Billing Resolution stated the hospitals were to be billed
monthly for the services provided. The Resolution had been approved by the Board of
County Commissioners. In July 2010,the hospitals decided the Resolution did not apply
any longer and refused to pay the invoices. He stated the billing issue was a difficult
thing to decipher.
Vice Chairman Metzger asked if the current Billing Resolution was going to be
changed and Chief Kopka replied affirmatively.
C. North Naples Medication/Procedure Request
Deputy Chief Wayne Watson stated:
• On October 21,2011,EMS received a letter from the North Naples Fire Control
and Rescue District requesting the addition of several medications and three
protocols to the current ALS non-transport protocol.
• North Naples met with Dr.Tober to begin discussions
• He noted Marco Island submitted a similar request approximately two years ago.
Marco conducted a lengthy study based on its geographic isolation and the time to
respond to locations. Suggestions were made to add several drugs. The Medical
Director met with Marco Island,reviewed the data presented,and expanded the
protocol by four drugs. Marco Island agreed to adopt the medications,and
increase its training and ride requirements.
• Based on the Marco Island research, EMS will provide four medications to North
Naples,i.e.,Atropine, Sodium Bicarbonate,Amiodarone/Lidocaine,and Narcan,
which have been proven effective.
• North Naples will be required to share its data, and revise its training to administer
the medications since they were not included in its standard medication list.
• Regarding the 12-lead EKG, due to technological advances and a reduction of
cost,the Medical Director granted preliminary approval to add it to North Naples'
protocol.
4
November 4,2011
• Marco Island participates in the Quality Assurance program and shares its results
with EMS.
• Marco Island presents a unique circumstance because it is an urban community in
a rural setting.
Vice Chairman Metzger stated he carried the same four medications in his med box
when he was initially certified in 1981. He noted their applications may have changed
over the years but he did not consider them to be"controversial." He asked what was the
basis for North Naples' request,especially with regard to the other medications.
Deputy Chief Jorge Aguilera responded North Naples had created an EMS Council
following its entry into the ALS Engine Program. Among the members of the Council
are the North Naples Medical Director and the two Associate Medical Directors who are
on Staff at NCH and Physician's Regional. During a Council meeting,discussion was
initiated by the Associate Medical Directors who suggested other medications that should
be included as minimum Standard of Care medications for an ALS provider.
He continued the Marco Island Fire Chief sent a letter in support of the addition of the
medications to the North Naples' protocol. He stated North Naples did not want to wait
until there was an incident in the field to request the additional medications which are
also considered to be Standard of Care by the American Heart Association.
Dr.Tober noted North Naples had acquired the same software as EMS and requested to
be provided monthly reports on ALS activities and hand-offs. He continued that in view
of the quick response time of the transport units and the average time/use of the requested
drugs,there may not be a compelling medical reason to distribute them. He recognized
there may be political reasons motivating the request for additional drugs.
Deputy Chief Aguilera requested Dr. Tober to provide his recommendation in writing.
Vice Chairman Metzger requested clarification from Dr.Tober.
Dr.Tober responded he has not received any reports on North Naples' activities,i.e.,
what is being done on scene and when. EMS run reports specify when a call originates in
North Naples and he stated one item of study is the overall provision of medical care at
the scene. While inclusion of the four drugs initially requested has been approved,a
decision on whether or not the other drugs are actually necessary can not be made until he
has received reports from North Naples.
Chairman Talano moved to approve distribution of the four drugs(Atropine,Sodium
Bicarbonate,Amiodarone/Lidocaine, and Narcan) as requested, and supported Dr.
Tober's proposal to determine if the other five medications are necessary only after
North Naples has submitted its monthly activities report.
Second by Rosemary LeBailly. Carried unanimously, 5—0.
Dr.Tober stated there were two unrelated issues concerning the 12-lead EKG. One was to
conduct the procedure in a quieter environment after patient is loaded onto the ambulance.
The other issue was if applications for 12-leads are granted to Marco Island and North
Naples,would it also be necessary to purchase 12-leads for the City of Naples.
Interim Chief Kopka noted cost is a factor. Auto-pulses are available and exceptions have
been created for its use. He confirmed Fire Districts are not obligated to obtain a 12-lead
EKG.
5
November 4,2011
Chairman Talano stated there are situations during the critical first 17 minutes of the call
when use of a 12-lead would be more helpful than the standard leads. He noted the request
for the 12-lead EKG had been approved by Dr. Tober.
Vice Chairman Metzger asked why chest decompression and external jugular would not be
granted. He acknowledged the procedures are not new and do carry some risk, but chest
decompression specifically could be acutely necessary. He was concerned that paramedics
would not be allowed to perform the it.
Dr. Tober responded part of the issue is to determine exactly what his office is responsible
for with another system's COPCN when it is implied he is the final overseer. He does not
train the North Naples paramedics. He continued the likelihood of a paramedic competently
performing either of the procedures is rare—even for full-time EMS providers—and less so
for North Naples where it would be the first time for many of its paramedics.
He referenced the Blue Ribbon Committee which strongly suggested that the number of
people armed with ALS capabilities is limited to mirror King County(Seattle,Washington).
Almost immediately after the suggestion was made,the Board of County Commissioners did
the opposite by granting a politically-charged COPCN to North Naples.
Vice Chairman Metzger admitted there were only a few times when he needed that skill
(i.e.,chest decompression)but when it was necessary,it was an immediate need because the
"patient as circling the drain"and without the ability to give chest decompression,the
outcome for the patient may have been different.
Dr.Taber stated King County has a population of two million and 250 paramedics while
Collier County has approximately 200 paramedics but only 450,000 people at the height
of season. The issue is adopting King County's proven profiles versus doing"whatever"
based on political whims.
Vice Chairman Metzger stated chest decompression is a training-associated skill that all
paramedics should know.
Dr.Tober countered external jugular is totally unnecessary since there are much safer, easier
way to access circulation.
Deputy Chief Watson noted the response units are equipped with I-O needles.
Vice Chairman Metzger reiterated check decompression should be granted.
Dr.Tober asked if it should be a BLS skill.
Battalion Chief Butcher suggested a more important skill was the ability to recognize
when chest depression should be administered immediately versus when it was necessary
to wait.
Deputy Chief Watson stated since it is does not come up very often,a protocol for
tension pneumothorax had not been developed.
Dt.Tober confirmed that 99%of chest decompressions administered were during traumatic
cardiac arrest calls.
Chairman Talano noted the other component was training and the availability of required
equipment.
Deputy Chief Aguilera stated simulators or manikins were used for practice.
Dr.Tober agreed with Battalion Chief Butcher that the ability to recognize when chest
depression was appropriate was more important than the ability to administer it.
Vice Chairman Metzger concurred but stated recognition was part of the physical skill that
should be taught as part of the training process. He stated supported granting the request
although not necessarily as a BLS skill. Individuals trained only as EMT/First Responders
should not necessarily be exposed, but definitely for Paramedics.
6
•
November 4,2011
Vice Chairman Metzger moved to approve granting North Naples'request to administer
chest decompression along with 12-lead EKG.
(It was noted the request for the 12-lead EKG has been granted.)
A second in support of the motion was not made. The Motion failed.
D. North Naples Equipment—Field Test of the Lucas Device
• It is an external chest compression device similar to the auto-pulse.
• It does not use bands as does the Auto Pulse—which are costly—and has a better
battery system.
Chairman Talano asked how the devices differ from each other.
It was noted:
• Originally it contained compressed air—it has been revised as a piston driven devise
—precision designed
• The rate of compression follows the AHA guidelines at 100 per minutes
• The Auto-Pulse rate of compression is 80 beats per minute
• The Auto-Pulse bands are single-use only and cost$130 each
• The Lucas features a suction cup which is reusable after cleaning and sterilization
• It is lighter and smaller
• Preliminary field test results are that it is quicker and easier to use.
• The Lucas Device is used when a patient has suffered cardiac arrest and is not
breathing—it performs chest compressions. The piston is adjustable and sensitive to
the depth of a patient's chest.
Deputy Chief Watson noted despite the expense,there have been very good results from
use of the Auto-Pulse. He stated the goal is to achieve comparable results from the Lucas
Device which is being tested by North Naples..
Dr.Tober stated the mechanical compression device used by EMS "bear hugs"the
patient and it has been very successful. The battery life is a problem and the expense of
the single-use bands.
S. STAFF REPORTS:
• Interim EMS Chief Kopka
o Extended an invitation to the Board to ride along on an EMS vehicle
o Is still trying to absorb the office procedures and will base his decisions on
statistics—data driven
o Is available to provide information on a quarterly basis regarding budget items
or response times,etc.,as requested
o Trying to utilize technology: Investigating a new tablet which is similar to the
I-Pad but less expensive—i.e.,dispatch information with a map and directions is
sent to the tablet
o Also field testing new programs such as Google-translator(from English to
other languages and vice versa)—it has the ability to ask simple medical
questions, i.e.,"Where is your pain? Do you have chest pain?"
7
November 4,2011
Chairman Talano requested a report on the effectiveness of the new tablet on response
times.
Chief Kopka will present data at the next meeting.
6. PUBLIC COMMENT:
(None)
7. BOARD MEMBER DISCUSSION:
(None)
8. NEXT MEETING DATE:Friday,January 20,2012 at 3:30 PM
There being no further business for the good of the County,the Meeting concluded by
order of the Chair at 4:43 PM.
EMERGENCY MEDICAL SERVICES POLICY
ADVISORY BOARD
James T. I,110 D.,Chairman
The Minutes were ppproved by the Board/Committee Chair on NOJe 1i x ! 2011ry
"as submitted" [V] OR "as amended" [ 1
8