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Agenda 10/08/2013 Item #11C 10/8/2013 11 .C. EXECUTIVE SUMMARY Recommendation to accept the information collected from the Public Safety Authority, County Medical Director's Office, County Emergency Medical Services and Physicians Regional Hospital regarding issues raised in agenda Item 101 on the May 14, 2013 BCC meeting relative to medical protocols. OBJECTIVE: To present information requested pursuant to Board action on Item 10.I. on the May 14, 2013 meeting agenda. CONSIDERATIONS: At the May 14, 2013 County Commission meeting, Commissioner Hiller presented agenda Item 10.1. requesting action be taken relative to the issues outlined in the executive summary. After Board discussion, the following motion was adopted, "The motion is for the County Manager to collect information from the PSA, the Medical Director, EMS and if Physicians Regional wishes to participate, information from them, and compile it and send it to the Board of County Commissioners for the purpose of resolving what apparently are differences in interpretation of the protocol and the applicability to protocol." The County Manager has collected the information requested from the above named agencies and has included same as backup material to this executive summary. FISCAL IMPACT:None LEGAL CONSIDERATIONS: This item has been reviewed by the County Attorney, raises no legal issues at this time, and requires majority vote for acceptance. -JAK GROWTH MANAGEMENT IMPACT: None RECOMMENDATION: To accept the information collected from the Public Safety Authority, County Medical Director's Office, County Emergency Medical Services and Physicians Regional Hospital regarding issues raised in agenda Item 10.I. on the May 14, 2013 BCC meeting relative to medical protocols. Prepared By: Leo E. Ochs,Jr., County Manager Packet Page-842- 10/8/2013 11 .C. COLLIER COUNTY Board of County Commissioners Item Number: 11.11.C. Item Summary: Recommendation to accept the information collected from the Public Safety Authority, County Medical Director"s Office, County Emergency Medical Services and Physicians Regional Hospital regarding issues raised in agenda Item 101 on the May 14, 2013 BCC meeting relative to medical protocols. (Leo E. Ochs,Jr., County Manager) Meeting Date: 10/8/2013 Prepared By Approved By Name: OchsLeo Title: County Manager Date: 10/2/2013 4:11:37 PM Packet Page-843- 10/8/2013 11.C. J/ I TI •J I J I. EXECUTIVE SUMMARY Recommendation that the Board of County Commissioners direct the `Medical Director Subcommittee' of the PSA investigate claims of actual and potential failed calls as they relate to protocols and training promulgated under the current county Medical Director. A full investigation is required to be conducted given the PSA's obligation to provide a quality assurance process and a duty to investigate problems as they arise and recommend solutions promptly. There are three matters that require such investigation: 1. In January, 2013 the county's Medical Director released updated protocols as final without allowing for review. The consequence was that protocols were released as official which contained life threatening standards. For example - a protocol was released with respect to pediatric rescue breathing which was incorrect, and, if administered by an EMS provider as prescribed would result in the death of the child. Protocols should not be released as official until validated by the appropriate agencies/boards. Medical accuracy is mandatory. 2. A young man passed away, allegedly because EMS failed to timely arrive at the scene. EMS claimed that no emergency tone was heard. There are complaints that the county's 800 Mega Hertz communications system is failing to set off the appropriate tones which are used to alert emergency vehicles of an incoming call. These failures are being reported as happening daily and may have contributed towards the death of one resident, and is threatening the lives of all. This matter must be immediately investigated and addressed. 3. A letter received from Physician's Regional Hospital, dated May 6, 2013 explains that the county's medical director was working "extremely closely with NCH to promulgate protocols seemingly effectuated by the threat of loss of market share to NCH." In an email dated December 20,2012, the county's medical director advocated against certain stroke protocols because these protocols would "divert 40% of the patients currently going to NCH." The medical director was in effect seemingly making decisions about which protocols were to be adopted based on how NCH's market share would be affected if stroke patients were transported to Physician Regional's new Comprehensive Stroke Center (the only such accredited stroke center in SW Florida) rather than to NCH. Protocols must be developed on what is in the best interest of the patient, not in any way based on the market share a hospital might lose. It appears that only 12-15% of the county's stroke victims are being transported to Physicians Regional notwithstanding the current protocol. There are two recent stroke related deaths where the patients were transported to NCH rather than the Physician's Regional stroke center begging the question as to whether these patients might have survived if transported to the stroke center. What has transpired is of the utmost seriousness. A full study into how many patients are being transported by county EMS to one hospital over another hospital is needed. Further,the timeliness and basis on which protocols are being established needs to be fully investigated. Lastly, the training of providers as to directions on where patients shall be transported under which conditions needs to be investigated. The Packet Page-214- Packet Page-844- 10/8/2013 11 .C. V/ I-T/ development of protocols and training of the EMS providers are the responsibility of the county's medical director. OBJECTIVE: That the Board of County Commissioners direct the `Medical Director Subcommittee' of the PSA investigate claims of actual and potential failed calls as they relate to protocols and training promulgated under the current county Medical Director. A full investigation is required to be conducted given the PSA's obligation to provide a quality assurance process and a duty to investigate problems as they arise and recommend solutions promptly. There are three matters that require such investigation: 1. In January, 2013 the county's Medical Director released updated protocols as final without allowing for review. The consequence was that protocols were released as official which contained life threatening standards. For example - a protocol was released with respect to pediatric rescue breathing which was incorrect, and, if administered by an EMS provider as prescribed would result in the death of the child. Protocols should not be released as official until validated by the appropriate agencies/boards. Medical accuracy is mandatory. 2. A young man passed away, allegedly because EMS failed to timely arrive at the scene. EMS claimed that no emergency tone was heard. There are complaints that the county's 800 Mega Hertz communications system is failing to set off the appropriate tones which are used to alert emergency vehicles of an incoming call. These failures are being reported as happening daily and may have contributed towards the death of one resident, and is threatening the lives of all. This matter must be immediately investigated and addressed. 3. A letter received from Physician's Regional Hospital, dated May 6, 2013 explains that the county's medical director was working "extremely closely with NCH to promulgate protocols seemingly effectuated by the threat of loss of market share to NCH." In an email dated December 20, 2012, the county's medical director advocated against certain stroke protocols because these protocols would "divert 40% of the patients currently going to NCH." The medical director was in effect seemingly making decisions about which protocols were to be adopted based on how NCH's market share would be affected if stroke patients were transported to Physician Regional's new Comprehensive Stroke Center (the only such accredited stroke center in SW Florida) rather than to NCH. Protocols must be developed on what is in the best interest of the patient, not in any way based on the market share a hospital might lose. It appears that only 12-15% of the county's stroke victims are being transported to Physicians Regional notwithstanding the current protocol. There are two recent stroke related deaths where the patients were transported to NCH rather than the Physician's Regional stroke center begging the question as to whether these patients might have survived if transported to the stroke center. What has transpired is of the utmost seriousness. A full study into how many patients are being transported by county EMS to one hospital over another hospital is needed. Further, the timeliness and basis on which protocols are being established needs to be fully investigated. Lastly, the training of providers as to directions on where patients shall be transported under which conditions needs to be investigated. The development of protocols and training of the EMS providers are the responsibility of the county's medical director. Packet Page-215- Packet Page-845- 10/8/2013 11 .C. .J/ I't/LV 1J I. CONSIDERATIONS: The PSA has a duty to ensure quality assurance of protocols and training promulgated/provided by the county's medical director. There have been numerous instances where such protocols and training have come into question, putting lives at risk. The Medical Director Subcommittee shall be tasked with the investigation of the three matters raised in this executive summary - specifically as relating to the release of inaccurate protocols, the failing county EMS communications system, the development of protocols based on hospital market share rather than patient care, and, training with respect to transport - again based on hospital market share rather than what is in the patient's best interest. These are matters of great importance since they involve the public's health and safety. The Board of County Commissioners cannot ignore what has come to light and must take corrective action as quickly as possible. FISCAL IMPACT: None at this time. LEGAL CONSIDERATIONS: This item has been reviewed by the County Attorney. If the Board wishes to pursue this matter, then for the sole purpose of minimizing the County's litigation exposure, the County Attorney requests that the Board directs the County Attorney to work with the County Manager in structuring and coordinating this investigation with the PSA. -JAK RECOMMENDATION: That the Board of County Commissioners direct the `Medical Director Subcommittee' of the PSA investigate claims of actual and potential failed calls as they relate to protocols and training promulgated under the current county Medical Director. A full investigation is required to be conducted given the PSA's obligation to provide a quality assurance process and a duty to investigate problems as they arise and recommend solutions promptly. There are three matters that require such investigation: 1. In January, 2013 the county's Medical Director released updated protocols as final without allowing for review. The consequence was that protocols were released as official which contained life threatening standards. For example - a protocol was released with respect to pediatric rescue breathing which was incorrect, and, if administered by an EMS provider as prescribed would result in the death of the child. Protocols should not be released as official until validated by the appropriate agencies/boards. Medical accuracy is mandatory. 2. A young man passed away, allegedly because EMS failed to timely arrive at the scene. EMS claimed that no emergency tone was heard. There are complaints that the county's 800 Mega Hertz communications system is failing to set off the appropriate tones which are used to alert emergency vehicles of an incoming call. These failures are being reported as happening daily and may have contributed towards the death of one resident, and is threatening the lives of all. This matter must be immediately investigated and addressed. 3. A letter received from Physician's Regional Hospital, dated May 6, 2013 explains that the county's medical director was working "extremely closely with NCH to promulgate protocols seemingly effectuated by the threat of loss of market share to NCH." In an email dated December 20, 2012, the county's medical director advocated against certain stroke protocols because these protocols would "divert 40% of the patients currently going to NCH." The Packet Page-216- Packet Page-846- 10/8/2013 11 .0. U/ I'tiLU I J I. medical director was in effect seemingly making decisions about which protocols were to be adopted based on how NCH's market share would be affected if stroke patients were transported to Physician Regional's new Comprehensive Stroke Center (the only such accredited stroke center in SW Florida) rather than to NCH. Protocols must be developed on what is in the best interest of the patient, not in any way based on the market share a hospital might lose. It appears that only 12-15%of the county's stroke victims are being transported to Physicians Regional notwithstanding the current protocol. There are two recent stroke related deaths where the patients were transported to NCH rather than the Physician's Regional stroke center begging the question as to whether these patients might have survived if transported to the stroke center. What has transpired is of the utmost seriousness. A full study into how many patients are being transported by county EMS to one hospital over another hospital is needed. Further, the timeliness and basis on which protocols are being established needs to be fully investigated. Lastly, the training of providers as to directions on where patients shall be transported under which conditions needs to be investigated. The development of protocols and training of the EMS providers are the responsibility of the county's medical director. PREPARED BY: Commissioner Georgia Hiller, Chair-District 2 Attachment.-Physician's Regional Letter dated May 6, 2013 mmimimiimimommimimmmimmimi Packet Page-217- Packet Page-847- 10/8/2013 11 .C. May 14, 2013 TRANSCRIPT OF THE MEETING OF THE BOARD OF COUNTY COMMISSIONERS Naples, Florida May 14, 2013 LET IT BE REMEMBERED, that the Collier County Commissioners, in and for the County of Collier, having conducted business herein, met on this date at 9:00 a.m. in REGULAR SESSION in Building "F" of the Government Complex, East Naples, Florida, with the following members present: CHAIRWOMAN: Georgia Hiller Tom Henning Tim Nance Donna Fiala Fred Coyle ALSO PRESENT: Jeffrey Klatzkow, County Attorney Leo E. Ochs, Jr., County Manager Crystal Kinzel, Clerk's Finance Director Mike Sheffield, Business Operations Manager - CMO Troy Miller, Television Operations Manager Page 1 Packet Page-848- 10/8/2013 11 .C. Item #10I THE BOARD OF COUNTY COMMISSIONERS DIRECT THE `MEDICAL DIRECTOR SUBCOMMITTEE' OF THE PSA INVESTIGATE CLAIMS OF ACTUAL AND POTENTIAL FAILED CALLS AS THEY RELATE TO PROTOCOLS AND TRAINING PROMULGATED UNDER THE CURRENT COUNTY MEDICAL DIRECTOR. A FULL INVESTIGATION IS REQUIRED TO BE CONDUCTED GIVEN THE PSA'S OBLIGATION TO PROVIDE A QUALITY ASSURANCE PROCESS AND A DUTY TO INVESTIGATE PROBLEMS AS THEY ARISE AND RECOMMEND SOLUTIONS PROMPTLY — MOTION TO REQUEST THE INSPECTOR GENERAL WITH FLORIDA'S DEPARTMENT OF HEALTH INVESTIGATE CLAIMS — FAILED; MOTION DIRECTING THE COUNTY MANAGER TO GATHER INFORMATION FROM ALL AGENCIES (PSA, EMS, MEDICAL DIRECTOR AND PHYSICIANS REGIONAL) AND REPORT BACK TO THE BOARD FOR DETERMINING ACCURACY — APPROVED COMMISSIONER COYLE: The motion is for the County Manager to collect information from the PSA, the Medical Director, EMS and if Physicians Regional wishes to participate, information from them, and compile it and send it to the Board of County Commissioners for the purpose of resolving what apparently are differences in interpretation of the protocol and the applicability to protocol. CHAIRWOMAN HILLER: Do I have a second? COMMISSIONER NANCE: There's a second. CHAIRWOMAN HILLER: So Commissioner Coyle has Packet Page-849- 10/8/2013 11.C. made a motion, Commissioner Nance has made a second. There being no further discussion, all in favor? COMMISSIONER FIALA: Aye. COMMISSIONER HENNING: Aye. COMMISSIONER COYLE: Aye. COMMISSIONER NANCE: Aye. CHAIRWOMAN HILLER: Any opposed? Aye. Motion carries 4-1 with Commissioner Hiller dissenting. And my comment is this is an attempt at a coverup. sow Packet Page-850- 10/8/2013 11.C. Public Safety Authority Information Packet Page-851- 10/8/2013 11 .C. Collier County Public Safety Authority September 23, 2013 Leo E. Ochs, Jr. Collier County Manager 3299 Tamiami Trail East Naples, FL 34112 Dear Mr. Ochs, Reference your letter dated June 17, 2013,requesting the Public Safety Authority (PSA) to review and evaluate issues discussed at the Board of County Commissioners (BCC) May 14, 2013 meeting,relating to agenda item 10 I. The PSA discussed these issues at the September 18, 2013 meeting and provide the following responses. 1. The Executive Summary for the first item stated that: "... the county's Medical Director released updated protocols as final without allowing for review." The PSA found that statement to be incorrect (by a unanimous vote). During the November 14, 2012 PSA Medical Directors Subcommittee meeting, electronic CDs were provided including the 2013-2014 proposed changes. No agency requested changes and during the January 16,2013 PSA Medical Directors Subcommittee meeting, CDs were again distributed, containing an electronic copy of the completely revised 2013-2014 protocols that would become effective on February 1, 2013. 2. The Executive Summary for that first item also stated: "The consequence was that protocols were released as official which contained life threatening standards. For example—a protocol was released with respect to pediatric rescue breathing which was incorrect and, if administered by an EMS provider would result in the death of the child." This statement appears to relate to a discussion during the April 17, 2013 Medical Directors Subcommittee meeting where Dr. Deborah Lopez recommended a change to the protocol for Pediatric Head injuries, stating that the ventilation rate of 10 breaths per minute has been determined to be inadequate and the rate should be based on the age of the child. As a result of that discussion, a change to EMS protocols was made on May 20, 2013,to divide the Respiratory Rate into three separate age groups: infant, child and adolescent. Packet Page-852- 10/8/2013 11 .C. Medical protocols are reviewed and adjusted on a continuing basis. In this instance, a local pediatric physician proactively proposed a protocol change,the PSA Medical Directors Subcommittee discussed the issue, accepted the recommendation and revised the protocol. The PSA determined (by a unanimous vote)that at NO time did EMS have a pediatric ventilation protocol that would have resulted in the death of a child. 3. The Executive Summary for the second item addressed the issues raised in a letter, dated May 6, 2013, from Physicians Regional Healthcare System(PRHS). The letter states, among other things, that the Medical Director is not following the new EMS protocols for transport of stroke patients to PRHS. On November 19, 2012, PRHS became a Comprehensive Stroke Center. On January 29, 2013, the PSA Medical Directors subcommittee and physicians from NCH and PRHS completed negotiations on a protocol change and agreed to have the more severe stroke patients transported by EMS to PRMC. You identified some of the issues included in the PRHS letter and requested the PSA to determine"... whether EMS under the direction of the County's Medical Director is following the adopted stroke protocols, including(1) the degree to which such protocols are being followed, (2)the numbers of patients being transported to which hospital and under what circumstances and(3)whether any protocols have been implemented or decisions made regarding stroke protocols based on market share to any specific hospital." The PSA discussed the various aspects of these issues, including a September 17, 2013 letter from PRHS which concluded that: "Physicians Regional Healthcare System is satisfied that, as of the date of this letter,the CCEMS Stroke Protocols are current and are being followed appropriately." After review of a variety of documents and discussion of the issue,the PSA determined (by a vote of 7 to 4) that: • All protocols were followed since February 1st, when they were initiated. EMS stated that all protocols are being followed 100%. • The number of patients being transported to the two respective hospitals stroke systems was consistent with these new protocols. During the first quarter of 2013 (with 2 months under the new protocols), PRHS--Pine Ridge was already receiving 49% of stroke transports and, during the second quarter,they received 71% of stroke patients. • There were no protocols or decisions implemented that reflected an attempt to protect the market share of Naples Community Hospital. • A summary letter, dated September 17, 2013, from Scott Campbell, PRHS CEO, reflects that all misunderstandings from the last 5 or 6 months of protocol initiation have been resolved. • There were legitimate concerns based on technical issues at the root of the misunderstandings and those things have been addressed. It did not bear out that there Packet Page-853- 10/8/2013 11 .C. was any ill will or market grabbing. There were well-intentioned providers trying to do the right thing—looking at data sets from different perspectives and drawing different conclusions. 4. Your letter also requested all relevant supporting documentation. A large number of documents were reviewed by PSA members, including BCC executive summaries, minutes of the May 14, 2013 BCC meeting, PSA Medical Directors subcommittee minutes, PRHS letters and letters in response, EMS information showing timelines of protocol reviews, charts showing protocol changes, transport of stroke patients to all area hospitals during the first and second quarters of 2013, etc. All information reviewed by PSA members is available in the EMS office coordinating PSA activities. 5. Additionally, the PSA is continuing to review the proposed Office of Medical Director organization, as requested by the BCC at their May 14, 2013 meeting (item 10H). North Naples Fire District Deputy Chief for EMS Jorge Aguilera, originator of this proposed organization, will make a presentation to the PSA at a special meeting on October 30, 2013. PSA members will evaluate the proposed organizational structure at this meeting. The PSA will also consider several potential ordinance changes on October 30, to be presented at a future BCC meeting. Sincerely, 7 Reg Buxton, Ckiir Collier County Public Safety Authority cc Commission Chair Georgia Hiller Commission Vice Chair Tom Henning Commissioner Fred Coyle Commissioner Donna Fiala Commissioner Tim Nance Packet Page-854- . 10/8/2013 11 .C. 7T " Office of the County Manager c Leo E. Ochs, Jr. -' 3299 Tamiami Trail East,Suite 202•Naples Florida 34112-5746•(239)252-8383•FAX:(239)252-4010 June 27, 2013 Mr. Reg Buxton 11806 Quail Village Way Naples FL 34119 Dear on, Following discussion of enclosed agenda item 10.I at the May 14, 2013 BCC meeting,the Board directed me to gather information from multiple agencies with respect to items 1 and 3 of this executive summary and to report back to the Board. I am advised by Chief Kopka that the full PSA and/or one of its sub-committees has previously reviewed and discussed these issues. To aid me in my further review of these matters, I would ask that you provide a summary of the PSA's review, evaluation and actions taken to date with respect to items 1 and 3 of the executive summary and all relevant supporting documentation. Additionally,please forward any other information that the PSA believes would further assist me in the conduct of this review. I would very much appreciate receiving this information no later than August 1, 2013. Thank you for your prompt consideration of this request and for your continued service to our community. Best regards, ,___c__ _ Leo E. Ochs, Jr. County Manager Packet Page-855- 10/8/2013 11 .C. EXECUTIVE SUMMARY Recommendation that the Board of County Commissioners direct the `Medical Director Subcommittee' of the PSA investigate claims of actual and potential failed calls as they relate to protocols and training promulgated under the current county Medical Director. A full investigation is required to be conducted given the PSA's obligation to provide a quality assurance process and a duty to investigate problems as they arise and recommend solutions promptly. There are three matters that require such investigation: 1. In January, 2013 the county's Medical Director released updated protocols as final without allowing for review. The consequence was that protocols were released as official which contained life threatening standards. For example - a protocol was released with respect to pediatric rescue breathing which was incorrect, and, if administered by an EMS provider as prescribed would result in the death of the child. Protocols should not be released as official until validated by the appropriate agencies/boards. Medical accuracy is mandatory. 2. A young man passed away, allegedly because EMS failed to timely arrive at the scene. EMS claimed that no emergency tone was heard. There are complaints that the county's 800 Mega Hertz communications system is failing to set off the appropriate tones which are used to alert emergency vehicles of an incoming call. These failures are being reported as happening daily and may have contributed towards the death of one resident, and is threatening the lives of all. This matter must be immediately investigated and addressed. 3. A letter received from Physician's Regional Hospital, dated May 6, 2013 explains that the county's medical director was working "extremely closely with NCH to promulgate protocols seemingly effectuated by the threat of loss of market share to NCH." In an email dated December 20, 2012, the county's medical director advocated against certain stroke protocols because these protocols would "divert 40% of the patients currently going to NCH." The medical director was in effect seemingly making decisions about which protocols were to be adopted based on how NCH's market share would be affected if stroke patients were transported to Physician Regional's new Comprehensive Stroke Center (the only such accredited stroke center in SW Florida) rather than to NCH. Protocols must be developed on what is in the best interest of the patient, not in any way based on the market share a hospital might lose. It appears that only 12-15% of the county's stroke victims are being transported to Physicians Regional notwithstanding the current protocol. There are two recent stroke related deaths where the patients were transported to NCH rather than the Physician's Regional stroke center begging the question as to whether these patients might have survived if transported to the stroke center. What has transpired is of the utmost seriousness. A full study into how many patients are being transported by county EMS to one hospital over another hospital is needed. Further,the timeliness and basis on which protocols are being established needs to be fully investigated. Lastly, the training of providers as to directions on where patients shall be transported under which conditions needs to be investigated. The Packet Page-856- 10/8/2013 11.C. development of protocols and training of the EMS providers are the responsibility of the county's medical director. OBJECTIVE: That the Board of County Commissioners direct the `Medical Director Subcommittee' of the PSA investigate claims of actual and potential failed calls as they relate to protocols and training promulgated under the current county Medical Director. A full investigation is required to be conducted given the PSA's obligation to provide a quality assurance process and a duty to investigate problems as they arise and recommend solutions promptly. There are three matters that require such investigation: 1. In January, 2013 the county's Medical Director released updated protocols as final without allowing for review. The consequence was that protocols were released as official which contained life threatening standards. For example - a protocol was released with respect to pediatric rescue breathing which was incorrect, and, if administered by an EMS provider as prescribed would result in the death of the child. Protocols should not be released as official until validated by the appropriate agencies/boards. Medical accuracy is mandatory. 2. A young man passed away, allegedly because EMS failed to timely arrive at the scene. EMS claimed that no emergency tone was heard. There are complaints that the county's 800 Mega Hertz communications system is failing to set off the appropriate tones which are used to alert emergency vehicles of an incoming call. These failures are being reported as happening daily and may have contributed towards the death of one resident, and is threatening the lives of all. This matter must be immediately investigated and addressed. 3. A letter received from Physician's Regional Hospital, dated May 6, 2013 explains that the county's medical director was working "extremely closely with NCH to promulgate protocols seemingly effectuated by the threat of loss of market share to NCH." In an email dated December 20, 2012, the county's medical director advocated against certain stroke protocols because these protocols would "divert 40% of the patients currently going to NCH." The medical director was in effect seemingly making decisions about which protocols were to be adopted based on how NCH's market share would be affected if stroke patients were transported to Physician Regional's new Comprehensive Stroke Center (the only such accredited stroke center in SW Florida) rather than to NCH. Protocols must be developed on what is in the best interest of the patient, not in any way based on the market share a hospital might lose. It appears that only 12-15%of the county's stroke victims are being transported to Physicians Regional notwithstanding the current protocol. There are two recent stroke related deaths where the patients were transported to NCH rather than the Physician's Regional stroke center begging the question as to whether these patients might have survived if transported to the stroke center. What has transpired is of the utmost seriousness. A full study into how many patients are being transported by county EMS to one hospital over another hospital is needed. Further,the timeliness and basis on which protocols are being established needs to be fully investigated. Lastly, the training of providers as to directions on where patients shall be transported under which conditions needs to be investigated. The development of protocols and training of the EMS providers are the responsibility of the county's medical director. Packet Page-857- 10/8/2013 11 .C. CONSIDERATIONS: The PSA has a duty to ensure quality assurance of protocols and training promulgated/provided by the county's medical director. There have been numerous instances where such protocols and training have come into question, putting lives at risk. The Medical Director Subcommittee shall be tasked with the investigation of the three matters raised in this executive summary - specifically as relating to the release of inaccurate protocols, the failing county EMS communications system, the development of protocols based on hospital market share rather than patient care, and, training with respect to transport - again based on hospital market share rather than what is in the patient's best interest. These are matters of great importance since they involve the public's health and safety. The Board of County Commissioners cannot ignore what has come to light and must take corrective action as quickly as possible. FISCAL IMPACT: None at this time. LEGAL CONSIDERATIONS: This item has been reviewed by the County Attorney. If the Board wishes to pursue this matter, then for the sole purpose of minimizing the County's litigation exposure, the County Attorney requests that the Board directs the County Attorney to work with the County Manager in structuring and coordinating this investigation with the PSA. -JAK RECOMMENDATION: That the Board of County Commissioners direct the `Medical Director Subcommittee' of the PSA investigate claims of actual and potential failed calls as they relate to protocols and training promulgated under the current county Medical Director. A full investigation is required to be conducted given the PSA's obligation to provide a quality assurance process and a duty to investigate problems as they arise and recommend solutions promptly. There are three matters that require such investigation: 1. In January, 2013 the county's Medical Director released updated protocols as final without allowing for review. The consequence was that protocols were released as official which contained life threatening standards. For example - a protocol was released with respect to pediatric rescue breathing which was incorrect, and, if administered by an EMS provider as prescribed would result in the death of the child. Protocols should not be released as official until validated by the appropriate agencies/boards. Medical accuracy is mandatory. 2. A young man passed away, allegedly because EMS failed to timely arrive at the scene. EMS claimed that no emergency tone was heard. There are complaints that the county's 800 Mega Hertz communications system is failing to set off the appropriate tones which are used to alert emergency vehicles of an incoming call. These failures are being reported as happening daily and may have contributed towards the death of one resident, and is threatening the lives of all. This matter must be immediately investigated and addressed. 3. A letter received from Physician's Regional Hospital, dated May 6, 2013 explains that the county's medical director was working "extremely closely with NCH to promulgate protocols seemingly effectuated by the threat of loss of market share to NCH." In an email dated December 20, 2012, the county's medical director advocated against certain stroke protocols because these protocols would "divert 40% of the patients currently going to NCH." The Packet Page-858- 10/8/2013 11.C. medical director was in effect seemingly making decisions about which protocols were to be adopted based on how NCH's market share would be affected if stroke patients were transported to Physician Regional's new Comprehensive Stroke Center (the only such accredited stroke center in SW Florida) rather than to NCH. Protocols must be developed on what is in the best interest of the patient, not in any way based on the market share a hospital might lose. It appears that only 12-15% of the county's stroke victims are being transported to Physicians Regional notwithstanding the current protocol. There are two recent stroke related deaths where the patients were transported to NCH rather than the Physician's Regional stroke center begging the question as to whether these patients might have survived if transported to the stroke center. What has transpired is of the utmost seriousness. A full study into how many patients are being transported by county EMS to one hospital over another hospital is needed. Further,the timeliness and basis on which protocols are being established needs to be fully investigated. Lastly, the training of providers as to directions on where patients shall be transported under which conditions needs to be investigated. The development of protocols and training of the EMS providers are the responsibility of the county's medical director. PREPARED BY: Commissioner Georgia Hiller, Chair-District 2 Attachment-Physician's Regional Letter dated May 6,2013 Packet Page-859- 10/8/2013 11 .C. 12 PHYSICIANS REGIONAL HEALTHCARE SYSTEM May 6, 2013 Collier County Board of County Commissioners do The Honorable Georgia Hiller, Chairwoman 3299 Tamiami Trail East, Suite 303 Naples, FL 34112 Dear Commissioner Hiller: There has been much public discussion recently regarding the Medical Director position for Collier County. The decision about how to proceed is one in which only the Commissioners can make, and Physicians Regional Healthcare System stands ready to support whatever decision you make. However, there have been comments made publicly which we feel need to be clarified. It is our responsibility- and one we take seriously-to provide the best care possible, as quickly as possible, to patients who have emergency conditions. To that end, we have made serving patients in an emergency condition a major priority. For example, as of May 3, 2013,the federal government's own website points out(www.hospitalcompare.hhs.00v)that patients who present to our Emergency Department are seen by a professional faster(in 35 minutes, vs. 72 minutes at NCH), receive pain medication faster for broken bones (53 minutes vs. 79 minutes at NCH), and leave without being seen at a lower rate (2%vs. 4% at NCH). This is not to say the care at NCH is not excellent, and certainly, we believe both systems prioritize care for patients in emergencies. But, given this proven commitment to quality, we would hope patients would be provided access to these services, certainly at their request, and also when our hospital is the closest one - as the county EMS protocols require. We have had circumstances where patients have complained that either—or both - of these conditions were present, and yet, the patient was not taken to Physicians Regional-Pine Ridge by EMS. We are somewhat puzzled by reading assertions in a few news stories that there have not been efforts to protect one particular hospital's business. We believe this very thing has happened, and we hope, as you consider the role of the • Collier Boulevard Campus • 8300 Collier Blvd.,Naples,FL 34114 • (239) 354-6000 Pine Ridge Campus • 6101 Pine Ridge Road,Naples,FL 34119 • (239)348-4000 www.PhysiciansRegional.com Packet Page-860- 10/8/2013 11.C. County, that the process remains objective. We believe this is in the best interest of patient care, and that is what should guide the County's policy. Physicians Regional Healthcare System invested significant resources in technology, recruitment of clinical staff, and experienced, highly regarded NeuroVascular/Endovascular Surgeons to build the only accredited Comprehensive Stroke Center in Southwest Florida to implement the best state of the art practice protocols to care for victims of stroke. To take it one step further, our program at PRHS is included in a Joint Commission Comprehensive Stroke Center Pilot Study to help establish standards of care in hospitals in the rest of the country. Yet, in email exchanges between NCH and the County's Medical Director, it is clear the Medical Director was working extremely closely with NCH to promulgate protocols seemingly effectuated by the threat of loss of market share to NCH. Clearly,this concern was expressed in his December 20th, 2012 email when he advocated that the protocols would 'divert about 40% of the patients currently going to NCH...." He said this would be a "disservice to the patients." Setting aside the disturbing email, and looking solely at the data, it is clear a distinct minority of stroke cases are being transported by EMS to Physicians Regional, notwithstanding its demonstrated capability and certification. Unless the data is wrong, only 12-15 percent of Collier County Stroke patients are being transported by EMS to Physicians Regional, notwithstanding the protocols and the fact that Physicians Regional is the only hospital locally that can provide the continuum of care necessary for this very deadly acute condition. In fact, CC EMS has been sending just as many stroke patients from North Naples to North Collier Campus, which is not a certified stroke center. We are unclear how bringing patients as quickly as possible to the area's only certified Comprehensive Stroke Center, an emergency department where the federal government's own website points out that patients presenting get care faster, would be a disservice to patients, which the current Medical Director asserted in his email. To the contrary, it is a life-saving service for patients. It is also concerning to see the prolonged and protracted 6-month timeline these EMS Stroke assessment protocols took to implement. We certainly agree with Packet Page-861- 10/8/2013 11 .C. • making sure diligence is done, but we should point out that these protocols are the same as those implemented by Miami/Dade and Broward Counties. The protocols are geared toward permitting EMS to stratify stroke victims such that those who need more advanced care are brought to the best-equipped location for the service. This is critical so as to avoid delays in care when patients must then be transferred. Clearly, bringing a patient to a location that can provide the range of services without transfer leads to better outcomes and no life- threatening delays. In our dealings with the County, we make every attempt to be responsive and forthcoming. This can be made more difficult if we believe the representative from the County may be acting as a proxy for other enterprises, which is indeed how we felt during the process of establishing the stroke program. It is our intent to always do what is best for our patients, and frankly, to collaborate with NCH and the County. We stand ready to be of service. Cordially, C. Scott Campbell Market CEO Physicians Regional Healthcare System Packet Page-862- 10/8/2013 11.C. Medical Director Information Packet Page-863- 10/8/2013 11 .C. Robert B. Tober, M.D., FACEP, FAAEM, Medical Director 2240 Southwinds Drive Naples, Florida 34102 May 29, 2013 Via Email Leo E. Ochs, Jr., County Manager 3299 Tamiami Trail East Naples, Florida 34112 Re: Initial Response to Claims Asserted in Item 101 on the Board of County Commissioner's May 14, 2013 Agenda Dear Mr. Ochs: As you know, Item 101 on the Mary 14, 2013 Board of County Commissioner's Agenda, which was placed on the Agenda by the Board Chair, raised a number of claims about my performance as Medical Director. It is my understanding that your office has been charged with investigating or coordinating an investigation of these claims and reporting back to the Board. Please accept this letter as my initial response to these claims, which I firmly believe that an impartial investigation will determine to be unfounded. First, it is important to address the references in the Board Chair's Executive Summary to "the PSA's obligations to provide a quality assurance process and "duty to investigate problems as they arise...." Quality Assurance, especially in the context of individual patient, involves privileged medical information that is not appropriate for review in a public meeting. The PSA agreed to this in their first meetings of the Medical Director's subcommittee and endorsed the continuance of the quarterly QA meetings held prior to the formation of the PSA. Those meetings continue with attendance from representatives of multiple districts and one member of the PSA Board (Dr. Panozzo). Physicians from both COPCN holders usually attend however. Thus, while 1 very much welcome the PSA's involvement in the investigation, this important principal of privilege must be kept in mind. Second, the Executive Summary states: "In January, 2013 the County's Medical Director released updated protocols as final without allowing for review. The consequence was that protocols were released as official which contained life- threatening standards." Packet Page-864- 10/8/2013 11.C. This is not correct. There are no life threatening standards in the protocols. Initially, some accurate history is in order. Process used to implement 2013 to 2014 protocols a. November 14, 2012 PSA meeting b. CD's were provided to all members of the Medical Subcomittee PSA for comment. c. The CD contained protocols for: d. 2009 to 2010 - Retired in 2011 e. 2011 to 2012 - Current as of the November meeting f. 2013 to 2014 - Proposed for comment but not implemented g. No response or input received h. No Concerns or Objections were raised i. January 16, 2013 PSA meeting j. New CD's were provided to all PSA members with proposed 2013-2014 protocols k. No response or input received I. No concerns or objections were raised m. Following the January 16 meeting the Protocols were printed and distributed n. Finally, in late January we received comments from Dr. Panozzo of NNFD and from Dr. Deborah Lopez a pediatric critical care physician in Naples. The issues were reviewed and determined to be subtle changes and not significant from a medical perspective. Typographical issues were corrected. There were no life threatening issues identified. An amendment to the initial ventilation rate was later added to reflect age-specific initial rates to address Dr. Lopez's issues. This was also done after further review by me and further NNFD "vetting"with the EMS council meeting in March. Third, the Executive Summary further states"a protocol was released with respect to pediatric rescue breathing which was incorrect, and, if administered by an EMS provider as prescribed would result in the death of the child. Protocols should not be released as official until validated by the appropriate agencies/boards." This is not correct. This protocol will not result in the death of a child. The basic protocol in question has been in effect without change since Feb. 1, 2011. Moreover, the appropriate agencies and boards have had access to this basic protocol since its original inception. Notably, the pediatric rescue breathing rate advised in the protocol is not a hard number to follow but merely a general guideline. The crucial criteria that will dictate the actual pediatric rescue breathing rate is the End Tidal CO2 levels, which are to be maintained within 35—45mmHa and pulse oximetry and this has not changed from the previous edition of the protocol. In 2013, the revisions made to the protocol in question included the addition of language which reinforced the importance of maintaining an appropriate end Tidal CO2 level. In all the material researched, including the Pediatric 2 Packet Page-865- 10/8/2013 11 .C. Advanced Life Support (PALS) guidelines, emphasis was placed on allowing the End Tidal CO2 levels to guide the respiratory rate in the management of patients with Increased Intracranial Pressure (IICP). To ensure that my assessment of the protocol is correct we consulted with doctors at the University of Miami who said that our protocols were good and certainly not life-threatening. Dr. Ivette Motola, M.D., Gordon Center for Research in Medical Education and Principal paramedic instructor reviewed the protocol and wrote a letter stating that the protocol was perfectly adequate and in no way life threatening. Dr Patti Cantwell, M.D., Chief of Pediatric Critical Care concurred. The letters were sent to both the BCC and to PSA. (Letters attached as Exhibit "1") Fourth, the Executive Summary sates: "A letter received from Physician's Regional Hospital, dated May 6, 2013 explains that the county's medical director was working "extremely closely with NCH to promulgate protocols seemingly effectuated by the threat of loss of market share to NCH." In an email dated December 20, 2012, the county's medical director advocated against certain stroke protocols because these protocols would "divert 40% of the patients currently going to NCH." The medical director was in effect seemingly making decisions about which protocols were to be adopted based on how NCH's market share would be affected if stroke patients were transported to Physician Regional's new Comprehensive Stroke Center (the only such accredited stroke center in SW Florida) rather than to NCH. Protocols must be developed on what is in the best interest of the patient, not in any way based on the market share a hospital might lose. It appears that only 12-15% of the county's stroke victims are being transported to Physicians Regional notwithstanding the current protocol. There are two recent stroke related deaths where the patients were transported to NCH rather than the Physician's Regional stroke center begging the question as to whether these patients might have survived if transported to the stroke center. What has transpired is of the utmost seriousness. A full study into how many patients are being transported by county EMS to one hospital over another hospital is needed. Further, the timeliness and basis on which protocols are being established needs to be fully investigated. Lastly, the training of providers as to directions on where patients shall be transported under which conditions needs to be investigated." There is a great deal of inaccurate and false information in these statements from the Executive Summary. I am totally unconcerned about the "market share" of NCH and Physicians Regional. In fact, that is not a term I used. A copy of the alleged email, which is included as Exhibit"2", makes clear that the context was all about what was best for the patient. Furthermore, the history of the discussions involving the implementation of the stroke protocols shows nothing but a group of doctors associated with both hospitals trying to do what is best for the patients (with the unfortunate exception of the inaccurate claims in May by Physicians Regional): August 2012 - EMS was contacted by Physicians Regional about the new stroke center 3 Packet Page-866- 10/8/2013 11 .C. It was planning to open at its Pine Ridge hospital. September 13 - Meeting held between EMS and Physicians Regional about the new center. Opening was planned for early October. Late September-Work was done to adjust the transport guidelines as soon as Physicians Regional was ready. September 30 - Physicians Regional advises that the stroke center would not be certified until November 1 but they were able to accept stroke patients immediately. October 2 -The transport protocols were changed to include Physicians Regional Stroke Center. The transport protocols were primarily to bring stroke patients to the nearest appropriate facility. October 3-The training staff of EMS attended an independent training seminar conducted by Dr. Paul Barnerjee, the Medical Director of Lake County EMS, who is often cited as one of the industry leaders in pre-hospital stroke treatment including by PRPR's team, on Advanced Stroke Triage protocols to better allow them to assist field personnel in moving forward with the changing standards in EMS. October 30 - Neurologists from NCH and Physician's Regional meet to come to consensus on stroke treatment parameters. EMS attended as observers and to gain clarification as needed so we could follow the direction from the stroke experts. January 2013 -Training was conducted at EMS headquarters by Dr. Eskioglu and Dr. Mason of Physicians Regional over a nine day period to insure all field personnel had a clear understanding of the capability of the comprehensive stroke center and the differentiation between both hospitals and which types of patients might benefit from diversion to a facility which might not be geographically closest based on specific medical criteria. January 29 - NCH and Physician's Regional neurologists met with members of the PSA to come to consensus on stroke treatment parameters. EMS attended to gain clarification from the stroke specialists who would be receiving our patients. February 1 — Dr. Eshioglu of Physicians Regional emails EMS Chiefs Kopka and Watson and me and states: "On behalf of the PRHS Comprehensive Stroke Center Program we appreciate al all the hard work that went into this protocol and we agree to the final version that you submitted. Thanks again and we look forward to working with you in getting the best clinical outcomes for treatment of stroke patients in Collier County." May 2013 - Physicians Regional executives contact Collier County Commissioners to complain because their start up Comprehensive Stroke Center only has 12 to 15% of 4 Packet Page-867- 10/8/2013 11 .C. stroke transports. In reality, transports to Physicians Regionsl are nearly double what they were a year earlier and the statistics show a corresponding drop at NCH. I want to ensure that patients get the best medical care possible as soon as possible. I believe that having Physicians Regional's Comprehensive Stroke Center is a very positive advantage to the community. It is also important to note that NCH has had excellent long-standing Primary Stroke capability and is upgrading that capability at the end of this summer 2013. Currently, I know that the severity of the stroke, distance to be travelled, traffic congestion, population concentration and a number of other factors are considerations in where stroke patients are taken. So do the people running the hospitals. Finally, under the transport protocols that I have implemented in conjunction with both hospitals, Physicians Regions is receiving far more stroke patients than previously: Time Period All Transports Strokes Only Jan to March 2012 NCH 47.89% 66.29% NCH North 24.84 4.38 PRCB 12.84 1.53 PRPR 14.45 27.81 Jan to March 2013 NCH 43.75 46.37 NCH North 24.14 2.00 PRCB 13.99 2.00 PRPR 18.15 49.60 Aprill to May 9, 2013 NCH 44.60 44.19 NCH North 24.59 2.33 PRCB 10.64 2.30 PRPR 20.17 51.17 The most discouraging thing here is that Physicians Regional either does not know or just does not care that there has been a big change and appears to be inaccurately advising our Commissioners that they are only getting 12 to 15 % of stroke transports. Fifth, the Executive Summary also raises an issue concerning the 911 /800 mega hertz call system. This issue is obviously of great concern to me insofar as quality patient care is concerned. Nevertheless, the proper operation of the system is an operational matter managed by the Sheriff—not the Medical Director and to the best 5 Packet Page -868- 10/8/2013 11 .C. of my knowledge has been addressed by the Sheriff. This fact should have been made clear in the Executive Summary. In closing, please note that this is an initial response. I am available to answer questions and will be happy to provide additional documentation. At the end of the day, my goal remains unchanged: to help Collier County achieve and maintain a world class EMS system. Sincerely, /Ma - Robert B. Tober, M.D., FACEP, FAAEM, Medical Director I'I 6 Packet Page-869- Gordon C 10/8/2013 11 .C. T Michael S. Gordon Center for Research in Medical Education "Saving Lives Through Simulation Technology" �d4catlon'M A University May 9,2013 of Miami Robert Boyd Tober,M.D.,FACEP Center of Medical Director CCEMS Excellence 6400 Davis Blvd.,Suite 104 Naples,Florida 34102 Feldman Dear Dr.Tober, Division of Multiprofessionel I have reviewed the pediatric head injury airway protocols that have been in effect in CCEMS for Health Education many years. I fully appreciate your trying to get your medics to target a particular and appropriate reflection of adequate ventilation by aiming for an ETCO2 of 35-45mm of mercury. In the past few Friends For Life years,therapies in medicine, including oxygen,have been increasingly geared towards a target or Division of outcome and that is what you are doing by giving the paramedics a target ETCO2 in ventilating Research head injured patients. and Technology Studies have revealed that most resuscitations are accompanied by too rapid ventilation Kennedy (hyperventilation)in the majority of circumstances such as this,and it is,therefore, imperative to Division of avoid hyperventilation. Severe hyperventilation can cause alkalosis and cerebral vessel Prehospital and Emergency vasoconstriction which can lead to poor outcomes in head injury.Although an initial suggested y Healthcare ventilation rate of 10 is lower than usually recommended,you have,at the same time,reminded the paramedics to target an appropriate ETCO2.We have learned,that most healthcare practitioners do a poor job of actually counting ventilatory rates in resuscitations or very ill patients. That is why there is an increasing focus on targets such as the ETCO2 and Pulse Ox that give a good assessment of actual ventilation and oxygenation and guide the provider to either raise or lower the ventilation rate. Miami International In summary,there is no absolute number for appropriate rates of ventilation,only ranges. Alliance for Sometimes ventilation rates must be very slow to reach target ETCO2 values and sometimes high. I Medical-education do not see anything inappropriate and certainly not life-threatening in this protocol given the Innovation a worldwide targeting emphasized. consortium of physicians and educators Sincerely, Ivette Motola,MD,MPH Director,Division of Prehospital and Emergency Healthcare Gordon Center for Research in Medical Education Assistant Professor of Emergency Medicine University of Miami Miller School of Medicine M1fi1L EXHIBIT LEONARD M.MILLER SCHOOL OF MEDICINE Post Office Box 016960(D-41).Miami,Florida 33101 Location: 1120 N.W. 14th Street . Miami,Florida 33136 Tel: 305-243-6491 . Fax: 305-243-6136 . Web: WWW.GCRME.MIAMI.EDU Packet Page-870- 10/8/2013 11 .C. G.Patricia Cantwell,M.D. .�I Ie�lt�l \I1't:It�l'1'S't1N 11 t, Division Chief •uavtasnYa MIAMI liri inisrs¢ra t i.??i t'I !'. Barry Gelman,M.D. nsumthle Jcyapalan,0.0. Gwenn E.McLaughlin,M.D. Michael Nares,M.D. Brent Pfeiffer,M.D. Juan Pablo Solaro,M.D. Shivani Tripathi,M.D. May 10,20[1133, AN Dear Or. er: It was a pleasure to speak with you and discuss specifics of your Pediatric Head Injury/Increased ICP protocol for use in Collier County Emergency Medical Services. I have continued to participate in pre-hospital training, particularly as it relates to pediatrics and disaster medicine/Urban Search and Rescue. It seems like eons ago when we were teaching ACLS at the Medical Training and Simulation Laboratory. Your reassessment of CCEMS's long-standing Head Injury protocol Is certainly timely in light of the updated Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants,Children and Adolescents(2003, 2012—Pediatric Crit Care Med 2012 Vol 12,No 1 Suppl). Your protocol certainly reflects the fact that despite the initial 2003 guidelines against hyperventilation,this technique is still utilized. There are studies that attest to the fact that a significant percentage of patients with severe traumatic brain injury have significant hypocarbia within the first 48 hours of admission. Throughout my career,I have focused upon advising prehospital and hospital medical personnel who are providing manual positive pressure ventilation(via BVM or Err)to"slow down". Certainly,hypoxemia is going to be the major factor in an untoward outcome;however your focus upon minimizing the tendency to hyperventilate is laudable. My only comment with regard to the stipulated respiratory rates of 10-12 bpm in your protocol would be that there would be a quick retort that the patients would be hypo ventilated leading to hypercarbia. Your protocol addresses that concern by focusing upon ventilation in order to achieve the target ETCO2 35- 45mmHg. I have taken the opportunity to review a couple of prehospital protocols(FDNY and City of Miami) in order to peruse how these professionals address the fact that during a pediatric resuscitation,the adrenaline and angst of caring for a traumatized child places them into turbo mode. The ATLS guidelines (9ed)stipulate"maintain adequate ventilation"followed by"controlled ventilation"with PaCO2 ETCO2 35 mmHg;the pediatric chapter essentially just includes a table of age-appropriate vital signs. It is a blessing that our goals of care are now focusing upon target ranges of oxygenation/ventilation rather than having the notion that health care providers are meticulously counting. Upon further reflection,stipulating a mere rate neglects mention of the effect of depth of ventilation. In my opinion, the CCEMS protocol absolutely addresses a scenario that should,the stipulated rates of 10-12 bpm be insufficient,the practitioner will adjust the rate to maintain the target ETCO2 of 35-4SmmHg. It is a daunting challenge to convey the fact that vital sign ranges vary with pediatric ages. Division of Pediatric Critical Care P.O.Box 016960(R131) Miami,FL 33101 Phone 305 585-6051 o fax 305 325-0293 Packet Page -871- 10/8/2013 11 .C. G.Patricia Cantwell,M.D. ? I Ie�litll l'\11'l:lttirl'S'<)F 111.�Jtl !.i:C: l: Division Chief -a it �.:.Il l!. miasma navvnIRAinrsrsure .;I.! ;;'i'°..: BarryGehnan,M.O. Asumthia leyapalan,D.O. Gwenn E.McLaughlin,M.D. Michael Nares,M.D. Brent Pfeiffer,M.D. Juan Pablo Solana,M.U. Shivani Tripathi,M.D. At our Institution,we are constantly made aware of the need to reframe written guidelines to minimize consternation about interpretation. I would certainly review the capabilities of the prehospital personnel to monitor ETCO2,i.e.via endotracheal tube and nasal cannula. Our institution does not have the widespread ability to monitor ETCO2 via nasal cannula. It would be my suggestion to merely remove a stipulated rate since the protocol covers a broad range of pediatric ages and emphasize normoventilation(age appropriate rate and adequate chest wall excursion). I would address the caveat that ALL monitors sometimes fail us and that oxygenation is of paramount importance,followed by a directive to avoid rapid,shallow ventilator rates. We have been so fortunate to have CCEMS service on the front lines. I cannot recall all the patients transferred to our institution from your area who were clearly handled with expert prehospital care. It saddens me that many of our prehospital providers do not get follow-up from the outcomes of their management. Please keep up your passion for cutting edge pre-hospital medical management. If you have any questions,or need any additional help from me,do not hesitate to contact me. Sincerely, Tar\0-ok j G.Patricia Cantwell,MD Professor and Chief of Pediatric Critical Care Medicine Director,Pediatric Palliative Care Medical Manager,US&R South Florida TF2 University of Miami Miller School of Medicine Holtz Children's Hospital—East Tower 6006 Phone:(305)585-6051 Fax:(305)325-0293 III Division of Pediatric Critical Care P.O.Box 016960(R131) Miami,FL 33101 Phone 305 585-6051 a Fax 305 325-0293 Packet Page-872- 10/8/2013 11 .C. -----Forwarded Message From: KopkaWalter<WalterKopka @colliergov.net> To:Robert Tober<rbtobermd @yahoo.com> Sent:Tuesday, May 21,2013 10:17 AM Subject: RE: Email Sent 12/20/2012 at 8:14 am FYI. Ball is in the court of PRMCPR. They have had neurology letter now for weeks. Essentially,adopting the LAMS score would divert about 40%of the patients currently going to NCH within the IV-t-PA window with scores on the NIH stroke scale of only 4-5 which would be a disservice to the patients. Merry Christmas. Bob • ---On Thu, 12/20/12,Dutcher,Phil<Pitii.Dutclrer(anc%and orE>wrote: From:Dutcher,Phil<Phil.Dutcher@nchmd.org> Subject:Re: PRMCPR???? To: "Robert Tober"<rbtobermd@ayahoo.com> Date: Thursday, December 20, 2012,6:50 AM Bob, I have contacted them twice since we sent the e-mail proposing our protocols and each time the response is " we are reviewing your information and will get back to you soon". I will call Todd Lupton this morning. Phil Sent from my iPhone EXIIIBlT . 1 Packet Page-873- 10/8/2013 11 .C. On Dec 20,2012, at 6:03 AM, "Robert Tober" <rbtobermd @vahoo.com>wrote: Hi Phil, Any word from PRMCPR and out stroke proposals?? I do need to take some action ASAP. Thanks. Have a good Christmas. Bob CONFIDENTIALITY NOTICE-Visit our website at http://www.nchmd.org/ This email and any files transmitted with it are from the NCH Healthcare System.This message is confidential and is intended only for the addressee.If you are not the intended recipient or have received this email in error, please call us immediately at(239) 624-5000 and ask to speak to the message sender or promptly email the message sender of the delivery error and then delete the message.Thank You. Walter Kopka,Chief Collier County Emergency Medical Services (EMS) Packet Page-874- 10/8/2013 11 .C. Physicians Regional Information Packet Page-875- 10/8/2013 11.C. PHYSICIANS REGIONAL HEALTHCARE SYSTEM September 17, 2013 Leo E. Ochs, Collier County Manager Delivered Via Email Office of County Manager 3299 Tamiami Trail East, Suite 202 Naples, FL 34112 Robert Tober, M.D. Collier County EMS Medical Director 8075 Lely Cultural Parkway, Suite 267 Naples, FL 34113 Re: EMS Stroke Protocols Dear Mr. Ochs and Dr. Tober: Following my letter dated May 6,2013 to the Board of County Commissioners which questioned Stroke protocols, representatives from Physicians Regional Healthcare System and Collier County EMS met on May 23, 2013 to discuss the current Stroke volume data and the clinical destination protocols. Per CCEMS, the data being captured by CCEMS prior to April 1, 2013 was unspecific and did not allow for a true representation and/or count of Stroke related transports. Based on our understanding, CCEMS leadership made changes (effective April 1, 2013)to both the system and the process in identification of a primary Stroke alert diagnosis to more accurately reflect the Stroke volumes. During that same meeting CCEMS leadership also discussed that the Stroke destination forms that were approved in early 2013 had not been fully implemented. Collier County EMS leadership stated that effective in May 2013, any old forms and/or systems related to the old Stroke protocols had been removed and replaced with the new Stroke forms and processes. There have been a few subsequent meetings with CCEMS to review the data and the revised implementation of the Stroke forms and processes. As a result, and at this time, we believe the current data being captured more accurately reflects the statistics of Stroke related cases. Consequently, and based on our understanding as outlined in this letter, Physicians Regional Healthcare System is satisfied that, as of the date of this letter, the CCEMS Stroke Protocols are current and are being followed appropriately. Sincerely, C. Scott Campbell Market Chief Executive Officer Collier Boulevard Campus • 8300 Collier Blvd., Naples, i'L 34114 • (239) 354-6000 Pine Ridge Campus • 6101 Pine Ridge Road, Naples, FL 34119 • (239) 348-4000 www.PhysiciansRegional.co gional.com Packet Page-876- * 10/8/2013 11 .C. `-t Office of the County Manager Leo E Ochs, Jr. '`�� ` ` "" 3299 Tamiami Trail East,Suite 202•Naples Florida 34112-5746•(239)252-8383'FAX(239)252-4010 - July 10,2013 Physicians Regional Healthcare System Attention: C. Scott Campbell,Market CEO Pine Ridge Campus 6101 Pine Ridge Road Naples FL 34119 S Gc _ Dear MLCabell, Following discussion of the enclosed agenda item 10.I. at the May 14,2013 BCC meeting,the Board directed me to gather information from multiple agencies with respect to the three items outlined in this executive summary and to report back to the Board. Item number 3of this executive summary specifically references your letter to Chairwoman Hiller dated May 6,2013 in which you expressed a number of concerns regarding the Medical Director's transport protocols for stroke patients. To aid me in my further review of these matters,I would ask that you provide me any additional information that would further support your position on this issue. Specifically,you state in your letter that ... "it is clear a distinct minority of stroke cases are being transported by EMS to Physicians Regional, notwithstanding its demonstrated capability and certification. Unless the data is wrong, only 12—15 of Collier County Stroke patients are being transported by EMS'to Physicians Regional, notwithstanding the protocols and the fact that Physicians Regional is the only hospital locally that can provide the continuum of care necessary for this very deadly acute condition. In fact, CC EMS has been sending just as many stroke patients from North Naples to North Collier Campus, which is not a certified stroke center." Without knowing more about the time frame and context in which this statement was made, it is difficult for me to certify its accuracy in view of conflicting statements and information received from other interested parties in this issue. I would very much appreciate any clarify information on this matter at your earliest convenience as the Board is expecting a report in early September. Thank you for your prompt consideration of this request and for your continued service to our community. Sincerely, ......,c,c)., Leo E. Ochs,Jr. County Manager LEO:mjb I Packet Page-877- • 10/8/2013 11.C. EXECUTIVE SUMMARY Recommendation that the Board of County Commissioners direct the `Medical Director Subcommittee' of the.PSA investigate claims of actual and.,potential failed calls as they relate to protocols and training promulgated under the current county Medical Director. A full investigation is required to be conducted given the PSA's obligation to provide a quality assurance process and a.duty to investigate problems as they arise and recommend solutions promptly. There are three matters that require such investigation: 1. In January, 2013 the county's Medical Director released updated protocols as final without allowing for review. The consequence was that protocols were released as official which contained life threatening standards. For example - a protocol was released with respect to pediatric rescue breathing which was incorrect, and, if administered by an EMS provider as prescribed would result in the death of the child. Protocols should not be released as official until validated by the appropriate agencies/boards. Medical accuracy is mandatory. 2. A young man passed away, allegedly because EMS failed to timely arrive at the scene.. EMS claimed that no emergency tone was heard. There are complaints that the county's 800 Mega Hertz communications system is failing to set off the appropriate tones which are used to alert emergency vehicles of an incoming call. These failures are being - reported as happening daily and may have contributed towards the death of one resident, and is threatening the lives of all. This matter must be immediately investigated and addressed. 3. A letter received from Physician's Regional Hospital, dated May 6, 2013 explains that the county's medical director was working "extremely closely with NCH to promulgate . protocols seemingly effectuated by the threat of loss of market share to NCH." In an email dated December 20,2012, the county's medical director advocated against certain stroke protocols because these protocols. would "divert 40% of the patients currently going to NCH." The medical director was in effect seemingly making decisions about which protocols were to be adopted based on how NCH's market share would be affected if stroke patients were transported to Physician Regional's new.Comprehensive Stroke Center (the only such accredited stroke center in SW Florida) rather than to NCH.. Protocols must be developed on what is in the best interest of the patient, not in any way based on the market share a hospital might lose. It appears that only 12-15% of the county's stroke victims are being transported to Physicians Regional notwithstanding the current protocol. There are two-recent stroke related deaths where the patients were transported to NCH rather than the Physician's Regional stroke center begging the question as to whether these patients might have survived if transported to the stroke center. What has transpired is of the utmost seriousness. A full study into how many patients are being transported by county EMS to one hospital over another hospital is needed. Further,the timeliness and basis on which protocols are being established needs to be fully investigated. Lastly, the training of providers as to directions on where patients shall be transported under which conditions needs to be investigated. The Packet Page-878- 10/8/2013 11 .C. • • development of protocols and training of the EMS providers are the responsibility of the county's medical director. OBJECTIVE: That the,Board of County Commissioners direct the `Medical Director - Subcommittee' of the PSA investigate claims of actual and potential failed calls as they relate to protocols and training promulgated under the current county Medical Director. A full investigation is required to be conducted given the PSA's obligation to provide a quality assurance process and a duty to investigate problems as they arise and recommend solutions promptly. There are three matters that require such investigation: 1. In January, 2013 the county's Medical Director released updated protocols as final without allowing for review. The consequence was that protocols were released as official which contained life threatening standards. For example - a protocol was released with respect to pediatric rescue breathing which was incorrect, and, if administered by an EMS provider as prescribed would result in the death of the child. Protocols should not be released as official until validated by the appropriate agencies/boards. Medical accuracy is mandatory. 2. A young man passed away, allegedly because EMS failed to timely arrive at the scene. EMS claimed that no emergency tone was heard. There are complaints that the county's 800 Mega Hertz communications system is failing to set off the appropriate tones which are used to alert emergency vehicles of an incoming call. These failures are being reported as happening daily and may have contributed towards the death of one resident, and is threatening the lives of all. This matter must be immediately investigated and addressed. 3. A letter received from Physician's Regional Hospital, dated May 6, 2013 explains that the county's medical director was working"extremely closely with NCH to promulgate protocols seemingly effectuated by the threat of loss of market share to NCH." In an email dated December 20, 2012, the county's medical director advocated against certain stroke protocols because these protocols would "divert 40% of the patients currently going to NCH." The medical director was in effect seemingly making decisions about which protocols were to be adopted based on how NCH's market share would be affected if stroke patients were transported to Physician Regional's new Comprehensive Stroke Center (the only such accredited stroke center in SW Florida) rather than to NCH. Protocols must be developed on what is in the best interest of the patient, not in any way based on the market share a hospital might lose. It appears that only 12-15%of the county's stroke victims are being transported to Physicians Regional notwithstanding the current protocol. There are two recent stroke related deaths where the patients were transported to NCH rather than the Physician's Regional-stroke center begging the question as to whether these patients might have survived if transported to the stroke center. What has transpired is of the utmost seriousness. A full study into how many patients are being transported by county EMS to one hospital over another hospital is needed. Further, the timeliness and basis on which protocols are being established needs to be fully investigated. Lastly, the training of providers as to directions on where patients shall be transported under which conditions needs to be investigated. The development of protocols and training of the EMS providers are the responsibility of the county's medical director. • Packet Page-879- - 10/8/2013 11.C. CONSIDERATIONS: -The PSA has a duty to ensure quality assurance of protocols and training promulgated/provided by the county's medical director. There have been numerous instances where such protocols and training have come into question, putting lives at risk. The Medical Director Subcommittee shall be tasked with the investigation of the three matters raised in this executive summary - specifically as relating to the release of inaccurate protocols; the failing county EMS communications system, the development of protocols based on hospital market share rather than patient care, and, training with respect to transport - again based on hospital market share rather than what is in the patient's best interest. These are matters of great importance since they involve the public's health and safety. The Board of County Commissioners cannot ignore what has come to light and must take corrective action as quickly as possible. • FISCAL IMPACT: None at this time. LEGAL CONSIDERATIONS: This item has been reviewed by the County Attorney. If the Board wishes to pursue this matter, then for the sole purpose of minimizing the County's litigation exposure, the County Attorney requests that the Board directs the County Attorney to work with the County Manager in structuring and coordinating this investigation with the PSA. -JAK RECOMMENDATION: That the Board of County Commissioners direct the `Medical Director Subcommittee' of the PSA investigate claims of actual and potential failed calls as they relate to protocols and training promulgated under the current county Medical Director. A full investigation is required to be conducted given the PSA's obligation to provide a quality assurance process and a duty to investigate problems as they arise and recommend solutions promptly. There are three matters that require such investigation: 1. In January, 2013 the county's Medical Director released updated protocols as final without allowing for review. The consequence was that protocols were released as official which contained life threatening standards. For example - a protocol was released with respect to pediatric rescue breathing which was incorrect, and, if administered by an EMS provider as prescribed would result in the death of the child. Protocols should not be released as official until validated by the appropriate agencies/boards. Medical accuracy is mandatory. 2. A young man passed away, allegedly because EMS failed to timely arrive at the scene. EMS claimed that no emergency tone was heard. There are complaints that the county's 800 Mega Hertz communications system is failing to set off the appropriate tones which are used to alert emergency vehicles of an incoming call. -These failures are being reported as happening daily and may have contributed towards the death of one resident, and is threatening the lives of all. This matter must be immediately investigated and addressed. 3. A letter received from Physician's Regional Hospital, dated May 6, 2013 explains that the county's medical director was working "extremely closely with NCH to promulgate protocols seemingly effectuated by the threat of loss of market share to NCH." In an email dated December 20, 2012, the county's medical director advocated against certain stroke protocols because these protocols would "divert 40% of the patients currently going to. NCH." The Packet Page -880- - 10/8/2013 11 .C. • medical director was in effect seemingly making decisions about which protocols were to be adopted based on how NCH's market share would be affected if stroke patients were transported to Physician Regional's new Comprehensive Stroke Center (the only such accredited stroke center in SW Florida) rather than to NCH. Protocols must be developed on what is in the best interest of the patient, not in any way based on the market share a hospital might lose. It appears that only 12-15% of the county's stroke victims are being transported to Physicians Regional notwithstanding the current protocol. There are two recent stroke related deaths where the patients were transported to NCH rather than the Physician's Regional stroke center begging the question as to whether these patients might have survived if transported to the stroke center. What has transpired is of the utmost seriousness. A full study into how many patients are being transported by county EMS to one hospital over another hospital is needed. Further,the timeliness and basis on which protocols are being established needs to be fully investigated. Lastly, the training of providers as to directions on where patients shall be transported under which conditions needs to be investigated. The development of protocols and training of the EMS providers are the responsibility of the county's medical director. PREPARED BY: Commissioner Georgia Hiller, Chair-District 2 Attachment-Physician's Regional Letter dated May 6, 2013 • Packet Page -881- 10/8/2013 11 .C. PHYSICIANS REGIONAL HEALTHCARE SYSTEM May 6, 2013 Collier County Board of County Commissioners c/o The Honorable Georgia Hiller, Chairwoman 3299 Tamiami Trail East, Suite 303 • Naples, FL 34112 Dear Commissioner Hiller. There has been much public discussion recently regarding the Medical Director position for Collier County. The decision about how to proceed is one in which only the Commissioners can make, and Physicians Regional Healthcare System • stands ready to support whatever decision you make. However, there have been comments made publicly which we feel need to be clarified. It is our responsibility- and one we take seriously-to provide the best care • possible, as quickly as possible, to patients who have emergency conditions. To that end, we have made serving patients in an emergency condition a major priority. For example, as of May 3, 2013,the federal government's own website points out(www.hospitalcompare.hhs.gov)that patients who present to our Emergency Department are seen by a professional faster(in 35 minutes, vs. 72 minutes at NCH), receive pain medication faster for broken bones (53 minutes vs. 79 minutes at NCH), and leave without being seen at a lower rate (2% vs. 4% at NCH). This is not to say the care at NCH is not excellent, and certainly, we believe both systems prioritize care for patients in emergencies. But, given this proven commitment to quality, we would hope patients would be provided access to these services, certainly at their request, and also when our hospital is the closest one - as the county EMS protocols require. We have had circumstances where patients have complained that either—or both - of these conditions were present, and yet, the patient was not taken to Physicians Regional-Pine Ridge by EMS. We are somewhat puzzled by reading assertions in a few news stories that there have not been efforts to protect one particular hospital's business. We believe this very thing has happened, and we hope, as you consider the role of the • Collier Boulevard Campus • 8300 Collier Blvd.,Naples,FL 34114 • (239) 354-6000 Pine Ridge Campus • 6101 Pine Ridge Road,Naples,FL 34119 • (239) 348-4000 www.Physicia n sRegionat.com - �. . Packet Page-882- r,._ ," • 10/8/2013 11.C. • • County, that the process remains objective. We believe this is in the best interest of patient care, and that is what should guide the County's policy: Physicians Regional Healthcare System invested significant resources in technology, recruitment of clinical staff, and experienced, highly regarded NeuroVascular/Endovascular Surgeons to build the only accredited Comprehensive Stroke Center in Southwest Florida to implement the best state of the art practice protocols to care for victims of stroke. To take it one step further, our program at PRHS is included in a Joint Commission Comprehensive Stroke Center Pilot Study to help establish standards of care in hospitals in the rest of the country. Yet, in email exchanges between NCH and the County's Medical Director, it is clear the Medical Director was working extremely closely • with NCH to promulgate protocols seemingly effectuated by the threat of loss of market share to NCH. Clearly, this concern was expressed in his December 20th, 2012 email when he advocated that the protocols would divert about 40% of the patients currently going to NCH...." He said this would be a "disservice to , the patients." Setting aside the disturbing email, and looking solely at the data, it is clear a distinct minority of stroke cases are being transported by EMS to Physicians Regional, notwithstanding its demonstrated capability and certification. Unless the data is wrong, only 12-15 percent of Collier County Stroke patients are being transported by EMS to Physicians Regional, notwithstanding the protocols and the fact that Physicians Regional is the.only hospital locally that can provide the continuum of care,necessary for this very deadly acute condition. In fact, CC EMS has been sending just as many stroke patients from North Naples to North Collier Campus, which is not a certified stroke center. We are unclear how bringing patients as quickly as possible to the area's only certified Comprehensive Stroke Center, an emergency department where the federal government's own website points out that patients presenting get care faster, would be a disservice to patients, which the current Medical Director asserted in his email. To the contrary, it is a life-saving service for patients. it is also concerning to see the prolonged and protracted 6-month timeline these EMS Stroke assessment protocols took to implement. We certainly agree with .q ' Packet Page-883- • 10/8/2013 11 .C. making sure diligence is done, but we should point out that these protocols are the same as those implemented by Miami/Dade and Broward Counties. The protocols are geared toward permitting EMS to stratify stroke victims such that those who need more advanced care.are brought to the best-equipped location for the service. This is critical so as to avoid delays in care when patients must then be transferred. Clearly, bringing a patient to a location that can provide the range of services without transfer leads to better outcomes and no life- threatening delays. In our dealings with the County, we make every attempt to be responsive and forthcoming. This can be made more difficult if we believe the representative from the County may be acting as a proxy for other enterprises, which is indeed how we felt during the process of establishing the stroke program. It is our intent to always do what is best for our patients, and frankly, to collaborate with NCH and the County. We stand ready to be of service. Cordially, C. Scott Campbell Market CEO Physicians Regional Healthcare System • • • I M _Y�},+ •-�3-` vT� ,k i 3 `i a •�' c T t Packet Page-884- M . ' 10/8/2013 11.C. INTERNAL MEMORANDUM TO: Leo Ochs, County Manager FROM: Walter Kopka, Chief THRU: Len Price, Administrator Dan Summers, Director DATE: June 21,2013 Updated July 24,2013 (in bold, italic) RE: Stroke Protocol Mr. Ochs, Per your request I am providing you a summary of the changes that have been made to the EMS stroke protocol. • September 30,2012, EMS and Physicians Regional staff met to discuss proposed stroke protocol changes. EMS was informed that Physician's Regional would become a Comprehensive Stroke Center on November 1,2012, but they would be able to receive stroke patients effective immediately. • October 2,2012, EMS revised the Transport Destination Protocol and distributed changes agency wide. • Several meetings occurred between Collier County EMS, Physicians Regional and Naples Community Hospital staff in an attempt to agree on protocol changes to define"Stroke Alert" patients. Stroke protocols were discussed at PSA Medical Director's Subcommittee Meetings. • During the months of November and December Collier County EMS, Physicians Regional and Naples Community Hospital staff worked together to develop a stroke assessment form that would be utilized by paramedics to determine transport destination of"Stroke Alert" patients. • January 2013,Collier County EMS,along with neurosurgeons from Physicians Regional, conducted 9 days of training for all staff on the new stroke protocol and assessment form.This protocol and assessment form was a significant change in the treatment and transport of stroke patients from past practice. • January 29,2013,Collier County EMS Staff and neurosurgeons from Naples Community Hospital and Physicians Regional met at the PSA Medical Director Subcommittee Meeting to discuss scoring criteria (LAMS)to determine transport destination for stroke patients. • February 1,2013, revised protocols were implemented • In March 2013,after gathering approximately one month of data for stroke patients,Collier County EMS determined that the Patient Care Reporting System (Image Trend)needed to be adjusted to define"Stroke Alert" patients.Collier County EMS worked with Patient Care Reporting System (Image Trend)to develop specific"user defined" questions to capture more accurately"Stroke Alert"data Packet Page-885- 10/8/2013 11 .C. INTERNAL MEMORANDUM • Statistics generated from Collier County EMS Patient Care Reporting System o Patients defined as"stroke" (various complaints, not necessarily defined "stroke alert" patients) o February 1-March 31,2013 o NCH-DT received 78 patients o Physicians Regional Pine Ridge received 86 patients • Statistics generated from Collier County EMS Patient Care Reporting System o Patients defined as"Stroke Alert" (after"user defined" question created within Patient Care Report which fully effectuates protocol) o April 1-May 31,2013 o NCH-DT received 22 patients o Physicians Regional Pine Ridge received 33 patients • This data is generated from paramedics completing a field assessment with limited diagnostic equipment • This data cannot be compared to hospital data that analyzes"all" patients received by the facility. • Transport data may be affected by the right of the patient to choose transport destination • Collier County EMS Staff has met with Physicians Regional staff twice to discuss and compare statistics for"Stroke Alert" patients o 2 outliers were discussed • Patient 1 was transported to the nearest facility(NCH-DT)and was prior to the implementation of the new protocols • Patient 2 was referred to Collier County EMS Training Department for quality assurance review and has been addressed o During the month of May,Collier County EMS staff assured that"old" assessment forms were removed from the system and current form was added o Collier County EMS"Stroke Alert" statistics are in concurrence with Physicians Regional "Stroke Alert"data for the month of May o Collier County EMS and Physicians Regional are scheduled to meet in July to compare June data • A meeting between EMS and Physicians Regional staff was scheduled for July 10t. This meeting was canceled by Physician's Regional due to a change in administrative staff at their facility.Physician's Regional staff has stated"no recent issues or concerns"and it looks like the revised and enhanced protocol implementation has taken hold". In summary,we are confident with the changes to the Patient Care Reporting System.Collier County EMS is able to define"Stroke Alert" patients accurately according to the new protocol.We will continue to meet with Physicians Regional to discuss data and we will investigate if a discrepancy arises.The PSA Medical Director Subcommittee should be tasked with any future protocol changes. oofititk Packet Page-886- 10/8/2013 11 .C. enc Emer g Y Medical Services Information Packet Page-887- 10/8/2013 11 .C. Co r County Office of the County Manager MEMO Date: May 14, 2013 To: Board of County Commissioners From: Leo E. Ochs, Jr., County Manager - Subject: Internal Investigation As per your direction given at the May 14, 2013 Board of County Commissioners meeting, attached please find the March 12, 2013 memorandum from Chief Walter Kopka regarding the Internal Investigation of events that occurred on December 14, 2012. Packet Page-888- 10/8/2013 11 .C. PREPARED IN ANTICIPATION OF LITIGATION, REFLECTS THE MENTAL IMPRESSIONS, LITIGATION STRATEGIES AND LEGAL THEORIES OF THE UNDERSIGNED ATTORNEY AND IS EXEMPT FROM PUBLIC RECORDS DISCLOSURE PURSUANT TO § 119.071(1)(d), FLA. STAT. THIS MESSAGE IS INTENDED FOR THE RECIPIENT ONLY. IF YOU RECEIVED THIS COMMUNICATION IN ERROR, PLEASE NOTIFY THE SENDER IMMEDIATELY. USE OR DISSEMINATION BY ANY PERSON OTHER THAN THE INTENDED RECIPIENT IS STRICTLY PROHIBITED. INTERNAL MEMORANDUM TO: Leo Ochs, County Manager FROM: Walter Kopka, Chief THRU: Len Price,Administrator Dan Summers, Director DATE: March 12, 2013 RE: Internal Investigation Situation: On December 10 2012 at 11:04 am Medic 42 and Engine 72 were dispatched to 5120 Coral Wood Drive. Medic 42 did not receive initial notification and there was a four minute delay in EMS responding to the call. When contacted a second time by Dispatch,the EMS crew advised that they did not receive the tones. Further,the crew documented on the incident report that"the station received no tones and the tablet received no information". Details of the event and corrective actions taken follow. Excerpt from Recording Provided by CCSO (Time Stamped) 11:04:45 Tones sounded, Medic 42 and Engine 72 dispatched to 5120 Coral Wood Dr 11:05:47 Engine 71 responds in place of Engine 72, Engine 72 in service 11:08:44 Dispatch checks the status of Medic 42; Medic 42 advises they received no tones; Second set of tones sent 11:09:59 Medic 42 responds from the station 11:11:59 Engine 71 arrives on scene 11:15:51 Medic 42 arrives on scene 11:17:53 Medic 42 makes contact with patient Page 1 of 4 Packet Page -889- 10/8/2013 11 .C. PREPARED IN ANTICIPATION OF LITIGATION, REFLECTS THE MENTAL IMPRESSIONS, LITIGATION STRATEGIES AND LEGAL THEORIES OF THE UNDERSIGNED ATTORNEY AND IS EXEMPT FROM PUBLIC RECORDS DISCLOSURE PURSUANT TO § 119.071(1)(d),FLA. STAT. THIS MESSAGE IS INTENDED FOR THE RECIPIENT ONLY. IF YOU RECEIVED THIS COMMUNICATION IN ERROR, PLEASE NOTIFY THE SENDER IMMEDIATELY. USE OR DISSEMINATION BY ANY PERSON OTHER THAN THE INTENDED RECIPIENT IS STRICTLY PROHIBITED. 11:33:10 Medic 42 leaves for Physicians Regional Pine Ridge hospital with two firefighters on board 11:37:55 Medic 42 arrives at Physicians Regional Pine Ridge hospital Background Information on EMS Notification Systems EMS has multiple notification devices to receive information from Collier County Sheriffs Office(CCSO) Communications Center: • • VHF Pager system (tones)—this system is generated by the CCSO Computer Aided Dispatch sending the activation for the specific requested apparatus via a transmitter to the specific designated pager frequency. The page is a six(6)second tone.Any interruption of that six(6)second tone will drop the page and the pager will not activate. o This consists of a mounted pager,speakers and antennae in each EMS station. o Each crew carries a portable pager. o This is a one way device-it only receives information. • Tablet-this is a handheld device that receives a text message via the CCSO Computer Aided Dispatch.The text message uses a program to convert the message to a map as well as provides the dispatch information. o The tablet is a cellular receiving device.As with any cellular device reception is dependent upon all factors that affect cellular service including(but not limited to) location,tower,carrier and obstructions. o This is a one way device-it only receives information. • Portable Radio—800mHz o Each crew member has a portable radio which is a two way device which receives audio information as well as transmits audio information to dispatch and/other apparatus. o As with a cellular device the reception is dependent upon all factors that affect cellular service including (but not limited to) location,towers and obstructions. Possible EMS Notification Issues The reason for the lack of notification of the receiving devices cannot be definitively determined. VHF Pager: Prior to this incident there were documented pager/reception issues and hardware upgrades were made to the system.There are no systems that log or track incoming pages from the transmitter to the receiving device. NOTE: A pager in the standby mode is silent.Once the pager is activated,the pager becomes"live"therefore ANY radio transmissions are heard through the pager.The pager reset button needs to be pressed to put in back in the standby/silent mode. If the pager had activated,the crew would have to reset both the personal pager(carried on person) as well as the station pager. Each pager is independent and the reset button would need to be pressed on each pager to reset/silence them. The crew verified that they did not reset the pagers and no radio transmissions were heard. Page 2 of 4 Packet Page-890- • 10/8/2013 11 .C. PREPARED IN ANTICIPATION OF LITIGATION, REFLECTS THE MENTAL IMPRESSIONS, LITIGATION STRATEGIES AND LEGAL THEORIES OF THE UNDERSIGNED ATTORNEY AND IS EXEMPT FROM PUBLIC RECORDS DISCLOSURE PURSUANT TO § 119.071(1)(d),FLA. STAT. THIS MESSAGE IS INTENDED FOR THE RECIPIENT ONLY. IF YOU RECEIVED THIS COMMUNICATION IN ERROR, PLEASE NOTIFY THE SENDER IMMEDIATELY. USE OR DISSEMINATION BY ANY PERSON OTHER THAN THE INTENDED RECIPIENT IS STRICTLY PROHIBITED. Tablet: It is not known why the tablet did not receive the text message.While we can verify that the text message was sent by Dispatch, Sprint I shows that the text message was not received. Portable Radio:There are many factors that could have contributed to the EMS crew not hearing the dispatch over the radio. o The radio scans four(4)channels-therefore one of the other scanned channels could have blocked out the dispatch. o Station noise-the crew was vacuuming around that time. o Reception problems with the radios depending upon location and interference. Deviations from Protocol There are two deviations from protocol. 1. Collier County Fire Chief Association (CCFCA)—Communication Manual Initial Radio Announcement/Dispatch CM 10-15 Failure to Acknowledge on Call Back "Any agency that fails to acknowledge responding to an incident within two minutes should be contacted by Control North or Control South over the radio to see if the agency is in fact responding." This was not done for four(4) minutes. 2. Collier County Collective Bargaining Unit Contract Article 28.2 Work Duties "During the hours of 0830 and noon,employees should perform assigned vehicle/station duties zone familiarization,study medical/operational protocols, or community events. Radios will be monitored between 0700 and 2130 hours." The Standard Operating Guideline for Standard Station Duties states: "Fridays Deep station GI... Floors including all living areas,office,storage area, garage bays and bathrooms swept and mopped (or vacuumed in appropriate areas)." The crew acknowledges vacuuming and performing required station maintenance around the time of this dispatch,which may have limited their ability to monitor the radio. Corrective Actions/Mitigation • The Collier County Sheriff's Office has stated the deviation from the Collier County Fire Chief Association (CCFCA)—Communication Manual was a human error in that the dispatcher missed recognizing a visual display that two (2) minutes had passed and Medic 42 had not responded yet.Since then, EMS has been told the notification is not only a visual display-but also an audible tone as well. Page 3 of 4 Packet Page-891- 10/8/2013 11 .C. PREPARED IN ANTICIPATION OF LITIGATION, REFLECTS THE MENTAL IMPRESSIONS, LITIGATION STRATEGIES AND LEGAL THEORIES OF THE UNDERSIGNED ATTORNEY AND IS EXEMPT FROM PUBLIC RECORDS DISCLOSURE PURSUANT TO § 119.071(1)(d), FLA. STAT. THIS MESSAGE IS INTENDED FOR THE RECIPIENT ONLY. IF YOU RECEIVED THIS COMMUNICATION IN ERROR, PLEASE NOTIFY THE SENDER IMMEDIATELY. USE OR DISSEMINATION BY ANY PERSON OTHER THAN THE INTENDED RECIPIENT IS STRICTLY PROHIBITED. • A reprogramming of the paging system (narrow banding)was completed in January. EMS pagers have been inventoried and reprogrammed if applicable. • A protocol has been established that documents when pagers and/or tablets do not activate.This report is sent to County staff as well as Sheriff's office staff to determine the cause of the incident as well as any patterns that can be established. • A draft protocol change to the Collier County Fire Chief Association (CCFCA)—Communication Manual has been submitted to the Collier County Fire Chief Association (CCFCA)—Communication sub- committee to change the notification to 30 seconds (from 2 minutes)from when responding apparatus must acknowledge a dispatch.This will decrease the amount of time dispatch has to "wait"to verify if responding apparatus has acknowledged a page.This is scheduled to be heard by the subcommittee this month and if approved it could be heard by the fire chiefs next month. • EMS is in the process of changing the protocol that will require one (1) personnel to monitor the radio if one crew member is working in a noisy environment. Hardware changes are also being reviewed to determine if better listening devices are available for working in noisy environments. EMS staff should have final protocol revisions completed in 60 days. • EMS is reviewing the policy of scanning portable radio"channels"to determine if a policy change will assure that the proper channels are monitored at all times. EMS staff should have final protocol revisions completed in 60 days. • The station pagers/antennas will be reviewed to determine antennae design, condition and performance. • EMS field staff is testing an alternative cellular carrier to determine if alternate devices/carriers should be utilized.An alternate cellular carrier has been tested and has proven to work well.Alternate devices will be explored in the next 90 days. • EMS staff have developed an automated query that reports calls in which the response to dispatch is greater than two minutes. EMS staff is planning to meet with the CCSO staff in the next 30 days to determine a plan to review the reports. • There are long term changes to the Sheriffs Office Computer Aided Dispatch system and receiving hardware and devices.This is a longer term element that will change software and hardware at the Sheriffs Office level as well as the responder level. In summary,the four(4) minute difference between the initial dispatch and secondary dispatch has been reviewed and corrective actions to mitigation recurrences have been taken and will continue to take place to improve the system. While the EMS response was delayed in this instance,the tiered response system worked as it was designed.The fire department arrived six minutes after the initial dispatch. EMS arrived seven minutes after the second dispatch. Had EMS responded at the same time as the fire department apparatus,the fire department apparatus still would have arrived on the scene prior to EMS and initiated basic life support protocols. The patient arrived at the hospital 33 minutes after the initial dispatch. The Medical Examiner's report on this case is not complete at this time. Amok Page 4 of 4 Packet Page-892- 10/8/2013 11 .C. INTERNAL MEMORANDUM TO: Leo Ochs, County Manager FROM: Walter Kopka, Chief THRU: Len Price,Administrator Dan Summers, Director DATE: May 29,2013 RE: Internal Investigation —Follow Up Mr.Ochs, Below is an update to the Internal Investigation completed on March 20,2013. Included are corrective actions as well as associated time frames. Corrective Actions/Mitigation and Status 1. A reprogramming of the paging system(narrow banding)was completed in January. EMS pagers have been inventoried and reprogrammed if applicable. a. Complete March 7,2013 b. Documented in narrow banding spreadsheet 2. A protocol has been established that documents when pagers and/or tablets do not activate.This report is sent to County staff as well as Sheriff's office staff to determine the cause of the incident as well as any patterns that can be established. a. Complete February 19, 2013 b. Documented in General Order,Reporting Missed Tones or Tablet Notification c. Ongoing 3. A draft protocol(introduced by EMS)was submitted to the Collier County Fire Chief Association(CCFCA) Communication Subcommittee to add an acknowledge page protocol.The protocol would require responding apparatus to acknowledge the dispatch within 30 seconds.This will decrease the amount of time dispatch has to"wait"to verify if responding apparatus have received a page. a. This was heard by the fire chief's subcommittee on March 21,2013 and did not get a second/or approved. i. This same draft protocol item was brought to the Collier County Fire Chief's Association on May 23,2013 and did not get supported or approved.The 30 second "acknowledge" page was addressed and did not gain support because of the amount of time it takes to dispatch a call and the amount of radio traffic. 4. A draft protocol(introduced by EMS)to change the Collier County Fire Chief's Association (CCFCA)— Communication Manual was submitted to the Collier County Fire Chief's Association —Communication subcommittee to change the turn out time(call dispatched to apparatus responding)to 90 seconds (from 2 minutes). Page 1 of 3 Packet Page-893- 10/8/2013 11 .C. INTERNAL MEMORANDUM a. The protocol was approved by the Collier County Fire Chief's Association Communication Subcommittee on March 21, 2013. b. The protocol was approved by the Collier County Fire Chief's Association on May 23,2013 and will be submitted to the Collier County Sheriff's Office. c. This is complete internally at EMS with a change in the Communications SOG on May 13, 2013. 5. EMS is in the process of changing the protocol that will require one(1)personnel to monitor the radio if one crew member is working in a noisy environment.Hardware changes are also being reviewed to determine if better listening devices are available for working in noisy environments. EMS staff should have final protocol revisions completed in 60 days. a. Complete May 13, 2013 b. Documented in SOG Communications 6. EMS is reviewing the policy of scanning portable radio"channels'to determine if a policy change will assure that the proper channels are monitored at all times.EMS staff should have final protocol revisions completed in 60 days. a. Complete May 13,2013 b. Documented in SOG Communications 7. The station pagers/antennas will be reviewed to determine antennae design,condition and performance. a. In progress-expected to be complete within 90 days b. Emergency Medical Services, Emergency Management information Technology staff are reviewing current equipment. Documented in Paging System Review. c. The need for station pagers may be minimized or even eliminated with the "Locution" project mentioned in#10 below. 8. EMS field staff is testing an alternative cellular carrier to determine if alternate devices/carriers should be utilized.An alternate cellular carrier has been tested and has proven to work well.Alternate devices will be explored in the next 90 days. a. In 30 days options will be outlined for devices and carriers available as well as field testing. b. Staff has reviewed alternate software available for handheld notification devices. c. Staff is reviewing alternative devices and possible alternative carriers to test handheld notification devices. 9. EMS staff have developed an automated query that reports calls in which the response to dispatch is greater than two minutes. EMS staff is planning to meet with the CCSO staff in the next 30 days to determine a plan to review the reports. a. Meeting complete March 27,2013 b. A query mechanism is in place for EMS Command Staff to review and document calls in which the response to dispatch time is greater than two minutes. c. Ongoing 10. There are long term changes to the Sheriff's Office Computer Aided Dispatch system and receiving hardware and devices.This is a longer term element that will change software and hardware at the Sheriff's Office level as well as the responder level. Page 2 of 3 Packet Page-894- 10/8/2013 11 .C. INTERNAL MEMORANDUM a. CCSO has chosen a vendor to provide an upgraded station notification system called Locution. Locution Systems provides automated dispatching and station alerting products for the public safety industry.CCEMS along with CCSO and fire districts throughout the county met with representatives from Locution on May 13,2013,to determine the needs and system design. CCEMS is currently reviewing the needs of each EMS station. The Medical Examiner's report on this case is not complete at this time. Page 3 of 3 Packet Page -895- ICI 10/8/2013 11 .C. INTERNAL MEMORANDUM TO: Leo Ochs, County Manager FROM: Walter Kopka, Chief THRU: Len Price, Administrator Dan Summers, Director DATE: July 3, 2013 RE: Internal Investigation—Follow Up#2 Mr. Ochs, Below is an update to the Internal Investigation Follow Up completed on May 29, 2013. Updates are bold and italicized. Corrective Actions/Mitigation and Status 1. A draft protocol (introduced by EMS)was submitted to the Collier County Fire Chief Association (CCFCA) Communication Subcommittee to add an acknowledge page protocol.The protocol would require responding apparatus to acknowledge the dispatch within 30 seconds.This will decrease the amount of time dispatch has to "wait"to verify if responding apparatus have received a page. a. This was heard by the fire chief's subcommittee on March 21, 2013 and did not get a second/or approved. i. This same draft protocol item was brought to the Collier County Fire Chief's Association on May 23, 2013 and did not get supported or approved.The 30 second "acknowledge" page was addressed and did not gain support because of the amount of time it takes to dispatch a call and the amount of radio traffic. At this time, this proposal(submitted by EMS)does not have further momentum. If needed,further action(s)will need to be taken by Administrator Price or County Manager Ochs. 2. A draft protocol (introduced by EMS)to change the Collier County Fire Chief's Association (CCFCA)— Communication Manual was submitted to the Collier County Fire Chief's Association —Communication subcommittee to change the turn out time (call dispatched to apparatus responding)to 90 seconds (from 2 minutes). a. The protocol was approved by the Collier County Fire Chief's Association Communication Subcommittee on March 21, 2013. b. The protocol was approved by the Collier County Fire Chief's Association on May 23, 2013 and will be submitted to the Collier County Sheriffs Office. c. This is complete internally at EMS with a change in the Communications SOG on May 13, 2013. This item is complete internally by EMS. Turn out times in excess of ninety seconds are monitored by EMS supervisory staff and require a documented reason by EMS field staff. Updates are pending from the Collier County Fire Chiefs Association and the Sheriffs Office. ofitittk Page 1 of 2 Packet Page-896- 10/8/2013 11 .C. INTERNAL MEMORANDUM 3. The station pagers/antennas will be reviewed to determine antennae design,condition and performance. a. In progress-expected to be complete within 90 days b. Emergency Medical Services, Emergency Management Information Technology staff are reviewing current equipment. Documented in Paging System Review. c. The need for station pagers may be minimized or even eliminated with the"Locution" project mentioned in#10 below. The Paging System Review report is complete. This item will be reviewed post"Locution"implementation to determine the need and extent of station pagers and components. 4. EMS field staff is testing an alternative cellular carrier to determine if alternate devices/carriers should be utilized. An alternate cellular carrier has been tested and has proven to work well.Alternate devices will be explored in the next 90 days. a. In 30 days options will be outlined for devices and carriers available as well as field testing. b. Staff has reviewed alternate software available for handheld notification devices. c. Staff is reviewing alternative devices and possible alternative carriers to test handheld notification devices. This is a more difficult item to define and address simply because there is no pattern of failures that EMS can document.As with any cellular device, reception can be intermittent at certain locations and times. EMS staff currently is using a "tablet"device with is a cellular device which receives 9-1-1 call information and places the dispatch information on a map to direct responding apparatus. On the date of this incident —the tablet did not receive the dispatch information or activate. EMS Field staff has done minimal testing (week long)on a different cellular device and carrier. Initially the devices show possible positive results- with comments from users that the device worked"perfectly"without documented failures.EMS will be reviewing options to expand this field test to different locations/EMS stations/apparatus. 5. There are long term changes to the Sheriffs Office Computer Aided Dispatch system and receiving hardware and devices.This is a longer term element that will change software and hardware at the Sheriff's Office level as well as the responder level. a. CCSO has chosen a vendor to provide an upgraded station notification system called Locution. Locution Systems provides automated dispatching and station alerting products for the public safety industry. CCEMS along with CCSO and fire districts throughout the county met with representatives from Locution on May 13, 2013,to determine the needs and system design. CCEMS is currently reviewing the needs of each EMS station. Several meetings with EMS,Sheriffs Office,fire districts and Locution have taken place. The vendor has provided information about the notification system,components,options and requirements. Site visits have taken place to review station plans and options.A letter has been sent to EMS from the Sheriffs Office stating the Sheriff will provide the core components for Locution as well as the requirements for EMS.EMS has budgeted for these requirements and have staff working with Locution,Sheriff's Office and the fire districts.Sheriffs Office staff has indicated a end of calendar year purchase. The Medical Examiner's report on this case is not complete at this time. Page 2 of 2 Packet Page-897- 10/8/2013 11.C. MEMORANDUM TO: Chief Walter Kopka,Collier County EMS FROM: Dan E.Summers, Director DATE: May 22, 2013 RE: Internal Investigation Memorandum of March 12, 2013 In your memo referenced above on page 4 you requested my office to assist with a review of station pagers and antennas to determine antenna design, condition and performance as part of a corrective action process. My review is noted below. Summary: In our review of stations with the greatest potential of VHF pager transmission signal interference (North Naples-vicinity)we found all pagers and associated receivers working during our review. Signal strength from the County's VHF transmitter that activates the pager was working properly and exterior reception was good to excellent. While Harris/Communications International, (the equipment manufacturer and local service dealer)continue to address an extremely rare intermittent paging transmission interruption originating from the CCSO 911 Center,we found that field receiving of paging and performance was sufficient in both signal strength and audio quality from the field perspective during our review. While recommendations will be made to address the age of the equipment, strategies for additional levels of redundancy, and hardware in the EMS station facilities,the redundancy of both a "station-fixed pagers"and a second crewmember assigned pager provides an acceptable level of reliability complimented by timely telephone contact from 911 if warranted. It should also be noted that while there are efforts by the Collier County Sheriffs 911 to fund and construct an network based dispatch system that may allow for more building automation and dispatch text to personal devices, the VHF paging system should not be abandoned in any fashion. While the exact cost to make the upgrades discussed below have not yet been thoroughly evaluated,the cost for replacement conventional-type VHF equipment to make these upgrades and minor replacement(s) is extremely competitive and the work relatively simple. Packet Page-898- 10/8/2013 11 .C. *Recommendations, Discussion and Observations: 1. Collier County EMS field personnel who are assigned supplemental duties to oversee the EMS division's radio equipment are extremely dedicated and to the extent resources are available,worked to ensure reliable field equipment. EMS staff has been diligent with the necessary FCC narrow-banding effort. 2. The VHF band,transmitter,and paging configuration from the transmitter site to the end- user is extremely robust and signal strength and audio quality for a county of this size is quite good. 3. As age of a station facility increases,there is the tendency to overlook or become complacent with both data and radio systems being co-located on the same worktable or computer station. This is co-location of equipment can generate spurious radio frequency interference.While we did not observe any significant signal or audio loss when this was observed,the practice of placing computer modems, routers,and wireless devices next to one-another with adjacent paging receivers should be discouraged and separation devised between these networks to avoid any future signal degradation. 4. While we observed all the paging systems working we are making the following recommendations that may be classified as preventative maintenance and general housekeeping: a. Initiate a phased approach to re-wiring and replacing the aged configuration of speakers and paging alert devices in each station beginning with those sites that are the farthest distance from the VHF tower and in the urban corridor typically more susceptible to radio interference. This effort should include: i. Improving the cabinet or workstation station receiver location and low voltage speaker wiring to avoid any accidental disconnect of any speakers or receiver. ii. Installation of uninterruptable power supply that could help prevent any loss from power surge, power interruption or lighting strike. iii. Confirmation of the installation of paging audio speakers in the bathrooms of stations. iv. Installation and consistent use system-wide of either a supplemental horn, strobe light or overhead lighting when tones are activated, especially for the evening hours or when crews are servicing their ambulance in the bay areas when high noise situations may occur. v. Replacement and proper placement of VHF external antennas for the paging system receiver. We observed many of the exterior antennas for the paging system did not clear the metal roof-ridge of the station. Exterior antennas Packet Page-899- 10/8/2013 11 .C. should favor the line of site concept to the tower and have at least a three foot clearance from a metal roof building. These exterior antennas for the receivers would do well to have lower loss antenna cabling utilized and as a rule,where wall mounted towers are available, higher antenna height is always better. Lighting surge protection devices should also be installed. b. The Motorola brand "Minitor" pager receiver product is the "staple" of fire and EMS paging systems around the world and predominately used within Collier County EMS and fire services. The product utilized is very robust and ruggedized for public safety use. The Minitor product utilization should be continued, but the following recommendations are being made. i. Acquire additional pagers so that the pagers may be sent to a Motorola authorized service center annual for a "bench-check". While these are extremely reliable units,the minor cost and quick turn-around (3—day typically)with a preventive maintenance program will help mitigate any future failures and address any potential power supply or battery issues. ii. The 110VAC power supply and re-chargeable battery components of the units should be replaced on a schedule, rather than waiting for failure to be observed. These components are inexpensive and can be easily stocked and exchanged. iii. As funds become available, migrate the pager and portable radio batteries to lithium-ion batteries where appropriate. c. In some stations,the Minitor receiver was being used as the receiving base station for the crew quarters dispatch receiver. Again, these units are quite robust, but may lack the features best suited for in-building notification as noted below. i. The Minitor amplified pager and charging station may not have enough audio output to reliably drive all the overhead speakers in the crew quarters,depending on the speaker type, number and station design. ii. We observed that in some cases the Minitor audio speaker output was tied to a residential quality(Radio Shack)amp to drive in-station audio speakers. Additionally, it was quite easy to accidentally adjust the volume level on the Minitor receiver that was being adapted to serve as the station receiver. A design change is recommended below in item d. It should also be noted that the crew's assigned pager also provides a back-up to the station pager. Packet Page-900- 10/8/2013 11.C. d. EMS staff may wish to consider the following: i. Acquire a base-station type tone alert activated receiver that is totally dedicated for the long-term use as a stationary receiver and is designed with audio outputs, minimum volume levels and relays for alert devices such as strobe lights or station lighting controls. Again we stress that this effort should be segregated from the pending network based notification system be considered by the Collier County Sheriffs office and when and if that system is acquired,the VHF paging shall remain as a redundant back-up system. The Federal Signal brand "Informer" product series, may be an reasonable and reliable consideration. ii. Once the base-station type tone alert activated receivers are installed with improved antenna configurations the available Minitor units could be placed in crew-rotation for annual preventative maintenance efforts and used and for spare units during repair. 5. During our inspection we feel that we would be remiss if we did not mention the following for future consideration: a. American Messaging a nationwide text paging system currently being used by Emergency Management and the Sheriff's 911 might be a consideration for a redundant alpha-numeric pager and or alpha-numeric desktop device. These subscription cost are quite low and we have found the system very reliable in Collier County. We have not evaluated the equipment cost for a desktop resource. b. All of the EMS station rely upon the "receive only" of the VHF paging or monitoring the County's 800mhz radio and responding via the handheld portable radio or mobile radio. Should grant funds become available or other funding source the installation of a low power two-way base station might be worthy of consideration as a continuity of government communication resource during catastrophic disaster events. c. A phased approach to replacing aging low voltage wiring, antennas and speakers would be a worthwhile investment in future reliability and protection from lighting or power surges. This will require some close coordination with agencies and facilities in which EMS units are co-located. d. Paging receiving stations and the associated building speaker hardware controls should be in a more secure area that would avoid the accidental power cord or speaker cable "bumps or tugs", that could cause an interruption to the system when other portable equipment is being utilized or re-located. Packet Page-901- 10/8/2013 11 .C. In closing, I would like to thank Mr.John Daly and Paramedic Geoff Swets, who accompanied me on these site visits as part of our evaluation process. Staff will continue efforts to build a quality control component to this communication network. Staff will complete this quality control standard within the next 90 days. Thank you. Packet Page-902- 10/8/2013 11 .C. 0. i •unty Memorandum To: Leo Ochs, County Manager CC: Len Price, Administrative Services Administrator Mike Berrios, Information Technology Director From: John Daly, Telecommunications Manager Date: September 27, 2013 Subject: 800 MHz System Dropped Audio/Paging Tone This memo will summarize the steps that have been taken to resolve the occurrence of missing or dropped audio on the 800 MHz system. This problem was most noticeable on Fire/EMS calls when the paging alert tones were not properly transmitted by the system. This issue has proved problematic to resolve due to the intermittent nature of occurrence. The initial reports of this issue were received last fall and corresponding repair efforts resulted in four to six week periods of problem free system performance. In February of this year the problem became more prevalent. The vendor's technical support group has provided specific recommendations for system testing and resolution efforts to the local technical staff. In addition system engineers were sent to Collier to monitor these efforts which included: • Hardware replacement at the dispatch console position, this is the first step in troubleshooting • A radio system audit of the technical parameters in various components including; site transmitters, audio cards, radio system switch configuration, and the software and hardware revision levels of system components • Data and audio capture of radio system activity for analysis by the vendor's engineering staff • Modification to specific radio system configurations, these changes are made incrementally and then evaluated for success in resolution • Replacement of specific components based on system testing and the system audit The radio system vendor did issue a Technical Service Memo to all customers in July regarding this audio issue and recommended replacement of the audio cards for each dispatch console with a newer version. Unfortunately this did not resolve the issue in Collier. The vendor recommendation for Collier is that we revert to an older generation audio card and this has resolved the problem. We have had no further reports of missing audio and specific testing efforts have verified the problem does not occur with the older generation card. Information Technology Department Packet Page-903- 10/8/2013 11.C. This is a serious issue and any occurrence is a cause for concern. The difficultly in resolution is related to the intermittent nature of the problem. Between February and August dispatch processed 22,835 Fire/EMS run numbers. There were only 47 verified incidents of dropped audio resulting in a paging tone being dropped. The system testing that has been conducted during the troubleshooting process of this issue has identified the same rate of occurrence, approximately .2% of transmissions, and this rate has remained consistent. Outside of radio system efforts, staff has worked with the various agencies and provided guidance with the paging equipment resident in each department. I know EMS has initiated preventative maintenance efforts for their station alerting equipment although I don't have a status on these efforts. Please let me know if additional information or clarification is needed.A delineated time line of the technical efforts is available if desired. Information Technology Department Packet Page-904-