Minutes for July 16, 2018

Meeting Facilitator Chris Thomas Called the meeting to order and began introductions all around the room and from participants on the phone. Chris asked for any updates or corrections needed to the draft minutes from the previous meeting. No comments or concerns on last meeting’s minutes were requested.

Chris opened the discussion by reviewing the progress to date regarding where various policies and authority should be with which system participants. Up until now we have considered what is under the direction of the LEMSA direction and then everything else becomes under Board of Supervisors (BOS). There had been an interest identified earlier to have some policies and procedures vested in other public agencies which ones were the stakeholders interested in seeing vested in the public agencies?

Kurt Henke (California Chiefs, Sonoma County, Fire Chiefs, and AP Triton) opined that those agencies that have 201 rights, defined as public agencies with continuous EMS service from 1980, have control over first responder dispatch, ambulance transport, and staffing. The administration of the local system is under local government control, and local government has the right to administer their system. Those issues need to be delineated.

One example is the Sonoma Valley Fire and Rescue Authority. SVFRA has the ability to decide what apparatus they respond to 911 calls with, but patient care is under the medical direction of the LEMSA.

Non-201 fire agencies need to be considered on a case by case basis. Protection for those public agencies that have not provided ALS since 1980, but may want to offer increased services going forward. Most Fire services have offered some level of medical care when responding prior to 1980, but it is not universal, since new entities have been formed since that time.

An example is the Geyserville Fire Protection District. Geyserville did not have an actual district structure prior to 1980 although it was a volunteer service before becoming a district.

The distinction leaves out other services who are not public providers. Is there a need for separate Policy & Procedures for those agencies that did not operate in 1980 or earlier other than a case by case review for administration? None was noted.

Chris acknowledged the distinctions made between medical control and administration and asked was there anything else? Response times were the only other item proposed as a provider-policy decision.

Tim Aboudara (California Professional Firefighters-Santa Rosa Firefighters Local 1401) expressed concerns regarding the requirement Santa Rosa Fire has with compliance issues for 1st responder standard at calls within 6 min, 90% of the time. Tim stated the requirement is in the City Charter and under the control of the City. Tim felt if responding fire resources were restricted from an emergent (lights and sirens) response, the Department would be unable to meet the requirements of the City Charter. Mechanics of dispatching would cause the Department to fail to meet the expectations of their public. Santa Rosa is the largest consumer of EMS Services provided via EOA 1, and City Government needs to have say in response times and does address medical first responders in the City Charter.

It was pointed out that the EOA covers multiple jurisdictions in addition to the City of Santa Rosa. Establishing response times differently within the EOA by individual local jurisdictions might create some difficulties. It was also noted that some of that happens already via established zones within the EOA.

Tim Aboudara brought up Omega protocol priority dispatch (referencing a method by which a dispatcher would determine through a card system whether a first responder would be dispatched to a low acuity medical call) as a concern. Staff reminded the group that CVEMSA has no interest in reducing responding resources beyond what a jurisdiction wishes to send to 911 calls. Tim A. felt Santa Rosa public expectation was a fire department response to a 911 call and that the City wants to send first responders, even though LEMSA may not want to dispatch them. Concern raised that the EMD process relies on information provided by a lay person, and that information has an influence on the response based on that layperson’s reporting of events that are happening, rather than a professional responder. CVEMSA restated its position as discussed earlier and noted in a white paper on the topic: the choice of whether to send medical first response and what to send as medical first response is at the discretion of the public provider agency; the LEMSA has set a minimum standard for types of medical responses.

There was a discussion on REDCOM dispatch personnel advising responders that a particular response is “code 2” or “has been reduced to code 2” while the responders are still en-route. Concerns that if the dispatcher advises the responding units the response code has been reduced, then a code 3 responder could face liability for a collision while operating with lights and sirens.

Tim Aboudara also pointed out that the reduction of an ambulance to Code 2 once fire had arrived could result in an extended that the time a fire resource needed to stay on scene thus reducing its availability to respond to other calls.

Aaron Abbot (REDCOM Exec. Director), pointed out the Medical Priority Dispatch system of determining the likely seriousness of patient illness and injury is approved by the medical director. But IAED (International Academy of Emergency Dispatch) does not specify response code. Driving operations are determined by the responders based on company polices, local conditions and knowledge specific to that call. Aaron also pointed out the distinction between code 2 and code 3 responses are made within the EOA area, in response to EOA needs only (i.e. those deriving from the EOA agreement), and no other individual agency has response code determinations. AMR response time compliance is structured based on response to determinants and that makes the difference important to that provider. REDCOM does not make policy for the use of lights and sirens, but does provide the determinant and corresponding response code to responders in the City of Santa Rosa because of their relationship with the EOA provider and the need to coordinate AMR’s contractually-regulated response. Per REDCOM protocol, REDCOM dispatches all resources over the radio initially code 3. If anything changes in the EMD process that allows the call to be downgraded to a longer response time, REDCOM advises the responders of that information as well.

Tim Aboudara felt public agency first responders need durable influence over policy decisions in this area. Concerns about the impact of decisions in this area could affect changes in response time standards and subsequent complications in Santa Rosa with EOA contract.

Matt Dahl brought up concerns about the concept of Omega call determinants, particularly those defining response as an ambulance call only as one of the reasons that the stakeholders had been concerned about the original draft EMS language which was broadly stated along the lines of ‘according to LEMSA policies’. While the LEMSA has not changed its position with respect to public agencies having the ability to send whatever they want as first response to incidents, it was acknowledged that the broad language they proposed in their hopes to reduce the need, generally, to amend the ordinance in the future, was so broad as to allow for the interpretation that they might change their policy on dispatch in the future to restrict public agency first response. It was pointed out that while they had not anticipated this concern, the LEMSA has already committed to addressing it specifically in the ordinance (per the earlier stakeholder meeting discussion on Dispatch).

Chris moved the conversation to the next item on the agenda, by asking the public agencies to consider the policy development policy. What is missing? What part of the process needs to be connected to the EMCC? Stakeholders have previously raised a concern about needing a collaborative process for patient treatment protocol development; what’s wrong or missing in this process?

Tim Aboudara brought forward a previous conflict – Santa Rosa Fire Department wanted to use the Lucas device (a commercially available mechanical compression device used for performing chest compressions on cardiac arrest patients) and the LEMSA medical director did not support the use of the device in the same manner the Fire Department wished to use it. Tim asked about process is in place to appeal the medical director’s decisions. How do we bring it forth for discussion during the public comment process? Further, he noted there is no appeal process after public comment.

Bryan Cleaver, EMS Agency Administrator, advised stakeholders that the EMS Agency does have a process for appealing decisions, but it is an informal process of ongoing discussion and engagement rather than a formalized appeal. Field paramedics can discuss issues with medical director at ALS Update, and CVEMSA is always open to seeing new evidence to show different outcomes for patients under a different protocol. Bryan agreed there is a need to formalize this appeal process. One possibility that was suggested was a protest and a response showing the science and how the decision was made. Possibly could be a panel with local EMS physicians and a transparent discussion leading to a recommendation to the medical director but it was stated that ultimately it is Dr. Luoto’s final decision due to the inherent responsibility for the care in the system under his own medical license.

Bryan described some of the ways the EMS Agency collaborates with EMS system partners when considering new policy or revisions to current policy. Dr. Luoto lectures at the monthly CVEMSA ALS Update class. Dr. Luoto hears from the field paramedics regarding any needs change and seeks input on any policies out in draft form at that time. Policy changes are done first at a staff level with input from a workgroup as needed, and then out to public comment, including MAC and EMCC discussion. Input throughout the process helps inform the final decision making that results in a policy or treatment guideline change.

Another question arose to be answered in this discussion: how does CQI support MAC and EMCC and is it the same as it functions with respect to the REDCOM Board?

Chris Thomas asked Bryan Cleaver to write something about MAC and EMCC and how one or more of those committees could be used to facilitate an appeal process.

After asking if there was anything else stakeholders wanted besides a more formalized appeal process in the development of policy and hearing none, Chris then asked folks to think about other input with respect to EMCC and MAC and CQI for next time and moved the group to the wrap-up as adjournment time was near. He shared that the EMS Agency had been in communication with the California EMS Authority who requested a timeline for the EOA RFP process. CVEMSA provided a high level time line, and are working on more detailed version. An update including EMSA RFP review was requested of CVEMSA and has been provided.

Chris mentioned that early on in the stakeholder engagement process a request was made regarding an evaluation of LEMSA. Sonoma County Department of Health Services has authorized a scope of work for a consultant. That scope will include questions asked of stakeholders related to stakeholder relations and perceived LEMSA biases. The evaluation will include much more than just evaluating stakeholder relations; the LEMSA must self-evaluate every year and an outside expert can help with that process. Chris asked the group to consider what input they want into the evaluation and to be able to discuss at an upcoming meeting.

Chris also mentioned the EMS Agency is working with presenters for an upcoming session to hear about future innovations and efficiencies in EMS Systems. Staff are asking both presenters to send out a summary of what they will cover. Urban and Rural LEMSAs innovations and efficiencies are one set of interest topics. Steve Suter asked about the possibility of adding an additional speaker; and Bryan indicated that it would be considered, potentially adding another date to cover other portions of the future innovations and efficiencies topic as needed. Steve was asked to send suggested speakers to Jen Banks.