Transcript
Santa Clara County Emergency Medical Services Agency
Semi-Annual Report
May
2013
January 1, 2012 to December 31, 2012
County of Santa Clara
Public Health Department
Emergency Medical Services Agency 976 Lenzen Avenue, Suite 1200 San José, CA 95126 408.885.4250 voice 408.885.3538 fax www.sccemsagency.org
April 5, 2013
Honorable Members of the Health and Hospital Committee and the Board of Supervisors:
The Santa Clara County EMS Agency is pleased to present to you its semiannual report reviewing the operations of the EMS Agency and discussing the status of the Santa Clara County EMS System. This report emphasizes the period from July 1, 2012 through December 31, 2012, but includes information from January 1, 2012 through December 31, 2012, to provide context and precedent. During 2012, much of the work of the EMS Agency and the EMS System focused in three areas: 1) fully implementing the contract between Rural/Metro of California, Inc. and the County of Santa Clara; 2) assuring first responder and County Ambulance compliance with contractual response time standards; and, 3) conducting long term EMS System strategic planning to position the Santa Clara County EMS System to excel in an approaching era of health reform. Successes and challenges in each of these areas are discussed in this report. The Santa Clara EMS Agency and EMS System are embracing the concept of the Triple Aim: improving the quality of clinical care, improving efficiency and effectiveness, thus controlling or reducing costs, and increasing levels of patient and stakeholder satisfaction. You can be assured that the Santa Clara County EMS System is meeting its responsibility to you, the system stakeholders, and the public to provide high quality, clinically-safe, and operationally-efficient emergency medical services to the County of Santa Clara. As always, please don’t hesitate to contact me with any questions. The EMS Agency appreciates your leadership and support to ensure a high quality EMS System in Santa Clara County.
Sincerely,
Michael Petrie EMS Director
Board of Supervisors: Mike Wasserman, Dave Cortese, Ken Yeager, Joe Simitian County Executive: Jeffrey V. Smith
Table of Contents
Table of Contents ................................................................................................................................................ 2 EMS Agency Activities ....................................................................................................................................... 3
Rural/Metro serving as County Ambulance ...........................................................................................................3 EMS System Strategic Assessment and Strategic Planning Process .......................................................................4 Medication Shortages.............................................................................................................................................6 Diversion and Delay of Ambulances at Hospital Emergency Departments ...........................................................6 The Comprehensive EMS Data System...................................................................................................................8 Wildland Fire and Multiple Patient Management Plan Exercises ..........................................................................9 Sobering System .....................................................................................................................................................9
EMS Trust Fund .................................................................................................................................................11
EMS Trust Fund Revenue..................................................................................................................................... 11 EMS Trust Fund Expense ..................................................................................................................................... 12 EMS Agency Fee Schedule ................................................................................................................................... 14
EMS System Descriptive Statistics ..............................................................................................................16 Prehospital Clinical Care and Quality Improvement ...........................................................................18
Rural/Metro Response Times .............................................................................................................................. 18 Map of SCC EOA Response Subzones and City Boundaries................................................................................. 20 Mutual Aid Provided by Rural/Metro .................................................................................................................. 21 Mutual Aid Provided to Rural/Metro .................................................................................................................. 22 Fire Department First Responder Response Times ............................................................................................. 23 Air Ambulance Transports ................................................................................................................................... 26
Hospital and Specialty Care Facilities .......................................................................................................27
Hospital Volume and Destinations ...................................................................................................................... 27 Hospital Diversion of Ambulances....................................................................................................................... 28 Trauma Care System............................................................................................................................................ 29 Stroke Care System.............................................................................................................................................. 30 STEMI Care System .............................................................................................................................................. 31
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EMS Agency Activities
This semi-annual report emphasizes the six-month period from July 1, 2012 through December 31, 2012, but includes information from throughout calendar year 2012 to provide context and precedent to the reader. Consequently, some important activities that were previously discussed in the November 2012 annual report are restated or revised in this report.
Rural/Metro serving as County Ambulance
Rural/Metro of California, serving as County Ambulance, began providing 911 emergency ambulance and paramedic services to the County of Santa Clara on July 1, 2011. However, it has taken approximately 18 months to fully develop the comprehensive and integrated EMS System envisioned in the Emergency Medical Services Agreement between Rural/Metro of California, Inc. and the County of Santa Clara. This agreement is widely considered one of the most comprehensive in California; compelling Rural/Metro to provide service and system benefit to the Santa Clara County EMS System at levels well beyond those provided in other EMS Systems throughout California. During 2012, the EMS Agency and Rural/Metro worked closely to fully implement the contract. One of the most notable achievements was integrating fire departments and Rural/Metro into FirstWatch. FirstWatch is a datamining, reporting, and analysis system that allows fire departments, Rural/Metro, and the EMS Agency to more efficiently monitor and measure response time performance and automate performance reporting. FirstWatch also allows organizations to more rapidly identify unusual system activity, such as rising call volumes and sentinel events, such as a covert release of a chemical or biological agent. FirstWatch is also a powerful tool to improve operational efficiency by helping trend periods of high and low call volume, facilitating demand-based staffing patterns. FirstWatch is one of a number of technology-based information systems that will allow the EMS System to meet the goals of the Triple Aim: to provide higher levels of clinical quality, to maintain or improve efficiency, and, to improve patient and stakeholder satisfaction. The contract with Rural/Metro has brought numerous benefits to the Santa Clara EMS System, and the County of Santa Clara. During the past 18 months, Rural/Metro has developed a systemwide public education and information program, a coordinated multi-agency medical and continuing education training program, improved security measures for EMS personnel and ambulances, and unprecedented transparency in performance, finance, and operations, including publicly posting performance and financial data on their website. During two months in the second half of 2012, Rural/Metro failed to meet contractual response time standards. In October 2012, Rural/Metro recorded an 89.57% response time compliance rate to Code 3 (emergency red
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light and siren) calls in Zone 1 (Northwest Santa Clara County). In December 2012, Rural/Metro recorded an 89.66% response time compliance rate to Code 3 (emergency red light and siren) in Zone 4 (Southeastern San Jose and incorporated area). These response time compliance rates failed to meet the contractually-mandated 90th percentile response time standard. Although Rural/Metro failed to meet the response time standards by less than one-half of one percent and the EMS Agency is not aware of any detrimental patient outcomes related to these delayed response times, these two failures constituted a material breach of contract, because Rural/Metro failed to meet response time performance standards twice in a six month period. In response, Rural/Metro rapidly developed a comprehensive plan of correction and took other measures to correct this breach. Rural/Metro has subsequently met response time standards for all emergency and non-emergency calls in all zones. In spite of these response time challenges, the EMS Agency believes that Rural/Metro is a capable partner in the continued development of the Santa Clara County EMS System. The EMS Agency holds this position because Rural/Metro has met response time performance standards in all zones in January 2013, February 2013, and March 2013, and because Rural/Metro has materially met the deliverables in their contract, which signals a long term investment in the Santa Clara EMS System. Detailed information about EMS System performance, including Rural/Metro’s response time performance statistics, is provided on pages 15 through 31.
EMS System Strategic Assessment and Strategic Planning Process
The EMS System Strategic Assessment started in early July 2012 to help prepare the Santa Clara County EMS System to adapt to changes in health care operations and financing driven by national health reform. This project was intentionally scheduled to start soon after the US Supreme Court decided the Patient Protection and Affordable Care Act (PPACA) cases, and is scheduled to conclude by late June 2013. The assessment and planning process is considering a 3 to 7 year planning horizon, focusing on the Triple Aim: The project is divided into three phases. Phase 1 was the strategic assessment of the EMS System, which occurred between July and October 2012. During this phase, The Abaris Group, the consulting firm assisting the EMS Agency, interviewed key EMS System stakeholders including County and Santa Clara Valley Health and Hospital System leadership, fire service leadership, law enforcement, ambulance companies’ leadership and labor, hospital leadership, emergency department physicians and nurses, EMS agency personnel, and the EMS Medical Director. The Abaris Group also reviewed EMS System policies, procedures, and clinical protocols, and examined financial and operational records and reports. One essential component of the system analysis was the economic analysis of the projected financial effects of the Affordable Care Act on the County of Santa Clara EMS System. The Abaris Group modeled the financial effects of health reform based on Santa Clara County-specific data; rather than using more general state or national data. This level of specificity increases the value, credibility, and applicability of the assessment. At the end of Phase 1, The Abaris Group released the “Santa Clara County EMS System Assessment” report, which is available on the EMS Agency’s website. 1
1
http://www.sccgov.org/sites/ems/EMSStrategicPlanning/Pages/default.aspx 4
Santa Clara County EMS Agency
May 2013
Phase 2 is the development of the Santa Clara County EMS System Strategic Plan, based on the information contained in the “Santa Clara County EMS System Assessment” and developed during public strategic planning workshops. Phase 2 started on November 1, 2012 and will conclude in June, 2013. During Phase 2, seven strategic planning workshops were held, in which EMS System participants conducted a strategic environmental analysis; crafted Mission, Vision, and Values Statements; and created and prioritized 10 goals for the EMS System. These statements and goals are contained in the DRAFT EMS System Strategic Plan, which was released to EMS Stakeholders is mid-February. The 10 Goals identified in the DRAFT EMS System Strategic Plan are: Goal One: Goal Two: Research and design an Enhanced Contemporary EMS Medical Direction Model Evaluate and redesign the EMS System Stakeholder Committee Structure for effectiveness and focus Develop an effective Continuous Quality Improvement (CQI) Program Standardize EMS Communication and align the EMS Communication System Create enhanced collaborative models with stakeholder organizations in which EMS is an equal partner with other public safety and health organizations. Assure the Long Term Financial Solvency and Stability of the Santa Clara County EMS System Research, Design, and Implement Contemporary EMS Delivery Methods and Service Delivery Options Partner with Public Health and Public Safety Organizations to Align and Enhance Public Education and Prevention Efforts. Develop a Collaborative Model to Prevent and Respond to Emergency Department/Hospital Capacity Issues and Resulting EMS System Delays. Develop a Common Legislative Action Plan to Support the Implementation of this EMS Strategic Plan
Goal Three: Goal Four: Goal Five:
Goal Six:
Goal Seven:
Goal Eight:
Goal Nine:
Goal Ten:
From early March to late May, the EMS Agency and The Abaris Group will engage EMS System decision makers, medical and government leaders and health insurance providers in focused dialogues to better understand funding mechanisms, the local EMS healthcare environment, and to validate the Strategic Plan’s proposed goals. Based on these discussions, the EMS Agency will release a third draft of the EMS System Strategic Plan in early June, host a workshop to receive final comments from stakeholders in mid-June, and host a Strategic Planning Summit in late June 2013 to roll out the final approved Santa Clara County EMS System Strategic Plan. Phase 3 is the development of the implementation plan to support the goals and objectives in the EMS System Strategic Plan. Phase 3 is occurring concurrently with Phase 2. As EMS System decision makers are engaged, the EMS Agency and The Abaris Group will create best practice recommendations on implementing the goals and objectives in the EMS System Strategic Plan. These recommendations will be included in the EMS Strategic Plan.
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Medication Shortages
During 2012, the EMS Agency and paramedic agencies continued to adapt to shortages of medication used to treat patients in the prehospital setting, which is impacting medical providers nationwide. In Santa Clara County, the EMS System experienced shortages of six classes of medication, including medications used to treat cardiac arrest, severe allergic reactions, nausea, seizures, diabetic emergencies, and exposure to carbon monoxide. To adapt to these shortages, the EMS Agency authorized paramedic-provider agencies to use alternate medications, limited the use of anti-nausea medications to the most serious cases, allowed the use of differently-concentrated medications, and aggressively engaged pharmacies and medication vendors. Paramedics received focused retraining on these medications to assure patient safety, and no detrimental clinical incidents have been identified. The EMS Agency is also requiring paramedic-provider agencies to implement specific inventory management systems to identify potential shortages earlier; providing more time to mitigate the medication shortage. Unfortunately, the EMS Agency does not anticipate a swift resolution to the root problems causing the national medication shortage—decreased production, shortages of raw materials, and quality and purity problems. The EMS System will continue to adapt, with the first and overriding priority being clinically-safe patient care.
Diversion and Delay of Ambulances at Hospital Emergency Departments
Nationally, and within Santa Clara County, more patients present to hospital emergency departments than can be provided with immediate service. This may be due to the need to prioritize staffing and resources to those patients with life threatening medical conditions as well as Hospital system efficiency issues. These delays infrequently have an unintended, yet detrimental impact to the EMS system. Hospitals closing to ambulances, called “diversion,” impacts other local Emergency Departments by unexpectedly surging their volume of patients. Another phenomenon called “extended wall times” has a direct negative impact on the availability of pre-hospital EMS assets. Generally defined, wall times are the time interval starting when the ambulance arrives at the emergency department and ending when emergency department staff accepts responsibility for the patient and moves that patient off the ambulance gurney. When emergency departments are extremely busy, wall times are often extended. The EMS Agency has defined extended wall times as wall times greater than 15 minutes.
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Extended delays in off-loading and transferring the patient to the care of the Emergency Department team ties up the Paramedic Ambulance, essentially removing it from service. This can increase Ambulance response times across the rest of the EMS System and thus may degrade the overall quality of care. The California EMS Authority and the California Hospital Association note that “Delay in ED patient transfer has not been well studied in relation to patient care outcomes, but the associated factors of diversion status and ED boarding both have been linked to increases in patient morbidity and mortality” 2. In addition, extended wall time intervals delay the transfer of care to the clinical team of physicians and nursed in the Emergency Department. Since January 2012, the EMS Agency, working closely with the Hospital Council, has actively engaged hospitals’ emergency department managers, Chief Nursing Officers, Chief Executive Officers, and Rural/Metro management to reduce wall time intervals in Santa Clara County. Our collaborative work has been productive: We have reduced aggregate wall time hours, based on patient turnover delays of greater than 15 minutes, from approximately 437 hours in July 2011, to 240 hours in December of 2012—a reduction of 54%. The EMS Agency accepts that the measurement system used to assess wall time intervals is not perfect—logging the time the ambulance arrives at the hospital until the time when a nurse signs the electronic patient care record and moves the patient onto a hospital bed. Yet, it is the most accurate and uniformly applicable method identified.
Santa Clara EMS System Ambulance Wall Times > 15 Minutes Aggregate All Hospitals July 2011 through December 2012
600 500 400 300 200 100 0 437 420 382 393 330 291 279 288 290 552 312 289 280 264 261 267
240
254
Total Linear (Total)
While the reduction of aggregate extended wall times is a positive trend, the aggregate number of extended wall times remains higher than desirable. Note that the 240 hours every month is analogous to having a full time ambulance staffed but sitting idle for 24 hours a day for 10 days every month. In the longer term, the EMS Agency is using a collaborative approach to reduce or eliminate diversion and excessive wall times. The agency is engaging the hospitals and Rural/Metro in a Lean Six Sigma process to define, measure, analyze, improve, and control the structures and processes relating to the root causes of ambulance
2
Barton, Bruce, et al. EMS Patient Offload Delays in the ED: Background Information for a Stakeholder Meeting. California Emergency Medical Services Authority and California Hospital Association. 5 March 2013 7 May 2013
Santa Clara County EMS Agency
diversion and excessive wall times. This project is planned to begin in the fall of 2013 and conclude by June 30, 2014. During this time, the EMS Agency will work with stakeholders and consider the need to implement an administrative order to establish wall time standards and report on wall time performance.
The Comprehensive EMS Data System
The Santa Clara Comprehensive EMS Patient Care Data System will provide the infrastructure to enable Santa Clara County EMS System providers, including medical communication centers, fire service first responders, Rural/Metro, non-emergency ambulance providers, and hospitals to comply with State and County mandated EMS data reporting requirements. The EMS Data System will also support clinical, operational, quality improvement of the Santa Clara County EMS System, and facilitate research to further the science of emergency medical services. The Comprehensive EMS Data System will integrate all prehospital 911 data into a common system. Rural/Metro has been on the system since July 2011. As of March 2013, all fire departments (except Palo Alto Fire Department) have completed system training and have implemented or will implement the system by June 2013. Consolidation of fire department first responder and Rural/Metros patient care data into a single, consolidated EMS patient care record provides more accurate information to hospital medical personnel, and facilitates a more rigorous quality improvement program. The next steps in Comprehensive EMS Data System implementation is capturing patient care data (through the use of mobile devices), in the prehospital field setting at the patient’s side. This capability allows patient care to be documented as that care is provided; rather than waiting to return to a station to complete the patient care record. This improves the accuracy and timeliness of the patient care record. A task force has been created to develop data standards, policies, definitions, and data entry rules to support patient’s side capture, and is expected to complete its work by December 2013. By December 2013, the EMS Agency will also integrate non-911 ambulance service provider data, and countywide trauma, stroke, and cardiac databases into the Comprehensive EMS Data System. During 2014, the EMS Agency would like to integrate hospital data, including emergency department data into the Comprehensive EMS Data System. In aggregate, the Comprehensive EMS Data System will facilitate system analysis and operational and clinical quality improvement. It will also improve EMS System efficiency, as those with the rights and need to know can run detailed performance reports. Finally, information from the EMS Patient Care Data System will be used to support injury prevention, public health, and epidemiological functions, further enhancing healthcare in Santa Clara County.
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The EMS Agency has funded the Comprehensive EMS Patient Care Data without the use of any County general fund monies. The program has been funded, and is expected to continue to be fully funded through the use of EMS Franchise Fees, EMS Trust Fund monies, and grants.
Wildland Fire and Multiple Patient Management Plan Exercises
In July 2012, members of the Santa Clara County Medical Volunteers for Disaster Response (MVDR), Rural/Metro, and the EMS Agency provided medical support for a three day wildland fire exercise, which prepares area firefighters to fight fires in the rural and mountainous areas of the county. During the exercise, MVDR, Rural/Metro, and the EMS Agency provided medical protection and support services, including first aid and rehabilitation care for firefighters. EMS Agency personnel also serve on the Santa Clara County Overhead Support Team responsible for the planning and coordination of the event. In October 2012, Santa Clara County EMS conducted a full-scale exercise to practice multiple casualty incident response. A full scale exercise is an exercise where field personnel provide simulated rescue and care to victims and command and control is provided in real time. This exercise provided an opportunity for fire departments and emergency medical services providers in Santa Clara County to practice skills used during incidents that result in multiple patients, such as transportation accidents, earthquakes, large gatherings, hazardous materials, etc. The primary focus of this year’s exercise was rapid triage, treatment, and transport of patients. Capabilities tested during this event included the Santa Clara County EMS Multiple Patient Management Plan, interoperable communications systems (radio and internet based), countywide incident management practices, and use of emergency equipment provided through the State Homeland Security and Hospital Preparedness grant programs. Five hundred Santa Clara County EMS personnel and medical volunteers participated in this exercise over the course of three days. The leadership, professionalism, expertise, and cooperation demonstrated by Rural/Metro, area fire departments and fire districts, and the local non-emergency ambulance providers to plan, conduct, and evaluate these exercises was impressive. The EMS Agency looks forward to equally valuable exercises in 2013.
Sobering System
A preliminary EMS study, using data collected from July 1, 2011 through December 31, 2011, indicated that 7,000– 7,500 patients annually presenting with alcohol-related intoxication and other injuries, drugs, illnesses or
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complaints, are transported via 911 EMS ambulances each year to hospital Emergency Departments throughout Santa Clara County. Of these patients, approximately 2,720 annually are transported primarily for alcohol intoxication or other primarily-alcohol related effects, without drug, trauma, illness, or other confounding factors. A more detailed analysis, conducted using clinical and ICD-9 data collected from January 1, 2012 through June 30, 2012 indicated that approximately 1,120 patients annually could be transported directly from the field by a sobering van to a Sobering Center, using appropriate clinical protocols. Many of the balance of these patients could be medically screened and cleared at an Emergency Department, and then re-transported by sobering van to the Sobering Center, thus keeping the Emergency Department beds available for patients with more serious illnesses and injuries. Because many emergency departments are regularly overcrowded, the sobering system would reduce emergency department wait times, improve patient safety, and allow scarce emergency department resources to be focused on other patients with emergent conditions such as stroke, heart attack or serious injury. The Sobering Center may also lead to some patients seeking additional substance abuse treatment services that will, in the long term, prevent readmission in the Emergency Department for public intoxication. Sobering System Concept of Operations In the sobering system concept of operations, paramedics would respond to a 911 call for a medical emergency. Upon arrival, a paramedic would evaluate the patient, using a clinical protocol developed by the EMS Medical Director. If the paramedic determines that the patient’s primary clinical impression is alcohol intoxication without other complicating clinical issues, the patient may be deemed appropriate for transport by the sobering van directly to the Sobering Center. The sobering van would be a simple van, staffed by an Emergency Medical Technician-Basic (EMT-B) that carries basic first aid equipment and has a radio to summon emergency assistance. Should other medical concerns be present, the patient would be transported by ambulance directly to a hospital emergency department. All alcohol intoxicated patients arriving at the Emergency Department— both those transported by ambulance and those who self-present—may be medically screened and deemed appropriate for transport from the emergency department to the Sobering Center. A single sobering van would be operated 24 hours a day, 365 days a year. A second van would be staffed during peak periods. Admission to the Sobering Center would be determined by clinical protocols developed by the EMS Medical Director, the Medical Director of the Sobering Center and participating hospital emergency department medical directors. Initially, admissions to the Sobering Center would be directed from an EMS response, law enforcement or a patient “cleared” by a hospital emergency department and transported to the Sobering Center. Walk-in admissions to the Sobering Center would likely not be appropriate at this time. The Sobering Center would contain approximately 20 beds and operate 24 hours a day, 365 days a year. The Center would provide limited medical care, such as oral fluids or over the counter medication, in addition to providing a location for patients sleeping off their state of inebriation. Staffing would include an on-site Registered Nurse(s) and other attendant personnel for the acute phase of sobering. Other staff, such as Medical Social Workers, Mental Health specialists and Alcohol and Drug specialists may be on-site or connected with the patient at the time of discharge. A physician would be available by phone and a physician Medical Director would set overall clinical protocol and quality assurance. The typical length of stay for a patient would be between 6-12 hours. Patients whose clinical status deteriorates beyond the level of care provide in the Sobering
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Center would be re-transported to a hospital Emergency Department. This concept of operations is illustrated in the following graphic:
Future Steps The Santa Clara Valley Health and Hospital System (SCVHHS) is reaching out to hospitals and other potential funders of the sobering system. SCVHHS believes that a three-year pilot project is necessary to develop, finetune, and evaluate the system. SCVHHS brought a report and recommendation to the Health and Hospital Committee in the late Spring of 2013. If authorized by the Board of Supervisors, SCVHHS would anticipate the release of an RFP by the summer of 2013, with the expectation of having an operational Sobering Center in place by the winter of 2013.
EMS Trust Fund
The EMS Trust Fund’s purpose is to provide funding for projects with a countywide benefit to EMS System providers, enhance the services provided within the EMS System, and stand to improve the delivery of 911 emergency medical care in the County. The EMS Trust Fund is a backward-looking fund; that is, funds collected in one year are expended the following year. This provides policy and spending oversight by the Board of Supervisors, and provides adequate time to consider spending allocations in the context of strategic EMS System change.
EMS Trust Fund Revenue
The EMS Trust Fund is funded with revenues from liquidated damages (fines) from the contracted 911 paramedic ambulance provider for failing to meet per-call response time standards; monthly zone response time standards; or for failing to meet other contract stipulations, such as maintaining minimum ambulance
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availability or avoiding ambulance breakdowns. During Calendar Year 2012, Rural/Metro paid the following liquidated damages, which were placed into the EMS Fund. Month / Year January 2012 February 2012 March 2012 April 2012 May 2012 June 2012 July 2012 August 2012 September 2012 October 2012 November 2012 December 2012 TOTAL Average Monthly Liquidated Damages Amount $170,250 $256,750 $214,000 $220,000 $211,250 $231,500 $198,250 $233,750 $222,000 $297,750 $284,000 $281,250 $2,820,750 $235,062
The amount of these liquidated damages is significantly greater than the amount of liquidated damages in previous 911 paramedic ambulance contracts. However, the greater amount of liquidated damages is due to a substantially more expensive fine structure; rather than poor system or provider performance. In some cases, fine levels in the Rural/Metro contract are ten times greater than in the prior contract.
EMS Trust Fund Expense
EMS Trust Fund expenses are approved by the Health and Hospital Committee and the Board of Supervisors before the start of the fiscal year. The EMS Agency routinely provides detailed financial reports to the Health and Hospital Committee on the EMS Trust Fund. This EMS Trust Fund summary discusses how the expenditures from the EMS Trust Fund improve EMS within Santa Clara County. Category A: Reserve At the Board of Supervisors’ direction, starting in Fiscal Year 2011-2012, a reserve category was established in the EMS Trust Fund. This amount, which is at least 20% of the EMS Trust Fund, will be placed into reserve and used only for significant strategic projects that benefit the EMS System with a long range focus. These funds could also be used should the EMS System experience an unanticipated financial burden, such as the failure of an ambulance provider or an extraordinary increase of cost of service or supplies, or a material decrease in system-wide third-party payor reimbursement. During the 2012-2013 Fiscal Year, $976,659 of the EMS Trust Fund monies were placed into reserve.
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Category B: Training, Education and Recognition Allocations were approved to produce two videos to inform the public to pull to the right for red lights and sirens and to familiarize the public with the Santa Clara County EMS System. Videos are also being produced to standardize EMS training across fire departments and ambulance providers countywide. These videos will include “Santa Clara County Emergency Medical Services System Overview”, “County EMS Radio Communications”, “Establishment of Field Treatment Sites (FTS) and FTS Trailers Operations”, “Multiple Patient Management Plan (MPMP) Review”, and “Ambulance Muster Stations”. These training videos will help assure that all EMS personnel, regardless of their employer or the shift they work, can access the same high quality training to prepare them for EMS routine and disaster operations. Additionally, the EMS Agency will provide another series of courses to EMS System stakeholders to better understand the use of data and statistical processes to evaluate quality of care and operational effectiveness. This training is critical to the strategic goal of basing EMS System decisions on data and evidence. During the 2012-2013 Fiscal Year, $220,000 was allocated to training, education and recognition. Category C: Benefit to EMS System Stakeholders Funds were allocated from this category to assist EMS System Stakeholders with one-time or short-term needs. During Fiscal Year 2012-2013, funds were allocated to the fire departments within Santa Clara County to provide hardware associated with the County EMS System Data Project. This funding allocation is one-half of total funding of approximately $500,000, which will provide fire departments with the ability to enter and transmit patient care data from the scene of an emergency; rather than waiting to enter data until the unit has returned to a fire station. This allocation was essential to creating a comprehensive EMS System data collection and analysis capability. During the 2012-2013 Fiscal Year, $250,000 was allocated to short term and one time projects that benefit EMS System Stakeholders. Category D: Strategic Initiatives Projects in this category emphasize initiatives that strategically advance the Santa Clara County EMS System, often in the longer term. During FY 2012-2013, funds were allocated to conduct a strategic assessment of the EMS System and to develop a three to seven-year EMS System Strategic Plan. Monies were also allocated to fund further development of the Comprehensive EMS Data System. Category D funds were also spent to replace an aging EMS Duty Chief vehicle, to provide standardized personal protective equipment such as helmets and reflective jackets to private ambulance providers, to develop an EMS injury prevention program, to update EMS System policies and procedures, and to support development of the Sobering System. During Fiscal Year 20122013, $1,095,000 was allocated to strategic projects.
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EMS Agency Fee Schedule
The EMS Agency relies on fee-for-service fees for funding operations, including system-wide planning, policy and clinical protocol development, analysis, and operational and clinical quality improvement. The EMS Agency has not increased its fees since July 1, 2011. The EMS Agency did not request a fee modification from the Board of Supervisors for Fiscal Year 14, because unprecedented changes in the EMS System operations and EMS Agency planning and quality improvement linked to the EMS System Strategic Plan will occur in starting in the second half of Fiscal Year 14. The EMS Agency will likely request fee modifications after the strategic plan is complete, and the structure and processes of the revised EMS System are better quantified. The current fee structure is listed below: Private Ambulance Permit Fees Description Basic Life Support Ambulance Service Advanced Life Support Ambulance Service Critical Care Transport Ambulance Service Air Ambulance Service Permit Per Unit/Resource Permit FY12 $5,500.00 $6,000.00 $6,000.00 $8,000.00 $950.00
EMS Hospital Receiving Facility Fees Description 911 Paramedic Receiving Facility EMS Stroke Receiving Facility EMS Cardiac Receiving Facility EMS Trauma Receiving Facility FY12 $10,000.00 $10,000.00 $10,000.00 $100,000.00
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Fiscal Year 2013 EMS Agency Fee Schedule ITEM/SERVICE INDIVIDUAL FEES EMT-Basic Certification EMT Basic Re-Certification (biennial) EMT-P Local Accreditation Identification Card Replacement ID Card (certification, accreditation, system ID) Photocopying CORPORATE FEES Ambulance Service Permits (annual fee) Basic Life Support Advanced Life Support Critical Care Transfer Air Service Ambulance Vehicle Permits (annual fee) Basic Life Support Advanced Life Support Critical Care Transfer Air Unit Non-Transport BLS/ALS Unit Education Program Certification (every 4 years) EMT Program Paramedic Program Prehospital Continuing Education Specialty Care Designation (annual fee) Trauma Center Designation Stroke Center Designation STEMI Receiving Center Designation 911 Receiving Center Designation
FEE
$50 $50 $150 $20 $20 st $4.75 (1 page), $.10/ea. Addl.
$5,500 $6,000 $6,000 $8,000 $950 $950 $950 $950 $800 $1,000 $5,000 $1,000 $100,000 $10,000 $10,000 $10,000
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EMS System Descriptive Statistics
Listed in the following set of tables are statistics that describe the characteristics of the Santa Clara County EMS during Calendar Year 2012. The County of Santa Clara Daytime Population Resident Population Geographic Size Geographic Des. Municipalities 911 System Call Volume January through December 2012 Total Responses Total Events with Ground Ambulance Transports Total Patients Transported by Ground Ambulance EMS Aircraft Response EMS Aircraft Transports Specialty Center Patients Stroke Patients Trauma Patients STEMI Patients Pre-Hospital Care Provider Agencies Fire Departments Ground Ambulance Services Air Ambulance Services Pre-Hospital Care Personnel Emergency Medical Technicians Paramedics Mobile Intensive Care Nurses Accredited EMS Field Supervisors Permitted EMS Assets Fire Apparatus Private Ground Ambulances Private Air Ambulances Private EMS Non-Transport Units
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2,200,000 persons 1,800,000 persons 1,132 square miles 2/3 rural 15
108,763 75,713 74,695 183 109
1,243 3,520 204
11 10 2
2,194 888 33 11
159 209 3 18
Communications Centers Public Safety Answering Points (PSAPs) Secondary PSAPs Emergency Medical Dispatch Providers Private Ambulance Dispatch Centers Air Ambulance Dispatch Centers Acute Care Facilities Acute Care Hospitals Emergency Departments Level 1 Trauma Centers Level 2 Trauma Centers Base Hospitals Burn Centers Stroke Centers STEMI Centers County Managed Medical Health Resources Field Treatment Site Trailers Specialty Services Trailers Chem-Packs Medical-Health Operations Center EMS Radio Caches Disaster Medical Support Unit Training Programs Emergency Medical Technician Paramedic EMS Fellowship Ambulance Interfacility Transports Ground Ambulance 2012* Ground Ambulance 2011* Ground Ambulance 2010* 54,254 49,322 44,839 7 2 0 8 3 8 1 5 1 12 11 2 1 1 1 9 8 13 10 6 9 2
* As self-reported by ground ambulance providers
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Prehospital Clinical Care and Quality Improvement
Rural/Metro Response Times
The chart below identifies Rural/Metro’s response times to Code 3 (emergency red light and siren) calls by month from July 1, 2012 through December 31, 2012 in each of the five ambulance subzones within Santa Clara County. The response time standard is 90% or greater, and is represented by the yellow horizontal line on this graphic. In October 2012, Rural/Metro recorded an 89.57% response time compliance rate to Code 3 (emergency red light and siren) calls in Zone 1 (Northwest Santa Clara County). In December 2012, Rural/Metro recorded an 89.66% response time compliance rate to Code 3 (emergency red light and siren) in Zone 4 (Southeastern San Jose and incorporated area). Both of these response time compliance rates failed to meet the contractuallymandated 90th percentile response time standard. The EMS Agency is not aware of any detrimental patient outcomes related to these delayed response times.
County Ambulance Code 3 Response Times Zone 1- 5
100.00% 98.00% 96.00% 94.00% 92.00% 90.00% 88.00% 86.00% 84.00% Subzone 1 Subzone 2 Subzone 3 Subzone 4 Subzone 5 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12
Code 3 Responses Subzone 1 Subzone 2 Subzone 3 Subzone 4 Subzone 5
Jul 12 92.08% 94.05% 96.65% 94.61% 94.03%
Aug 12 91.61% 91.77% 94.95% 93.33% 93.03%
Sep 12 90.49% 90.48% 94.81% 92.10% 96.59%
Oct 12 89.57% 91.65% 94.27% 90.72% 93.40%
Nov 12 90.02% 90.26% 94.48% 90.59% 91.76%
Dec 12 90.66% 90.75% 93.77% 89.66% 94.72%
18 Santa Clara County EMS Agency May 2013
Ambulance Response Times to Non-Emergency Calls
The chart below identifies Rural/Metro’s response times to Code 2 (non-emergency) calls by month from July 1, 2012 through December 31, 2012 in each of the five ambulance subzones within Santa Clara County. The response time standard is 90% or greater, and is represented by the yellow horizontal line on this graphic.
County Ambulance Code 2 Response Times Zone 1- 5
100.00% 98.00% 96.00% 94.00% 92.00% 90.00% 88.00% Subzone 1 Subzone 2 Subzone 3 Subzone 4 Subzone 5 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12
Code 2 Responses Subzone 1 Subzone 2 Subzone 3 Subzone 4 Subzone 5
Jul 12 95.34% 96.30% 95.83% 95.90% 99.03%
Aug 12 93.36% 93.58% 95.62% 95.61% 95.05%
Sep 12 94.75% 93.81% 96.49% 92.02% 96.97%
Oct 12 94.98% 93.84% 92.32% 92.16% 96.20%
Nov 12 96.34% 94.00% 94.87% 92.66% 96.88%
Dec 12 97.34% 93.51% 92.84% 94.31% 97.62%
19 Santa Clara County EMS Agency May 2013
Santa Clara County EOA Response Subzones and City Boundaries
Subzone 1
Palo Alto Mountain View Los Sunnyvale Altos Los Hills Altos Santa Clara Cupertino Saratoga Campbell Milpitas
Subzone 3
San Jose
Monte Los Sereno Gatos
Subzone 4
Subzone 2
Morgan Hill
Subzone 5
Gilroy
Subzone 1: Subzone 2: Subzone 3: Subzone 4: Subzone 5:
Los Altos Hills, Los Altos, Mountain View, Sunnyvale and unincorporated areas Loyola, Moffet Field Campbell, Cupertino, Los Gatos, Monte Sereno, San Jose (West), Saratoga and the unincorporated areas of Burbank, Redwood Estates Milpitas, San Jose (North), Santa Clara San Jose (East, South) Gilroy, Morgan Hill and unincorporated areas San Martin
Source: Santa Clara County Exclusive Operating Agreeement, Exhibit B Developed by: Santa Clara County Emergency Medical Services Agency Created: 20090903
Mutual Aid Provided by Rural/Metro
The chart below identifies the number of times neighboring EMS Systems requested assistance from Rural/Metro by month from July 1, 2012 through December 31, 2012. In these instances, a Rural/Metro ambulance is immediately dispatched, unless the loss of that ambulance would materially degrade response times in the Santa Clara County EMS System. The EMS Agency is working closely with the Palo Alto Fire Department to reduce the number of Rural/Metro responses into Palo Alto. The high volume of Rural/Metro responses into Palo Alto is challenging to the Santa Clara County EMS System, as these responses encumber scarce ambulance resources that would otherwise be available for emergency response within the Santa Clara County Exclusive Operating Area. The Palo Alto Fire Department is adding additional EMS resources and the EMS Agency expects a marked decrease in the number of mutual aid calls into Palo Alto by May 2013.
Requests for Mutual Aid Assistance from Rural/Metro by Month (Jul to Dec 2012)
100 90 80 70 60 50 40 30 20 10 0 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 City of Palo Alto County of Santa Cruz County of San Mateo County of San Benito County of Stanislaus County of Merced County of Alameda
Mutual Aid Out of County City of Palo Alto County of Santa Cruz County of San Mateo County of San Benito County of Stanislaus County of Merced County of Alameda Total Requests
Jul 12 65 0 0 0 0 0 1 66
Aug 12 46 2 0 0 0 0 0 48
Sep 12 51 0 1 0 0 0 1 53
21
Oct 12 86 1 0 0 0 0 0 87
Nov 12 31 0 0 0 0 0 2 33
Dec 12 40 1 0 0 0 0 1 42
2012 Totals 606 11 3 0 0 1 8 629
Santa Clara County EMS Agency
May 2013
Mutual Aid Provided to Rural/Metro
Although infrequent, the Santa Clara County EMS System also relies on mutual aid to serve remote areas of the county. This table identifies that during 2012, the Santa Clara County EMS System did not request ambulance mutual aid. Mutual Aid Into County City of Palo Alto County of Alameda County of Merced County of San Benito County of San Mateo County of Santa Cruz County of Stanislaus Total Responses Jul 12 0 0 0 0 0 0 0 0 Aug 12 0 0 0 0 0 0 0 0 Sep 12 0 0 0 0 0 0 0 0 Oct 12 0 0 0 0 0 0 0 0 Nov 12 0 0 0 0 0 0 0 0 Dec 12 0 0 0 0 0 0 0 0 Totals 0 0 0 0 0 0 0 0
22 Santa Clara County EMS Agency May 2013
Fire Department First Responder Response Times
Fire Department First Responder Response Times to Emergency Calls
The chart below identifies fire department response times to Code 3 (emergency red light and siren) calls by month from July 1, 2012 through December 30, 2012 for each of the first-responder fire departments within Santa Clara County. Fire departments should achieve a response time of 90% or greater, and those who achieve a response time of 95% or greater are exempted from any response time liquidated damages incurred during that month. Starting September 2012 through December 2012, the San Jose Fire Department failed to comply with the 90th percentile response time performance standard. The San Jose Fire Department’s response time performance is detailed on the chart and graph below. The EMS Agency is not aware of any detrimental patient care outcomes assocated with these delayed response times. The San Jose Fire Department’s failure to comply with the 90th percentile response time performance standard for four consecutive months constitutes a material breach of Annex B of their Agreement with Santa Clara County to provide 911 Emergency Medical Services. Annex B is an optional annex, which provides funding from Rural/Metro to fire departments, if fire departments meet optional stringent response times standards. Annex B does not relate to the San Jose Fire Department’s ability to provide paramedic service, nor are fire departments required to enter into Annex B. Annex B provides that failure to meet the 90th percentile response time requirments for three consequtive months or four months in any twelve month period constitues a material breach of Annex B. San Jose Fire Department’s breach of Annex B occured at the end of October 2012, because San Jose Fire Department failed to meet the optional response time performance standards in February 2012, April 2012, and September 2012. Although the EMS Agency could have stopped payment from Rural/Metro to the San Jose Fire Department for this breach of Annex B, the EMS Agency exercised provisions of Annex B that allowed the San Jose Fire Department to implement a corrective action plan. San Jose Fire Chief Willie McDonald is personally involved in frequent meetings with the EMS Agency. He expects that that San Jose Fire Department response times will meet the optional funding standards contained in Annex B by Summer 2013.
23 Santa Clara County EMS Agency May 2013
Fire Department Code 3 First Responder Response Time Compliance by Month
100.00% 98.00% 96.00% 94.00% 92.00% 90.00% 88.00% 86.00% 84.00% 82.00% 80.00% Gilroy Fire Milpitas Fire Mt View Fire San Jose Santa Clara Santa Clara South Sunnyvale Fire City Fire County Fire Santa Clara DPS County Fire Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12
Code 3 Response Gilroy Fire Milpitas Fire Mt View Fire San Jose Fire Santa Clara City Fire Santa Clara County Fire South Santa Clara County Fire Sunnyvale DPS
Jul 12 97.45% 99.20% 99.37% 90.11% 95.39% 96.56% 97.39% 99.55%
Aug 12 97.12% 98.72% 98.12% 91.67% 95.24% 96.14% 98.36% 98.76%
Sep 12 97.04% 96.76% 98.05% 88.74% 95.02% 95.48% 96.58% 98.28%
Oct 12 98.00% 93.95% 99.12% 88.01% 95.07% 95.74% 96.61% 98.31%
Nov 12 99.00% 95.19% 99.64% 87.61% 95.59% 97.50% 97.37% 97.81%
Dec 12 97.27% 95.00% 98.73% 87.44% 95.40% 97.11% 97.75% 98.16%
Fire Department Response Times to Non-Emergency Calls
The chart below identifies fire department response times to Code 2 (non-emergency) calls by month from July 1, 2012 through December 31, 2012 for each of the first-responder fire departments within Santa Clara County. Fire departments should achieve a response time of 90% or greater, and those who achieve a response time of 95% or greater are exempted from any response time liquidated damages incurred during that month. The cities of Gilroy and Milpitas respond Code 3 to all calls; therefore, they have no Code 2 responses.
24 Santa Clara County EMS Agency May 2013
Fire Department Code 2 Response Time Compliance by Month
100.00%
95.00%
Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12
90.00%
85.00%
80.00% Mt. View Fire San Jose Fire Santa Clara City Fire Santa Clara County Fire South Santa Clara County Fire
Code 2 Response Mt. View Fire San Jose Fire Santa Clara Fire Santa Clara County Fire South Santa Clara County Fire Sunnyvale Public Safety Dept.
Jul 12 100.00% 93.14% 97.66% 100.00% 100.00% N/A
Aug 12 100.00% 94.80% 97.24% 98.51% 100.00% N/A
Sep 12 100.00% 95.28% 96.88% 97.87% 100.00% N/A
Oct 12 94.12% 93.27% 97.62% 100.00% 100.00% N/A
Nov 12 100.00% 92.99% 97.66% 100.00% N/A N/A
Dec 12 100.00% 94.08% 100.00% 98.26% 100.00% N/A
25 Santa Clara County EMS Agency May 2013
Air Ambulance Transports
Air ambulance utilization continued at relatively low levels during 2012. This volume of responses and transports has remained static since approximately 2009. The EMS Agency considers this volume of air ambulance responses and transports appropriate.
Air Ambulance Transports
600 500 400 300 248 200 100 0 2001 2002 2003 2004 2005 2006 2007 2008 254 254 236 251 205 221 557 540 524 545 463 442 443
Number of Dispatches Number of Transports
184 207 137 111
176
179
183
103 2010
107 2011
109
2009
2012
Year 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Number of Dispatches 557 540 524 545 463 443 442 248 184 176 179 183
Number of Transports 254 254 236 251 205 221 207 137 111 103 107 109
Utilization Percent 46% 47% 45% 46% 44% 50% 47% 55% 60% 59% 60% 60%
26 Santa Clara County EMS Agency May 2013
Hospital and Specialty Care Facilities
Hospital Volume and Destinations
From July 1, 2012 through December 31, 2012, ambulance transports from the 911 System to hospitals within Santa Clara County occurred at the following volumes.
Ambulance Destination by Hospital July 1 to December 31, 2012
1600 1400 1200 1000 800 600 400 200 0 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 El Camino - Los Gatos El Camino - Mt. View Good Samaritan Kaiser - San Jose Kaiser - Santa Clara O'Connor Regional - San Jose Saint Louise Stanford VA - Palo Alto SCVMC
Hospital El Camino - Los Gatos El Camino - Mt. View Good Samaritan Kaiser - San Jose Kaiser - Santa Clara O'Connor Regional - San Jose Saint Louise Stanford VA - Palo Alto SCVMC Total
Jul 12 73 588 533 514 593 488 983 253 423 52 1,318 5,818
Aug 12 99 597 501 609 595 509 1,063 225 414 64 1,369 6,045
Sep 12 87 619 525 534 566 555 1,091 204 451 69 1,281 5,982
27
Oct 12 64 647 535 547 638 583 1,120 245 463 58 1,364 6,264
Nov 12 88 597 571 538 598 561 1,062 210 457 69 1,256 6,007
Dec 12 79 661 585 630 638 606 1,041 196 421 66 1,311 6,234
Total 981 7,677 6,599 6,808 7,416 6,703 12,525 2,705 5,176 752 15,681 73,023
Santa Clara County EMS Agency
May 2013
Hospital Diversion of Ambulances
Hospital diversion levels appeared to trend toward stabilization, with hospitals in general achieving lower diversion levels in Year 2012. However, the EMS Agency continues to monitor “ambulance wall times”. This is the practice of busy hospital emergency departments not timely accepting the ambulance patient, causing the ambulance crew to wait for extended periods at the hospital. The EMS Agency is working with the Hospital Council and local hospitals to resolve this problem.
Ambulance Diversion by Hospital July 1 to December 31, 2012
120 100 80 60 40 20 0 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12
El Camino - Los Gatos El Camino - Mt. View Good Samaritan Kaiser - San Jose Kaiser - Santa Clara O'Connor Regional - San Jose Saint Louise Stanford VA - Palo Alto SCVMC
Hospital El Camino - Los Gatos El Camino - Mt. View Good Samaritan Kaiser - San Jose Kaiser - Santa Clara O'Connor Regional - San Jose Saint Louise Stanford VA - Palo Alto SCVMC Total
Jul 12 0 6.25 7.51 0 4.51 6.01 6.01 4.94 3.01 35.21 18.62 92.07
Aug 12 0 9.03 13.52 0 0 9.02 5.93 6.41 4.51 50.4 22.18 121
Sep 12 0 4.5 13.53 0 0 9.24 13.53 3 4.5 98.61 9.52 156.43
Oct 12 0 1.5 3 0 1.5 6.02 14.55 8.45 11.67 76.6 26.06 149.35
Nov 12 0 5.68 5.48 0 3.01 13.17 10.59 7.18 7.75 22.16 30.13 105.15
Dec 12 0 8.54 0 0 3 15.05 33.39 16.72 1.5 30.1 40.4 148.7
Totals 0 114.16 77.67 3 34.59 115.53 141.58 77.67 79.12 683.48 253.29 1580.1
28 Santa Clara County EMS Agency May 2013
Trauma Care System
Between July 1, 2012 and December 31, 2012, 3,520 trauma patients were seen in the Santa Clara County trauma system. This includes 3,181 adults and 333 pediatric patients (pediatric age range is 0 to less than age 15). Eighty percent of trauma patients were transported to a trauma center by ambulance. Eleven percent of trauma patients were transported to a trauma center by an air ambulance, and nine percent of trauma patients were brought to a trauma center by a private vehicle.
County of Origin
The primary county of origin for trauma patients that enter the Santa Clara County trauma system is Santa Clara County with 68% of the total volume of trauma patients. The next four highest volume counties of origin are: San Mateo County at 14%; Santa Cruz County at 5%; Monterey County at 4%; and San Benito County at 3%.
Santa Clara Trauma System-Injury County of Origin July 1 to December 31, 2012
2229
438 162 Santa Clara County San Mateo County Monterey County 135 Santa Cruz County 80 San Benito County 96 No County Indicated 40 Other Counties
Mechanism of Injury
Ninety-six percent of the injuries in the Santa Clara County trauma system are caused by a blunt mechanism of injury, such as motor vehicle/motorcycle injuries, pedestrian struck by car, and bicycle accidents. The remaining four percent are caused by penetrating mechanisms, such as gunshot wounds, and stabbings. These percentages are consistent throughout the past four years.
29 Santa Clara County EMS Agency May 2013
Age Factors
The age ranges of trauma victims are: Age Range 0 through 5 years 6 years through 15 years 16 years through 21 years 22 years through 45 years 46 years through 65 years 66 years through 85 years 86 years through 100 years Total number of victims 129 205 463 1,247 447 304 109
Injury Severity
Using a calculation referred to as the Injury Severity Score (ISS), the EMS Agency determined that sixty-four percent (64%) of trauma patients have minor injuries (ISS less than 9), seventeen percent (17%) of trauma victims have moderate injuries, and nine percent (9%) are severely injured (ISS 15 to 75). Using a calculation referred to as the Injury Severity Score (ISS), the EMS Agency determined that seventy-four percent of trauma patients have minor injuries (ISS less than 9), twenty-one percent of trauma victims have moderate injuries, and four percent are severely injured (ISS 15 to 75). ISS Score 1 to less than 9 9 to less than 15 15 and greater Total Volume 2,411 631 352 Percent Volume 64% 17% 9%
Disposition from the Emergency Department
Forty-seven percent (47%) of trauma patients are admitted to the hospital. Fifty-three percent (53%) of trauma patients are discharged from the emergency department. Less than one percent (0.70 %) of trauma patients die in the emergency department.
Stroke Care System
The Santa Clara County Board of Supervisors approved a stroke care system developed by the Santa Clara County Emergency Medical Services Agency in March of 2006. This evidence- based system provides patients the opportunity to be transported to the closest, specially designated hospital, which can provide immediate stroke care services to patients showing symptoms of an acute stroke. The need for rapid intervention is based on the scientific evidence that if a stroke patient is treated with an anticlotting drug within three and a half hours of the onset of their symptoms, it is possible to prevent or reverse
30 Santa Clara County EMS Agency May 2013
the effects of the blocked circulation to the brain. The stroke system was designed with a specific goal: to increase the numbers of patients who arrived in the emergency department at the stroke center quickly enough to allow administration of the anti-clotting drug. A second goal of the stroke system is to educate the public about stroke symptoms and the need to rapidly call 9-1-1 if stroke symptoms are present. Historically in Santa Clara County, approximately 45% of patients come to a stroke center by ambulance. However, from July 1, 2012 to December 31, 2012, 49% of stoke patients arrived at a stroke center by ambulance. This increase is potentially related to the outreach activities accomplished by the “Stroke Busters”. Stroke Busters is a collaboration of Santa Clara County Stroke Centers, the EMS Agency, Rural/Metro, the Stroke Awareness Foundation, and the Peninsula Stroke Association, who are two non-profits who assist with outreach. In October 2012, the “Stroke Busters” attended the Health Concern Outreach program at the San Jose Flea Market. Nine hundred eight seven people of all ages and ethnicities received a blood pressure check and provided with stroke information. This annual event will continue indefinitely. July 2012 through December 31, 2012 Performance Data Criteria Total Stroke Volume Total Number of Ischemic Strokes Total Strokes Transported by EMS Total Strokes Self-Transported Total patients by interhospital Transfer % of Ischemic Stroke treated by IV tPA County Performance Data 1,243 957 612 553 80 10% Percentages 100% 77% 49% 44% 6% National Average (1-8%)
STEMI Care System
Santa Clara County’s STEMI (S-T Elevation Myocardial Infarction) Care System continues to be regarded as a model system of care. A STEMI is a serious type of heart attack associated with higher rates of morbidity and mortality. Patients identified by paramedics as STEMI Alert patients, based on a 12 lead electrocardiogram, are treated rapidly with Percutaneous Coronary Intervention (PCI), which includes balloon angioplasty and stents, to open the blockage in the artery. The median length of stay in the hospital after the procedure is two days. From July 2012 through December 2012, 95% of the patients treated with Percutaneous Coronary Intervention had median door to balloon (D2B) of less than 90 minutes, versus a national benchmark of 75% of cases treated in 90 minutes or less. During the last quarter of 2012, 46% of PCI patients had a door to balloon time of 60 minutes or less. There has been some discussion in the cardiac literature of resetting the goal to 60 minutes or less; however, for now, the benchmark remains at 90 minutes.
31 Santa Clara County EMS Agency May 2013
Santa Clara County STEMI System Median Door to Balloon Times in Minutes Annually 2009 to 2012
70
Door to balloon time in minutes
69
68 66 64 62 60 58
65 63 62 D2B (Med)
2009
2010
2011
2012
July to December 2012 Performance Data Criteria Total cases with documented STEMI Median Door to Balloon time in Minutes Goal Met (D2B <90 min 75% of cases National standard) Total STEMI cases brought by EMS Total STEMI Cases who self-transported Total STEMI Cases brought by Interfacility transport July to December 2012 204 62 95% of PCI cases were performed in less than 90 minutes 103 88 13 2012 Annual Data 435 62 95% of PCI Cases were performed in less than 90 minutes 242 174 19
32 Santa Clara County EMS Agency May 2013