Inspections of Jails/Prisons/Detention Centers

Recommendations 41

• R1

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  An increase in the number of newly insured patients as a result of healthcare reform placing higher demands on already strained, over-crowded emergency departments (ED).
• R2

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  Further pressure on a county where the demand for inpatient beds is already significantly greater than the supply.
• R3

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  A disproportionately low number of local primary and specialty care physicians.
• R4

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  An aging population with additional medical needs, and the evolving role of EMS in the healthcare system, e.g., community paramedicine. These demands are influencing the need for an unprecedented, proactive reevaluation and remodeling of the EMS system designed to provide better management of resources, real-time exchange of medical information and improvements in the delivery of appropriate, safe, cost effective and quality healthcare. The extent that these changes will ultimately impact EMS remains unclear, but it is evident that there are already increased demands on the EMS system and hospital EDs to provide primary care to the newly insured. There is also continued pressure to provide behavioral health services in the emergency setting. This results in the exacerbation of long-standing system inefficiencies, resource shortages and ED overcrowding. From the EMS perspective, the most tangible impact on the EMS system is ambulance patient offload delays (APOD) or the inability to move patients from ambulance gurneys to ED beds or chairs due to ED overcrowding. The number of APOD hours has been increasing out of proportion to the increases in 9-1-1 requests for medical assistance. APOD exceeded 20,000 hours in 2014. Without systemic interventions, the 2015 APOD numbers are on track to exceed 30,000 hours. i APOD not only impacts the transfer of care of patients, it delays the return of ambulances to respond to other calls for emergency services. The downstream effect of APOD is that first responders, including fire service and law enforcement personnel, must remain on scene longer than necessary thus delaying responses to a variety of emergencies including medical, fire, hazardous materials and crime related incidents. APOD directly affects the safety of patients and the general public that experience emergency response delays. Potential Solutions: An APOD Task Force comprised of stakeholders from San Bernardino and Riverside Counties identified a number of potential solutions to address these issues to promote better management of current resources, improve patient care and reduce APOD time resulting in the transfer of care and subsequent expeditious release of ambulances from EDs. These solutions include:
• R5

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  Implementation of pre-hospital triage strategies, such as enhanced 9-1-1 call screening and increased utilization of existing nurse advice lines designed to identify patients that do not require the historical EMS response or an ED to provide care for the patient’s medical complaint.
• R6

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  Development, implementation and continuation of ongoing public education strategies to address appropriate utilization of the EMS system and changing expectations that calling 9-1-1 always results in transportation to the ED. This must occur in partnership with healthcare insurance organizations, hospitals, EMS providers, and all levels of healthcare practitioners.
• R7

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  Implementation of EMS personnel on scene screening of non-critical patients, through approved protocols, that results in routing these lower acuity 9-1-1 patients to appropriate non- emergency department medical facilities i.e., urgent care centers and clinics.
• R8

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  Development of additional resources to support law enforcement and EMS personnel that encounter behavioral health patients and assist with the decision making regarding the placement of mental health holds commonly referred to as 5150s.
• R9

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  Development of protocols to guide the transportation of patients with behavioral health conditions such as a 5150 without a medical condition that meet specified screening criteria to appropriate behavioral healthcare settings. ii
• R10

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  Implementation and adoption of emerging technologies to assist the EMS personnel in the triage of both 9-1-1 patient responses and in the evolving community paramedicine models, including post discharge patient encounters. The possible solutions are in line with current regulations in California that allow for a variety of options and alternatives in the delivery of EMS patient care. However, a centralized medical control mechanism and process to manage the online medical direction to EMS personnel in a uniform manner does not currently exist in San Bernardino County. The concept of a centralized medical control is critical to implementing the possible solutions. Following APOD Task Force discussions, the Hospital Association of Southern California (HASC) and the 18 San Bernardino County hospital CEOs proposed exploring the creation of a centralized medical control and transportation hub, or MedCon for discussion purposes, to better address and implement these solutions. HASC and the hospital CEOs then asked the Inland Counties Emergency Medical Agency (ICEMA) to prepare a proposal for an ICEMA managed MedCon. It is believed that a centralized approach to providing medical direction to triage patients to appropriate destinations would better utilize current resources and provides a platform for the development and inclusion of identified solutions. This centralized medical control approach would also provide a focal point for the technologies necessary to address the challenges in effectively managing the strategies. It would also reduce medical control duplication and the costs associated with patient transport to inappropriate venues of care, i.e., EDs. The MedCon would require real-time situational awareness. This would be accomplished by leveraging and incorporating existing and emerging technologies so the centralized medical control staff, including on-duty emergency medicine physicians, can provide real-time medical direction to EMS personnel thereby improving community health in line with the San Bernardino County Board of Supervisors Countywide Vision. Based on the HASC and hospital CEOs request, ICEMA investigated the centralized medical control concept, including operational, financial and logistical needs associated with developing and managing such an operation. ICEMA concludes that the MedCon concept has merit and further exploration is warranted in order to achieve the objectives of responding to the changing healthcare environment, reducing overall costs by transporting patients to appropriate iii destinations for care, improving patient satisfaction and decreasing if not eliminating APOD and its effects on public health and safety. MedCon Functions: Under ICEMA’s Medical Director oversight, MedCon staff would provide the following value added operational functions:
• R11

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  Receive and approve EMS field personnel requests for treatment orders during 9-1-1 responses, specialty patient interfacility transfers and for community paramedicine (CP) post discharge follow-up visits if or when a local CP pilot program is fully implemented.
• R12

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  Approve patient requests for refusal of care or transportation against medical advice (AMA). This will also provide the opportunity for the patient to speak directly to an emergency medicine physician in complex cases where the AMA could have life threatening implications.
• R13

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  Provide real-time medical direction to EMS field personnel to approve non-urgent and non-acute patient transportation to pre-designated care facilities i.e., urgent cares and clinics.
• R14

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  Approve medical treatment of non-critical patient’s on scene and the subsequent release of non- critical patients for follow-up by the patient’s primary healthcare provider at a later time.
• R15

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  Provide a centralized point of access to behavioral and public health personnel when needed.
• R16

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  Utilize clinically persuasive technologies to aid in management of various illnesses, i.e., congestive heart failure (CHF) and diabetes.
• R17

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  Provide physician directed continuous quality improvement.
• R18

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  Provide a collaborative, integrated environment where behavioral health, law enforcement and the emergency medicine physician in the MedCon can work together, in real-time, to assist law enforcement and EMS field personnel in determining the appropriate use of 5150 holds.
• R19

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  Provide medical clearance for 5150 patient transportation to appropriate behavioral health facilities through the use of telemedicine (video conferencing) technologies leveraging the expertise of the MedCon emergency medicine physician.
• R20

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  Screen or authorize low acuity 9-1-1 call referrals using an established Emergency Medical Dispatch tier known as the Omega level, instead of dispatching the normal EMS response to all 9- 1-1 requests that result in unnecessary and costly EMS resource utilization and patient transports to EDs.
• R21

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  Monitor availability of 9-1-1 receiving hospitals and specialty care centers (STEMI, stroke and trauma) to manage transportation to the closest most appropriate medical facility. iv
• R22

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  Assist in facilitating interfacility transfers, including STEMI, stroke and trauma patients, using continuation of care protocols.
• R23

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  Expedite interfacility transfers outside the ICEMA region using the mutual aid system when local resources are depleted.
• R24

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  Direct patient destination and other care decisions during Multiple Casualty Incidents (MCIs) and disasters.
• R25

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  Authorize and monitor EMS aircraft utilization.
• R26

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  Authorize and help facilitate ambulance strike team deployment or other medical mutual aid requests.
• R27

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  Assist in the preemptive treatment and transport of patients at long-term and/or convalescent facilities.
• R28

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  Manage the initial screening and notifications for infectious disease responses, i.e., Ebola.
• R29

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  Facilitate the dispatch and transportation of the Hospital Emergency Response Team (HERT) comprised of trauma center surgeons and nurses to provide care during complex extrications of entrapped patients.
• R30

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  Function as the ICEMA duty officer to manage any EMS system issues.
• R31

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  Function as the conduit to the Medical Health Operation Area Coordinator (MHOAC), a role shared by the Public Health Officer and EMS Administrator.
• R32

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  Provide centralized access to the Inland Empire Health Information Exchange (IEHIE) portal for patient care information based on an existing agreement between ICEMA and the IEHIE. Logistics/Planning/Finance: The potential roles of the centralized medical control require significant front end planning to develop and implement the MedCon. This includes the technical requirements to fully leverage existing and emerging technologies, and to utilize and develop best practices. ICEMA envisions that telemedicine; computer aided dispatch linkage, geographical information systems (GIS) and advanced computer augmented communication technologies will be needed to provide appropriate functionality. ICEMA will require additional human resources, not currently available; to fully explore the logistical, operational and fiscal requirements of the ICEMA operated MedCon. Therefore, ICEMA recommends establishing an Ad Hoc MedCon advisory task force comprised of subject matter experts familiar with logistics, planning and finance that would be headed by the ICEMA EMS Administrator. v ICEMA or contract personnel would provide direct project planning oversight. The ICEMA EMS Administrator and ICEMA Medical Director would provide overall project planning and design oversight. The MedCon requirements will include identifying needs, such as a location, technical and communications equipment, and human resources i.e., emergency medicine physicians, to develop, implement and sustain the center. In addition, ICEMA staff resources will be needed to develop appropriate policies, treatment protocols and quality improvement methodologies to support the centralized medical control concept. The full impact on the ICEMA budget for the resources necessary to develop, implement and operate the MedCon are yet to be determined. Additional anticipated expenses include the development of contracts with alternate destination providers, i.e., urgent care centers, the promulgation of supporting policies and protocols, and the ongoing quality improvement processes to monitor the effectiveness of the MedCon. Additional evaluation of the funding streams must occur as part of the detailed planning process. Part of the analysis should include the anticipated decreases in ED and EMS resource utilization and associated savings of using lower cost points of care upon MedCon implementation. Healthcare insurance organizations, hospitals and EMS providers will see a corresponding and likely substantial reduction in operating costs. As a result, those entities could be considered as potential funding sources to support the development and implementation of the MedCon. The location of the ICEMA operated MedCon is one of the logistical needs that requires further exploration. Estimated total space to accommodate all of the functions is yet to be identified until the full scope of the MedCon operations are determined. At the minimum staff and supervisor workstations, space for server and voice/computer cabinets and equipment racks must be included. ICEMA recommends that board certified or eligible emergency medicine physicians provide the online centralized medical control services. This could be accomplished by using an emergency. medicine physician group or ICEMA contract physician employees with ICEMA provided support services. Anticipated positons include, but may not be limited to:
• R33

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  Emergency medicine physician(s)
• R34

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  Technical support staff
• R35

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  Omega call screener(s)
• R36

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  Incoming call taker(s)
• R37

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  Office Assistant III(s)
• R38
  EMS Specialist(s) Technologies would include hardware and software components necessary to provide required functionality. The infrastructure, such as the computer networks and hardware to host the technologies, would be available through the San Bernardino County Information Services Department at a cost to be determined based on need. Communications resources using the County’s 800 MHz system would be required to provide online access to EMS providers throughout the region. Enhanced services, such as the use of telemedicine technologies, will require software solutions that are HIPAA compliant and use existing communication technologies. Technical equipment required:
• R39

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  Workstation computers
• R40

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  Communication devices
• R41
  Video conferencing and software A Geographical Information System (GIS) would also be needed for real-time situational awareness. This system would integrate existing information sharing platforms, such as weather and road conditions, hospital status/bed availability, location of key infrastructure/facilities and the status for air/ground resources, into separate layers on a scalable visualization tool. The system would aggregate existing data from these information sources into an interoperable common operating picture for complete situational awareness. The use of GIS is in line with the Countywide Plan process that includes the use of a single GIS system that incorporates multiple information sources that can be accessed as needed by various users. The cost of developing the required GIS layers and integrating into the emerging countywide system are yet to be determined. MedCon will require computerized workstations that would include a minimum of a communications monitor, video monitor, and situational awareness monitor at each station with access to GIS and various other information sources including voice and software. vii ICEMA recommends the development and implementation of redundant MedCon capabilities that would be used in the event of failure of the primary MedCon. This redundancy can potentially be established with the evolving Riverside County EMS Agency centralized transportation hub to assure full information sharing and resulting in additional redundant capabilities that can be implemented during emergencies affecting one of the facilities. Satellite communications should also be incorporated to provide redundant communication capabilities during local or large scale disasters. This would allow fail-safe contingency services to occur in the event of a disruption of standard communication services including internet, phone, and radio. These services would use a variety of systems, including voice over internet technologies (VOIP), to achieve communications with and to assure redundancy and survivability. Conclusion: ICEMA would like to begin the detailed planning process in conjunction with key EMS system stakeholders to fully develop the MedCon as soon as possible. The concept has been discussed extensively in the APOD Task Force and in a number of other forums. ICEMA has received generally positive feedback during these discussions. In fact, the need to proceed rapidly is a continuing theme that has emerged from these discussions. Based on the feedback received this clearly represents an unprecedented opportunity to be proactive rather than reactive to the many challenges that are occurring in healthcare in the United States that directly affect the provision of EMS. The implementation of the MedCon concept has been identified as central to the strategy of reducing APOD and its unintended consequences. viii Attachment 2 ICEMA Bed Delay Report i Report Detail This report collects and summarizes the "Bed Delay" for a selected group of hospitals. "Bed Delay" is the time between arrival of an ambulance at a hospital and the hospital receiving the patient. The first 25 minutes are excluded from consideration. The only type of transports that are considered are 911 calls where the patient is treated and transported via ambulance. Abbreviated Name Full Name Name Full Name ARMC Arrowhead Regional Medical Center BCH Barstow Community Hospital BVCH Bear Valley Community Hospital CVMC Chino Valley Medical Center CRMC Colorado River Medical Center CHSB Community Hospital San Bernardino DVMC Desert Valley Hospital Center HDMC Hi-Desert Medical Center KHF Kaiser Hospital Medical Center - Fontana KHO Kaiser Hospital Medical Center - Ontario LLUMC Loma Linda University Medical Center MHMC Montclair Hospital Medical Center MCH Mountains Community Hospital RDCH Redlands Community Hospital SARH San Antonio Regional Hospital STBMC St. Bernardine Medical Center STMMC St. Mary Medical Center VALL JLP VA Loma Linda VVGMC Victor Valley Global Medical Center ICEMA, ePCR Database. Compiled 1/9/2017, PW. ii Total Bed Delay Hours* and Bed Delay Transports by Hospital January 2016 – December 2016 Total Bed Bed Delay Total Bed Delay Average Bed Delay Median Bed Delay Hospital Delay Hours Transports Transports Percentage by Patient by Patient ARMC 2073:08 4,552 13,314 34.2% 0:27 0:15 BCH 312:40 770 5,630 13.7% 0:24 0:14 BVCH 36.33 169 1,702 9.9% 0:12 0:06 CVMC 399.15 1,007 5,475 18.4% 0:23 0:11 CRMC 18:02 35 808 4.3% 0:30 0:11 CHSB 2077:03 3,298 6,214 53.1% 0:37 0:19 DVMC 4213:2 7,000 11,167 62.7% 0:36 0:20 HDMC 207:43 722 5,072 14.2% 0:17 0:09 KHF 3087:22 5,115 13,534 37.8% 0:36 0:17 KHO 1841:43 3,000 7,890 38.0% 0:36 0:19 LLUMC 2849:14 5,778 13,472 42.9% 0:29 0:16 MHMC 481:23 885 2,885 30.7% 0:32 0:17 MCH 10:45 44 512 8.6% 0:14 0:09 RDCH 3033:13 5,265 9,514 55.4% 0:34 0:20 SARH 3522:47 5,803 14,571 39.8% 0:36 0:18 STBMC 4288:59 7,673 13,754 55.8% 0:33 0:17 STMMC 4232:59 6,715 11,708 57.4% 0:37 0:18 VALL 104:30 6,715242 1,162 20.8% 0:25 0:13 VVGMC 3250:13 4,093 7,053 58.0% 0:47 0:21 Total 36040:59 62,167 145,437 42.7% 0:34 0:18 iii iv v 45 INSPECTIONS OF JAILS/PRISONS/DETENTION CENTERS WITHIN THE COUNTY OF SAN BERNARDINO