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Extracted from Consolidated Report

This investigation was originally published as part of a larger consolidated report containing multiple investigations. View the consolidated PDF for the complete document.

San Bernardino County Grand Jury • 2016-2017

High Desert Ambulance Availability and Bed Delay

9 pages

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⚠️ Translation Notice: This content has been automatically translated. The original English text is the official version. Translation may contain errors.

⚠️ Este contenido ha sido traducido automáticamente. El texto original en inglés es la versión oficial. La traducción puede contener errores.

Findings 8 findings

F1 Page 53

Demands on the 9-1-1 system are influencing the need for a re-evaluation of the EMS system. It was designed "to provide better management of resources, real-time exchange of medical information, and improvement in the delivery of appropriate, safe, cost effective, and quality healthcare." (Attachment 1, page i).

F2 Page 53

Bed delay directly affects the safety of patients and the general public who experience emergencies.

F3 Page 53

A shortage of ED beds and the lack of a trauma center exist in the High Desert. This shortage leads to hospital and emergency department overcrowding resulting in bed delays.

F4 Page 53

The misuse of the 9-1-1 system on a regular basis overloads dispatch and decreases the availability of ambulances.

F5 Page 53

A lack of coordination occurs among the three high desert hospitals, AMR, and SBCFD regarding overcrowding.

F6 Page 53

Communication problems result from AMR and SBCFD not operating on the same radio frequency.

F7 Page 53

Enhanced 9-1-1 call screening data is collected but not utilized.

F8 Page 53

No effective action has taken place to begin implementation of the ICEMA "Centralized Medical Control Proposal." 44 2016-2017 San Bernardino County Civil Grand Jury – HD Ambulance Availability and Bed Delay

Recommendations 84

R1
Page 52

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
Page 52

Further pressure on a county where the demand for inpatient beds is already significantly greater than the supply.
R3
Page 52

A disproportionately low number of local primary and specialty care physicians.
R4
Page 52

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. ii 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
Page 57

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
Page 57

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
Page 57

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
Page 57

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
Page 57

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. iii
R10
Page 58

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 iv
R11
Page 59

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
Page 59

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
Page 59

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
Page 59

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
Page 59

Provide a centralized point of access to behavioral and public health personnel when needed.
R16
Page 59

Utilize clinically persuasive technologies to aid in management of various illnesses, i.e., congestive heart failure (CHF) and diabetes.
R17
Page 59

Provide physician directed continuous quality improvement.
R18
Page 59

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
Page 59

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
Page 59

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
Page 59

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. v
R22
Page 60

Assist in facilitating interfacility transfers, including STEMI, stroke and trauma patients, using continuation of care protocols.
R23
Page 60

Expedite interfacility transfers outside the ICEMA region using the mutual aid system when local resources are depleted.
R24
Page 60

Direct patient destination and other care decisions during Multiple Casualty Incidents (MCIs) and disasters.
R25
Page 60

Authorize and monitor EMS aircraft utilization.
R26
Page 60

Authorize and help facilitate ambulance strike team deployment or other medical mutual aid requests.
R27
Page 60

Assist in the preemptive treatment and transport of patients at long-term and/or convalescent facilities.
R28
Page 60

Manage the initial screening and notifications for infectious disease responses, i.e., Ebola.
R29
Page 60

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
Page 60

Function as the ICEMA duty officer to manage any EMS system issues.
R31
Page 60

Function as the conduit to the Medical Health Operation Area Coordinator (MHOAC), a role shared by the Public Health Officer and EMS Administrator.
R32
Page 60

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. vi
R33
Page 61

Emergency medicine physician(s)
R34
Page 61

Technical support staff
R35

Shift supervisor vii
R36
Page 62

Omega call screener(s)
R37
Page 62

Incoming call taker(s)
R38
Page 62

Office Assistant III(s)
R39

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:
R40
Page 62

Workstation computers
R41
Page 62

Communication devices
R42

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. viii
R43
Page 52

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).
R44
Page 52

Further pressure on a county where the demand for inpatient beds is already significantly greater than the supply.
R45
Page 52

A disproportionately low number of local primary and specialty care physicians.
R46
Page 52

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. ii 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:
R47
Page 57

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.
R48
Page 57

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.
R49
Page 57

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.
R50
Page 57

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.
R51
Page 57

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. iii
R52
Page 58

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 iv
R53
Page 59

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.
R54
Page 59

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.
R55
Page 59

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.
R56
Page 59

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.
R57
Page 59

Provide a centralized point of access to behavioral and public health personnel when needed.
R58
Page 59

Utilize clinically persuasive technologies to aid in management of various illnesses, i.e., congestive heart failure (CHF) and diabetes.
R59
Page 59

Provide physician directed continuous quality improvement.
R60
Page 59

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.
R61
Page 59

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.
R62
Page 59

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.
R63
Page 59

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. v
R64
Page 60

Assist in facilitating interfacility transfers, including STEMI, stroke and trauma patients, using continuation of care protocols.
R65
Page 60

Expedite interfacility transfers outside the ICEMA region using the mutual aid system when local resources are depleted.
R66
Page 60

Direct patient destination and other care decisions during Multiple Casualty Incidents (MCIs) and disasters.
R67
Page 60

Authorize and monitor EMS aircraft utilization.
R68
Page 60

Authorize and help facilitate ambulance strike team deployment or other medical mutual aid requests.
R69
Page 60

Assist in the preemptive treatment and transport of patients at long-term and/or convalescent facilities.
R70
Page 60

Manage the initial screening and notifications for infectious disease responses, i.e., Ebola.
R71
Page 60

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.
R72
Page 60

Function as the ICEMA duty officer to manage any EMS system issues.
R73
Page 60

Function as the conduit to the Medical Health Operation Area Coordinator (MHOAC), a role shared by the Public Health Officer and EMS Administrator.
R74
Page 60

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. vi
R75
Page 61

Emergency medicine physician(s)
R76
Page 61

Technical support staff
R77

Shift supervisor vii
R78
Page 62

Omega call screener(s)
R79
Page 62

Incoming call taker(s)
R80
Page 62

Office Assistant III(s)
R81

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:
R82
Page 62

Workstation computers
R83
Page 62

Communication devices
R84

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. viii