Existing law establishes the Emergency Medical Services Authority, and requires it to adopt regulations that further the purpose of establishing a statewide system for emergency medical services. Existing law, the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act, authorizes each county to develop an emergency medical services program. The act further authorizes a local emergency medical services (EMS) agency to develop and submit a plan to the Emergency Medical Services Authority for an emergency medical services system, and requires the local EMS agency, using state minimum standards, to establish policies and procedures to assure medical control of the emergency medical services system that may require basic life support emergency medical transportation services to meet any medical control requirements, including dispatch, patient destination policies, patient care guidelines, and quality assurance requirements.

This bill would authorize a local EMS agency to adopt policies and procedures relating to ambulance patient offload time, as defined. The bill would require the authority to develop a statewide standard methodology for the calculation and reporting by a local EMS agency of ambulance patient offload time.

Existing law establishes the Emergency Medical Services Authority, and requires it to adopt regulations that further the purpose of establishing a statewide system for emergency medical services. Existing law, the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act, authorizes each county to develop an emergency medical services program. The act further authorizes a local emergency medical services (EMS) agency to develop and submit a plan to the Emergency Medical Services Authority for an emergency medical services system, and requires the local EMS agency, using state minimum standards, to establish policies and procedures to assure medical control of the emergency medical services system that may require basic life support emergency medical transportation services to meet any medical control requirements, including dispatch, patient destination policies, patient care guidelines, and quality assurance requirements.

This bill would authorize a local EMS agency to adopt policies and procedures relating to ambulance patient offload time, as defined. The bill would require the authority to develop a statewide standard methodology for the calculation and reporting by a local EMS agency of ambulance patient offload time.

Existing law establishes the Emergency Medical Services Authority, and requires it to adopt regulations that further the purpose of establishing a statewide system for emergency medical services. Existing law, the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act, authorizes each county to develop an emergency medical services program. The act further authorizes a local emergency medical services (EMS) agency to develop and submit a plan to the Emergency Medical Services Authority for an emergency medical services system, and requires the local EMS agency, using state minimum standards, to establish policies and procedures to assure medical control of the emergency medical services system that may require basic life support emergency medical transportation services to meet any medical control requirements, including dispatch, patient destination policies, patient care guidelines, and quality assurance requirements.

This bill would authorize a local EMS agency to adopt policies and procedures relating to ambulance patient offload time, as defined. The bill would require the authority to develop a statewide standard methodology for the calculation and reporting by a local EMS agency of ambulance patient offload time.

Existing law establishes the Emergency Medical Services Authority, and requires it to adopt regulations that further the purpose of establishing a statewide system for emergency medical services. Existing law, the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act, authorizes each county to develop an emergency medical services program. The act further authorizes a local emergency medical services (EMS) agency to develop and submit a plan to the Emergency Medical Services Authority for an emergency medical services system, and requires the local EMS agency, using state minimum standards, to establish policies and procedures to assure medical control of the emergency medical services system that may require basic life support emergency medical transportation services to meet any medical control requirements, including dispatch, patient destination policies, patient care guidelines, and quality assurance requirements.

This bill would authorize a local EMS agency to adopt policies and procedures relating to ambulance patient offload time, as defined. The bill would require the authority to develop a statewide standard methodology for the calculation and reporting by a local EMS agency of ambulance patient offload time.

Existing law establishes the Emergency Medical Services Authority, and requires it to adopt regulations that further the purpose of establishing a statewide system for emergency medical services. Existing law, the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act, authorizes each county to develop an emergency medical services program. The act further authorizes a local emergency medical services (EMS) agency to develop and submit a plan to the Emergency Medical Services Authority for an emergency medical services system, and requires the local EMS agency, using state minimum standards, to establish policies and procedures to assure medical control of the emergency medical services system that may require basic life support emergency medical transportation services to meet any medical control requirements, including dispatch, patient destination policies, patient care guidelines, and quality assurance requirements.

This bill would require authorize a local EMS agency to include in those adopt policies and procedures specified policies, including the establishment and enforcement of criteria relating to ambulance patient offload time, as defined, and for the transport of a patient to an alternate emergency department or facility under specified circumstances. defined. The bill would require the authority to develop a statewide standard methodology for the calculation and reporting by a local EMS agency of ambulance patient offload time.

Existing law, the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act, authorizes each county to develop an emergency medical services program. The act further authorizes a local emergency medical services (EMS) agency to develop and submit a plan to the Emergency Medical Services Authority for an emergency medical services system, and requires the local EMS agency, using state minimum standards, to establish policies and procedures to assure medical control of the emergency medical services system that may require basic life support emergency medical transportation services to meet any medical control requirements requirements, including dispatch, patient destination policies, patient care guidelines, and quality assurance requirements.

This bill would authorize the policies and procedures to allow for the transportation of a noncritical case that cannot be immediately admitted to a hospital emergency room to another appropriate medical treatment facility, including, but not limited to, a clinic, as defined, or a doctors office. require a local EMS agency to include in those policies and procedures specified policies, including the establishment and enforcement of criteria relating to ambulance patient offload time, as defined, and for the transport of a patient to an alternate emergency department or facility under specified circumstances. The bill would require the authority to develop a statewide standard methodology for the calculation and reporting by a local EMS agency of ambulance patient offload time.

Existing law, the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act, authorizes each county to develop an emergency medical services program. The act further authorizes a local emergency medical services (EMS) agency to develop and submit a plan to the Emergency Medical Services Authority for an emergency medical services system, and requires the local EMS agency, using state minimum standards, to establish policies and procedures that may require basic life support emergency medical transportation services to meet any medical control requirements including dispatch, patient destination policies, patient care guidelines, and quality assurance requirements.

This bill would authorize the policies and procedures to allow for the transportation of a noncritical case that cannot be immediately admitted to a hospital emergency room to another appropriate medical treatment facility, including, but not limited to, a clinic, as defined, or a doctors office.

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 1223

Author:(O'Donnell)

As Amended Ver:June 30, 2015

Majority vote

Original Committee Reference: HEALTH

SUMMARY: Requires the Emergency Medical Services Authority (EMSA) to develop, using input from stakeholders, a statewide standard methodology for the calculation and reporting of patient offload time by local emergency medical services (EMS) agencies. Defines "ambulance patient offload time" as the interval between the arrival of a patient transported by ambulance at an emergency department (ED) and the time that the ED assumes responsibility for care of the patient. Allows a local EMS agency to adopt policies and procedures for calculating and reporting ambulance patient offload time, as specified. Requires, if a local EMS agency adopts a policy for calculating and reporting ambulance patient offload time, to establish criteria for the reporting of, and quality assurance follow-up for, a "nonstandard patient offload time."

The Senate amendments define "nonstandard patient offload time" as an offload time that exceeds a period of time designated in the criteria established by the local EMS agency, but excludes from this definition instances in which the offload times exceed the designated period of time due to acts of God, natural disasters, or manmade disasters.

FISCAL EFFECT: According to the Senate Appropriations Committee, pursuant to Senate Rule 28.8, negligible state costs.

COMMENTS: According to the author this bill provides a definition for the term "ambulance patient offload time" and requires EMSA to create a methodology that local EMS agencies may use to create a policy for the measurement and reporting of ambulance patient offload time appropriate for their region. The author states this methodology will be devised using stakeholder input and flexible enough to meet the unique needs of each of the state's 33 local EMS agencies. The author argues that delays in patient offload time are becoming more of a problem than currently exists. A crucial first step in dealing with this issue is to properly identify and define what the issue is. The author concludes, this bill creates a common definition and a standard way of measuring the problem across the state, while allowing for the collection of the data needed address it.

The California Fire Chiefs Association (CFCA), sponsor of this bill, writes in support that current law requires EMS providers when responding to 9-1-1 calls to deliver their patients to licensed EDs. CFCA states that patients suffering from serious medical conditions and those with only minor issues go through the same process and are delivered to the same type of facility; at the same time EDs are busier than ever, this means that EMS responders are spending more time waiting to offload patients at EDs and this bill seeks to help alleviate this problem by requiring the adoption of a methodology to keep track of wait times. CFCA indicates that it is vital that as EDs and EMS providers take on a larger role in our healthcare system that state statutory and regulatory frameworks are updated to reflect reality. The California Professional Firefighters (CPF) also write in support that this bill will establish an important first step in defining "wall time" within the context of reducing or altogether eliminating wall time in our EMS system. CPF further writes that while a patient waits to be admitted to the hospital, EMS personnel responsible for his or her care cannot respond to other emergency calls while waiting to transfer the patient. According to CPF, not only does this prevent a patient from receiving appropriate and immediate care, it poses a public safety risk by having fewer qualified EMS personnel available to respond to other emergencies.

The Riverside County Regional Medical Center and the Urban Counties Caucus both write in opposition to the prior version of this bill, that although reducing ambulance waiting times is an important issue, local EMS agencies are currently working on a project to try and address one facet of this issue and suggest a local solution over a statewide construct, which may not work in all counties.

Analysis Prepared by: Patty Rodgers / HEALTH / (916) 319-2097 FN: 0001370

 THIRD READING  

Bill No: AB 1223

Author: O'Donnell (D)

Amended: 6/30/15 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 6-0, 7/8/15

AYES: Hernandez, Hall, Monning, Pan, Roth, Wolk

NO VOTE RECORDED: Nguyen, Mitchell, Nielsen

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

ASSEMBLY FLOOR: 76-0, 5/26/15 (Consent) - See last page for vote

SUBJECT: Emergency medical services: ambulance transportation

SOURCE: California Fire Chiefs Association

DIGEST: This bill requires the Emergency Medical Services Authority (EMSA) to adopt a statewide standard methodology for the calculation and reporting by a Local Emergency Medical Services Agency (LEMSA) of ambulance patient offload time, and permits a LEMSA to adopt policies and procedures for calculating and reporting ambulance patient offload time using the statewide methodology adopted by EMSA. This bill requires, if a LEMSA adopts a policy for calculating and reporting ambulance patient offload time, to establish criteria for the reporting of, and quality assurance follow-up for, a “nonstandard patient offload time.”

ANALYSIS:

Existing law:

1. Establishes EMSA, which is responsible for the coordination and integration of all state activities concerning emergency medical services (EMS), including the establishment of minimum standards, policies, and procedures.

2. Requires EMSA, utilizing regional and local information, to assess each EMS area or the system’s service area for the purpose of determining the need for additional emergency services, and the coordination and effectiveness of EMS.

3. Requires EMSA to develop planning and implementation guidelines for EMS systems which address specified components, including communications, system organization and management, and data collection and evaluation.

4. Authorizes counties to develop an EMS program and designate a LEMSA responsible for planning and implementing an EMS system, which includes day-to-day EMS system operations.

This bill:

1. Requires EMSA to develop, and after approval by the Commission on EMS, adopt a statewide standard methodology for the calculation and reporting by a LEMSA of ambulance patient offload time, using input from stakeholders, including, but not limited to, hospitals, LEMSAs, and public and private EMS providers.

2. Defines “ambulance patient offload time” as the interval between the arrival of an ambulance patient at an emergency department, and the time that the patient is transferred to an emergency department gurney, bed, chair, or other acceptable location and the emergency departments assumes responsibility for care of the patient.

3. Permits a LEMSA to adopt policies and procedures for calculating and reporting ambulance patient offload time, and requires a LEMSA that adopts these policies and procedures to do all of the following:

1. Use the statewide standard methodology for calculating and reporting patient offload time developed by EMSA pursuant to this bill; and,

2. Establish criteria for the reporting of, and quality assurance follow-up for, a “nonstandard patient offload time,” as defined in this bill.

4. Defines “nonstandard patient offload time” as an offload time that exceeds a period of time designated in the criteria established by the LEMSA, but excludes from this definition instances in which the offload times exceeds the designated period of time due to acts of God, natural disasters, or manmade disasters.

Comments

1. Author’s statement. According to the author, when someone is picked up by an ambulance, they are taken to a hospital emergency department. Once the patient is in the ambulance the EMS crew becomes responsible for their care until they are signed over to hospital staff. Patients who are suffering from a serious medical condition are quickly admitted into the hospital, but that is often not the case with patients with minor issues, who have to wait for a hospital bed to become available. A national study found that patient offload times had more than doubled since 2006, from 25 minutes to 45 minutes. Offload times in some parts of California can be much longer. EMSA reports that 13 of the states’ 33 LEMSAs identified the problem of ambulance patient offload times as an issue. These 13 agencies serve 70% of the state’s population. While some individual counties and hospitals have taken actions to alleviate the issue there has been no uniform, statewide, or comprehensive attempts to solve the problem of patient offload times or even define it. Without a common vocabulary when discussing this issue the state can’t begin to identify the problem let alone devise remedies.

2. Background and creation of toolkit to address offload delays. In 2013, the California Hospital Association and EMSA created the Ambulance Patient Offload Delay Collaborative to analyze and develop solutions for the offload delays that were increasing pressure on both hospitals and ambulance providers. The goals of this collaborative were to: a) develop standardized language, definitions, metrics and reporting opportunities for ambulance patient throughput; b) identify ways to reduce delays and improve transfer times; and, c) assist local jurisdictions in developing processes and sustainable goals to reduce the incidence of ambulance patient offload delays. In a national study involving 200 cities, including some in California, the national average wait time for handing off ambulance patients has doubled from 20 minutes in 2006 to more than 45 minutes. Through survey research, the collaborative learned that the offload delay problem in California is not uniform or consistently reported. Of the 124 hospitals that responded to the survey, 74 (or 60%) said that offload delays were “neutral” or “not significant,” which was consistent with what 19 out of 33 LEMSAs (58%) reported as well. In contrast, 45 hospitals and 13 LEMSAs reported that offload delays were “extremely significant,” “very significant,” or “somewhat significant.” However, those 13 LEMSAs reporting a problem represent regions that include 70% of California’s population.

As a result of this collaborative effort, in August of 2014 the Toolkit to Reduce Ambulance Patient Offload Delays in the Emergency Department (Toolkit) was published by the California Hospital Association. The Toolkit includes definitions, process guidelines and strategies to be considered to evaluate current practices and develop specific process improvements at the local level. The theme of the Toolkit was that local EMS systems and hospitals are unique, and that collaborative problem solving should be used to identify and solve problems locally. However, the Toolkit did identify three key factors for success, starting with improving the emergency department intake process, followed by continuous quality improvement measures, and hospital and LEMSA collaboration.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: No

SUPPORT: (Verified 8/18/15)

California Fire Chiefs Association (source)

California Ambulance Association

California Professional Firefighters

California State Firefighters’ Association

City of Culver City

League of California Cities

Long Beach Firefighters Association, Local 372

Paramedics Plus

United Firefighters of Los Angeles City, Local 112

OPPOSITION: (Verified 8/18/15)

California Hospital Association

Corona Regional Medical Center

Parkview Community Hospital Medical Center

ARGUMENTS IN SUPPORT: According to the author, this bill is sponsored by the California Fire Chiefs Association (CFCA), which states in support that hospital emergency departments are more crowded and busier than ever, which means that EMS responders are spending more of their time waiting to offload patients at emergency departments than fulfilling their primary duty of responding to emergency calls. CFCA states that this bill seeks to help alleviate these issues by requiring EMSA to develop a methodology for determining an acceptable amount of time for EMS crews to offload their patients at emergency departments. The California Ambulance Association (CAA) states that it supports this bill because it believes that it will ultimately result in cost savings to the EMS system. According to CAA, patient offload time has been a significant problem for ambulance providers. CAA agrees that a crucial first step in dealing with this issue is to properly identify and define metrics to measure the issue. The California Professional Firefighters states in support that this bill represents a good first step toward the development of standards to expedite the transfer of care between ambulance personnel and the emergency department staff of a general acute care hospital and mitigate delays in returning ambulances and pre-hospital care personnel to the EMS system. Paramedics Plus states in support that a five minute wait time reduction in Alameda County equates to one 24 hour ambulance deployment per day back into the 911 EMS system.

ARGUMENTS IN OPPOSITION: The California Hospital Association (CHA) states in opposition that numerous issues contribute to ambulance patient offload delays and emergency department crowding, and that hospitals are not the main problem. According to CHA, excess demand for emergency services, for the most part, is beyond both hospitals and EMS providers to exclusively solve. CHA states that standardization of ambulance patient offload delay methodology is a laudable goal, however, it does not address the individual local needs of each LEMSA and neighboring hospitals to solve problems with their existing resources. Finally, CHA states that the Ambulance Patient Offload Delay initiative has been operating for more than two years with many regional collaboratives already working collectively and cooperatively to solve this issue, and that legislation is unnecessary. According to CHA, one local area has discovered that offload delays are a product of their counties’ massive population growth with increased Medi-Cal patients seeking care in the area emergency departments, while another area showed that delays were attributable to the EMS crews restocking and completing their paperwork. CHA states that legislation that requires measurements that will be used in a retaliatory manner against hospitals is unfair and unnecessary.

ASSEMBLY FLOOR: 76-0, 5/26/15

AYES: Achadjian, Alejo, Travis Allen, Baker, Bigelow, Bonilla, Bonta, Brough, Brown, Burke, Calderon, Campos, Chang, Chau, Chiu, Chu, Cooley, Cooper, Dababneh, Dahle, Daly, Dodd, Eggman, Frazier, Beth Gaines, Gallagher, Cristina Garcia, Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez, Gordon, Gray, Grove, Hadley, Roger Hernández, Holden, Irwin, Jones, Jones-Sawyer, Kim, Lackey, Levine, Linder, Lopez, Low, Maienschein, Mayes, McCarty, Medina, Melendez, Mullin, Nazarian, Obernolte, O'Donnell, Olsen, Patterson, Perea, Quirk, Rendon, Ridley-Thomas, Rodriguez, Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting, Wagner, Waldron, Weber, Wilk, Williams, Wood, Atkins

NO VOTE RECORDED: Bloom, Chávez, Harper, Mathis

Prepared by: Vince Marchand / HEALTH /

8/19/15 20:42:59

**** END ****

SENATE COMMITTEE ON HEALTH

Senator Ed Hernandez, O.D., Chair

BILL NO: AB 1223

SUBJECT: Emergency medical services: ambulance transportation.

SUMMARY:

Requires the Emergency Medical Services Authority (EMSA) to adopt a statewide standard methodology for the calculation and reporting by a Local Emergency Medical Services Agency (LEMSA) of ambulance patient offload time, and permits a LEMSA to adopt policies and procedures for calculating and reporting ambulance patient offload time using the statewide methodology adopted by EMSA. Requires, if a LEMSA adopts a policy for calculating and reporting ambulance patient offload time, to establish criteria for the reporting of, and quality assurance follow-up for, a “nonstandard patient offload time.”

Existing law:

1. Establishes EMSA, which is responsible for the coordination and integration of all state activities concerning EMS, including the establishment of minimum standards, policies, and procedures.

2. Requires EMSA, utilizing regional and local information, to assess each EMS area or the system’s service area for the purpose of determining the need for additional emergency services, and the coordination and effectiveness of EMS.

3. Requires EMSA to develop planning and implementation guidelines for EMS systems which address specified components, including communications, system organization and management, and data collection and evaluation.

4. Authorizes counties to develop an EMS program and designate a LEMSA responsible for planning and implementing an EMS system, which includes day-to-day EMS system operations.

5. Establishes an 18-member Commission on EMS, within the California Health and Human Services Agency (HHSA). Defines the duties of the Commission to include reviewing regulations, standards, and guidelines developed by EMSA; advising EMSA on a data collection system; advise on emergency facilities and services, emergency communications, medical equipment, personnel training, and various aspects of the EMS system; and, to make recommendations for further development of the EMS system.

This bill:

1. Requires EMSA to develop, and after approval by the Commission on EMS, adopt a statewide standard methodology for the calculation and reporting by a LEMSA of ambulance patient offload time, using input from stakeholders, including, but not limited to, hospitals, LEMSAs, and public and private EMS providers.

2. Defines “ambulance patient offload time” as the interval between the arrival of an ambulance patient at an emergency department, and the time that the patient is transferred to an emergency department gurney, bed, chair, or other acceptable location and the emergency departments assumes responsibility for care of the patient.

3. Permits a LEMSA to adopt policies and procedures for calculating and reporting ambulance patient offload time, and requires a LEMSA that adopts these policies and procedures to do all of the following:

1. Use the statewide standard methodology for calculating and reporting patient offload time developed by EMSA pursuant to this bill; and,

2. Establish criteria for the reporting of, and quality assurance follow-up for, a “nonstandard patient offload time,” as defined in this bill.

4. Defines “nonstandard patient offload time” as an offload time that exceeds a period of time designated in the criteria established by the LEMSA, but excludes from this definition instances in which the offload times exceeds the designated period of time due to acts of God, natural disasters, or manmade disasters.

FISCAL EFFECT:

According to the Assembly Appropriations Committee, this bill will result in minor and absorbable costs to EMSA (General Fund or federal grant funds).

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, when someone is picked up by an ambulance, they are taken to a hospital emergency department. Once the patient is in the ambulance the EMS crew becomes responsible for their care until they are signed over to hospital staff.
   Patients who are suffering from a serious medical condition are quickly admitted into the hospital, but that is often not the case with patients with minor issues, who have to wait for a hospital bed to become available. A national study found that patient offload times had more than doubled since 2006, from 25 minutes to 45 minutes. Offload times in some parts of California can be much longer. EMSA reports that 13 of the states’ 33 LEMSAs identified the problem of ambulance patient offload times as an issue. These 13 agencies serve 70 percent of the state’s population. While some individual counties and hospitals have taken actions to alleviate the issue there has been no uniform, statewide, or comprehensive attempts to solve the problem of patient offload times or even define it. Without a common vocabulary when discussing this issue the state can’t begin to identify the problem let alone devise remedies.

2. Background and creation of toolkit to address offload delays. In 2013, the California Hospital Association and EMSA created the Ambulance Patient Offload Delay Collaborative to analyze and develop solutions for the offload delays that were increasing pressure on both hospitals and ambulance providers. The goals of this collaborative were to: 1) develop standardized language, definitions, metrics and reporting opportunities for ambulance patient throughput; 2) identify ways to reduce delays and improve transfer times; and, 3) assist local jurisdictions in developing processes and sustainable goals to reduce the incidence of ambulance patient offload delays. In a national study involving 200 cities, including some in California, the national average wait time for handing off ambulance patients has doubled from 20 minutes in 2006 to more than 45 minutes. Through survey research, the collaborative learned that the offload delay problem in California is not uniform or consistently reported. Of the 124 hospitals that responded to the survey, 74 (or 60%) said that offload delays were “neutral” or “not significant,” which was consistent with what 19 out of 33 LEMSAs (58%) reported as well. In contrast, 45 hospitals and 13 LEMSAs reported that offload delays were “extremely significant,” “very significant,” or “somewhat significant.” However, those 13 LEMSAs reporting a problem represent regions that include 70% of California’s population.

As a result of this collaborative effort, in August of 2014 the Toolkit to Reduce Ambulance Patient Offload Delays in the Emergency Department (Toolkit) was published by the California Hospital Association. The Toolkit includes definitions, process guidelines and strategies to be considered to evaluate current practices and develop specific process improvements at the local level. The theme of the Toolkit was that local EMS systems and hospitals are unique, and that collaborative problem solving should be used to identify and solve problems locally. However, the Toolkit did identify three key factors for success, starting with improving the emergency department intake process, followed by continuous quality improvement measures, and hospital and LEMSA collaboration.

3. Related legislation. AB 503 (Rodriguez), would permit a hospital to release patient-identifiable medical information to an emergency medical services provider, to a LEMSA, or to EMSA, for quality assessment and improvement purposes. AB 503 passed the Senate Health Committee by a vote of 8-0 on July 1, 2015.
   
   AB 1129 (Burke), requires an emergency medical care provider, when submitting data to a LEMSA, to use an electronic health record system that is compatible with specified standards, and that includes those data elements that are required by the LEMSA. Prohibits a LEMSA from mandating that a provider use a specific electronic health record system. AB 1129 passed the Senate Health Committee by a vote of 8-0 on July 1, 2015.

4. Prior legislation. AB 1621 (Lowenthal, 2014), would have required EMSA to adopt a single statewide standard for the collection of information regarding pre-hospital care for CEMSIS, required EMSA to develop standards for electronic patient care records systems used by LEMSAs and local pre-hospital EMS providers to ensure compatibility with CEMSIS, and required LEMSAs to submit patient information to EMSA utilizing the single statewide standard in a timely manner. AB 1621 was held on the Senate Appropriations Committee suspense file.
   
   AB 1975 (R. Hernández, 2014) would have required LEMSAs to contract with the American College of Surgeons every five years to conduct a comprehensive assessment of their regional trauma system. AB 1975 was held on the Assembly Appropriations Committee suspense file.
   
   SB 535 (Nielsen, 2013), would have increased the membership of the EMS Commission from 18 to 20 members, and required the additional members to be an air ambulance representative appointed by the Senate Committee on Rules, and representative appointed by the Speaker of the Assembly from a public agency that provides air rescue and transport. SB 535 was vetoed by the Governor.

5. Support. According to the author, this bill is sponsored by the California Fire Chiefs Association (CFCA), which states in support that hospital emergency departments are more crowded and busier than ever, which means that EMS responders are spending more of their time waiting to offload patients at emergency departments than fulfilling their primary duty of responding to emergency calls. CFCA states that this bill seeks to help alleviate these issues by requiring EMSA to develop a methodology for determining an acceptable amount of time for EMS crews to offload their patients at emergency departments. The California Ambulance Association (CAA) states that it supports this bill because it believes that it will ultimately result in cost savings to the EMS system. According to CAA, patient offload time has been a significant problem for ambulance providers. CAA agrees that a crucial first step in dealing with this issue is to properly identify and define metrics to measure the issue. The California Professional Firefighters states in support that this bill represents a good first step toward the development of standards to expedite the transfer of care between ambulance personnel and the emergency department staff of a general acute care hospital and mitigate delays in returning ambulances and pre-hospital care personnel to the EMS system. Paramedics Plus states in support that a five minute wait time reduction in Alameda County equates to one 24 hour ambulance deployment per day back into the 911 EMS system.

6. Opposition. The California Hospital Association (CHA) states in opposition that numerous issues contribute to ambulance patient offload delays and emergency department crowding, and that hospitals are not the main problem. According to CHA, excess demand for emergency services, for the most part, is beyond both hospitals and EMS providers to exclusively solve. CHA states that standardization of ambulance patient offload delay methodology is a laudable goal, however, it does not address the individual local needs of each LEMSA and neighboring hospitals to solve problems with their existing resources. Finally, CHA states that the Ambulance Patient Offload Delay initiative has been operating for more than two years with many regional collaboratives already working collectively and cooperatively to solve this issue, and that legislation is unnecessary. According to CHA, one local area has discovered that offload delays are a product of their counties’ massive population growth with increased Medi-Cal patients seeking care in the area emergency departments, while another area showed that delays were attributable to the EMS crews restocking and completing their paperwork. CHA states that legislation that requires measurements that will be used in a retaliatory manner against hospitals is unfair and unnecessary.

SUPPORT AND OPPOSITION:

Support: California Fire Chiefs Association (sponsor)

California Ambulance Association

California Professional Firefighters

California State Firefighters’ Association

League of California Cities

Paramedics Plus

Oppose: California Hospital Association

-- END --

Date of Hearing: May 20, 2015

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Jimmy Gomez, Chair

ABPCA Bill Id:AB 1223

Author:(O'Donnell) – As Amended Ver:May 14, 2015

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill requires the Emergency Medical Services Authority (EMSA) to adopt a statewide standard methodology for the calculation and reporting by a local EMS agency of ambulance patient offload time, as defined. It also authorizes a local EMS agency to adopt policies and procedures for calculating and reporting ambulance patient offload time, and requires the LEMSA to use the standard definition if it chooses to adopt such policies and procedures.

FISCAL EFFECT:

Minor and absorbable costs to EMSA (GF or federal grant funds).

COMMENTS:

1. Purpose. The author cites significant delays for first responders delivering patients to emergency departments. Collecting standardized data is an important step to quantifying and addressing the program.

2. Support. The California Fire Chiefs Association (CFCA), sponsor of this bill writes in support that current law requires EMS providers, when responding to 9-1-1 calls, to deliver their patients to licensed EDs. CFCA states that patients suffering from serious medical conditions and those with only minor issues go through the same process and are delivered to the same type of facility; at the same time EDs are busier than ever, this means that EMS responders are spending more time waiting to offload patients at EDs and this bill seeks to help alleviate this problem by requiring the adoption of a methodology to keep track of wait times.

3. Opposition. There was significant opposition to a prior version of this bill, but entities opposed have almost entirely removed their opposition with the latest set of amendments. No opposition is verified at this time, based on recent amendments.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: May 12, 2015

ASSEMBLY COMMITTEE ON HEALTH

Rob Bonta, Chair

ABPCA Bill Id:AB 1223 (

Author:O'Donnell) – As Amended Ver:May 5, 2015

SUBJECT: Emergency medical services: ambulance transportation.

SUMMARY: Requires the Emergency Medical Services Authority (EMSA) to develop, using input from stakeholders, a statewide standard methodology for the calculation and reporting of patient offload time by local emergency medical services (EMS) agencies. Defines “ambulance patient offload time” as the interval between the arrival of a patient transported by ambulance at an emergency department (ED) and the time that the ED assumes responsibility for care of the patient. Allows a local EMS agency to adopt policies and procedures for calculating and reporting ambulance patient offload time, as specified.

EXISTING LAW:

1. Establishes EMSA, which is responsible for the coordination and integration of all state activities concerning emergency medical services (EMS), including the establishment of minimum standards, policies, and procedures.
   
   

2. Authorizes counties to develop an EMS program and designate a local EMS agency responsible for planning and implementing an EMS system, which includes day-to-day EMS system operations.
   
   

3. Requires a local EMS agency that elects to implement a trauma care system to develop and submit a plan to the EMSA according to the regulations established prior to the implementation.
   
   

4. Requires EMSA to draft regulations specifying minimum standards for the implementation of a trauma care system including, among other things, data collection regarding system operation and patient outcome, and periodic performance evaluation of the trauma system and its components.
   
   

5. Establishes the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission) that accredits more than 20,000 health care organizations and programs, including hospitals, hospital EDs, doctors’ offices, nursing homes, office-based surgery centers, behavioral health treatment facilities, and providers of home care services.
   
   

FISCAL EFFECT: This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author this bill provides a definition for the term “ambulance patient offload time” and requires EMSA to create a methodology that local EMS agencies may use to create a policy for the measurement and reporting of ambulance patient offload time appropriate for their region. The author states this methodology will be devised using stakeholder input and flexible enough to meet the unique needs of each of the state’s 33 local EMS agencies. The author argues that delays in patient offload time are becoming more of a problem than currently exists. A crucial first step in dealing with this issue is to properly identify and define what the issue is. The author concludes, this bill creates a common definition and a standard way of measuring the problem across the state, while allowing for the collection of the data needed address it.
   
   

2. BACKGROUND.
   
   

   1. California’s EMS System. California operates on a two-tiered EMS system. EMSA is the lead agency and centralized resource to oversee emergency and disaster medical services. EMSA is charged with providing leadership in developing and implementing local EMS systems throughout California, and in setting standards for the training and scope of practice of various levels of EMS personnel. California has 33 local EMS systems that provide EMS for California's 58 counties. (Seven regional EMS systems comprised of 33 counties and 25 single-county agencies provide the services.) Regional systems are usually comprised of small, rural, less-populated counties, and single-county systems generally exist in the larger and more urban counties.
      
      

      1. Local EMS agencies. Local EMS agencies are responsible for planning, implementing, and managing local trauma care systems, including assessing needs, developing the system design, designating trauma care centers, collecting trauma care data, and providing quality assurance.
         
         

      2. Trauma planning. EMSA provides statewide coordination and leadership for the planning, development, and implementation of local trauma care systems. EMSA's responsibilities include the development of statewide standards for trauma care systems and trauma centers, the provision of technical assistance to local agencies developing, implementing or evaluating components of a trauma care system, and the review and approval of local trauma care system plans to ensure compliance with the minimum standards set by EMSA.
         
         

   2. Emergency Departments. EDs are found in approximately two out every three California hospitals. They are licensed to provide 24-hour outpatient emergency medical services and are a critical point of entry to inpatient hospital care. EDs are licensed at a Standby, Basic, or Comprehensive level depending upon the level of emergency care provided.
      
      The California Emergency Medical Services Authority (EMSA) defines basic, standby, and comprehensive emergency services as follows:
      
      

      1. Basic service level provides emergency medical care in a specifically designated part of the hospital that is staffed and equipped at all times to provide prompt care for any patient presenting urgent medical problems.
         
         

      2. Standby service level provides emergency medical care in a specially designated part of the hospital that is equipped and maintained at all times to receive patients with urgent medical problems and is capable of providing physician service within a reasonable time.
         
         

      3. Comprehensive service level provides diagnostic and therapeutic services for unforeseen physical and mental disorders that, if not properly treated, would lead to marked suffering, disability, or even death. The scope of services is comprehensive with in-house capability for managing all medical situations on a definitive and continuing basis.
         
         

   3. EMSA Wall Time Collaborative (Collaborative). In 2012, EMSA and the California Hospital Association, along with other stakeholders including public and private EMS providers, joined together to collaborate on the problem of delayed ambulance offload times (also called wall times, patient parking, ambulance wait times, capture of emergency medical services, patient handover delays, and patient offload delays) and find solutions. There have been many recent studies examining ways that can cut down the time EMS personnel are waiting with a patient in the ED until the hospital officially assumes responsibility of the patient and EMS providers are released. The result of the Collaborative is the “Toolkit to Reduce Ambulance Patient Offload Delays in the Emergency Department.” The Collaborative Toolkit features process improvement models and strategies to mitigate offload delays and suggests that hospitals and EMS providers:
      
      

      1. Develop metrics and measure uniformly;
         
         

      2. Develop best practices to address the problem;
         
         

      3. Dialogue with hospitals and medical systems;
         
         

      4. Encourage habitual offenders to improve; and,
         
         

      5. Observe the impact of new Joint Commission metrics on hospital throughput.
         
         

The Collaborative adopted the National Association of EMS Physicians position statement that wall time is the interval between arrival of an ambulance patient at the ED until the EMS and ED personnel transfer the patient to an ED stretcher and the ED staff assume the responsibility for care for the patient. Some of the solutions agreed upon by the Collaborative are rapid triage; have a physician in triage; get patients off gurneys, if they are not needed; institute observation areas and additional waiting areas—treatment, lab, discharge; find solutions to decrease traffic to the ED, including Mobile Integrated Healthcare (Community Paramedicine) and interventions to decompress ED EMS traffic, including: 9-1-1 triage; guidelines to evaluate and refer without transport when it is not needed; establish alternate destinations; and, assist in post-discharge patient integration and follow-up.

The Collaborative cites a study involving 200 cities (including California cities) which found that the national average wall time is over 45 minutes, double the average time in 2006. The study found the results are a loss of nearly five million hours of EMS system productivity. One unnamed hospital in the study had 17,408 hours of wall time in 2012, costing $2.6 million in lost production time for crews. On average the hospital had a wall time average of two to three hours and four ambulances waiting. According to the Collaborative, fewer ambulances in the community may result in longer response times; the inability for EMS providers to meet contractual response obligations; costs shifting from hospital to EMS systems; and, readiness cost of paramedics and advanced life support units absorbed by EMS system.

The Collaborative found the problem of ED overcrowding and delayed ambulance offload times have increased nationally and in other countries. The problem is complex and multifactorial with causes that span the entire health care delivery system, such as use of EDs by walk-ins, higher patient volumes, and increased rates in the elderly populations.

The Collaborative compared available data for several local EMS agencies, looked at what other states are doing or have done – including what legislation has been implemented, and what other countries are doing. The British National Health Service (NHS) Confederation in 2012 released the publication, Zero Tolerance: Making Ambulance Handover Delays a thing of the past. Patient handover means the time when clinical handover has been completed and the patient has been physically transferred onto a hospital trolley bed, chair, or waiting area, and the ambulance equipment has been returned to crew enabling them to leave. Handover is captured at this point in the process and the expectation is that from arrival to handover occur within 15 minutes. Delays are jointly owned and considered a whole system issue, although EMS systems charge hospitals for any delays over 15 minutes and stipulates a zero tolerance for delays more than one hour. The NHS Confederation also established the term “never event” as an unacceptable delay in patient handover and specified such an event is a “serious, largely preventable patient safety incident that should not occur if the available preventative measures have been implemented by healthcare providers.” Also defined are ambulance arrival, clinical handover, and patient handover. Ambulance arrival means when the ambulance parks to offload the patient; clinical handover means the time at which essential clinical information about the patient has been passed from the ambulance crew to a clinician within the ED.

4. Joint Commission. Joint Commission accreditation can be earned by many types of health care organizations, including hospitals, doctors’ offices, nursing homes, office-based surgery centers, behavioral health treatment facilities, and providers of home care services. The Joint Commission is designated by the Centers for Medicare and Medicaid Services (CMS) as an accreditor for Medicare initial certification, and can provide accreditation and Medicare certification simultaneously. In order to earn Joint Commission accreditation or certification, an organization must first meet their state licensure requirements. The Joint Commission sets higher standards than the CMS Conditions of Participation (CoP). CMS provides a baseline, but Joint Commission accreditation goes beyond the CoP in addressing the delivery of safe, quality patient care. The consultative nature of the Joint Commission survey helps organizations and programs improve patient care. The Joint Commission sets specific quality standards and requirements for certification and accreditation, but also provides recommendations, guidelines, and planning assistance.
   
   The Joint Commission accreditation standards for Emergency Department Patient Flow, effective January 1, 2014, state that boarding is the practice of holding patients in the ED or another temporary location after the decision to admit or transfer has been made. The hospital should set its goals with attention to patient acuity and best practice; it is recommended that boarding time frames not exceed four hours in the interest of patient safety and quality of care. The Joint Commission recognizes that specific ambulance offloading time frames will vary from one organization to the next; for this reason, they have established a four-hour time frame to serve as a guideline to help hospitals set a reasonable goal for offloading. The four-hour time frame is not a requirement for accreditation because the Joint Commission recognizes that meeting such a time frame is not, in some cases, within the control of the accredited organization.
   
   

5. The Centers for Medicare and Medicaid Services. CMS regulations recognize wall time or “parking” patients in hospitals and refusing to release EMS equipment or personnel jeopardizes patient health and impacts the ability of EMS personnel to provide emergency services to the rest of the community. CMS also states that delaying ambulance ED offload may result in a violation of the Emergency Medical Treatment and Labor Act (EMTALA); and, raises serious concerns for patient care and the provision of emergency services in a community. However, CMS clarifies these regulations do not mean that “a hospital will not necessarily have violated EMTALA if it does not, in every instance, immediately assume from the EMS provider all responsibility for the individual, regardless of any other circumstances in the ED…. In some circumstances it could be reasonable for the hospital to ask the EMS provider to stay with the individual until such time as there were ED staff available to provide care to that individual. If the provider cannot perform an immediate Medical Screening Exam, it must still triage the patient’s condition immediately to ensure immediate intervention is not required.”
   
   

6. Community Paramedicine (CP). CP is a new and evolving model of community-based health care in which paramedics function outside their customary emergency response and transport roles in ways that facilitate more appropriate use of emergency care resources and/or enhance access to primary care for medically underserved populations. The aim of CP includes improving wall time waits, preventing overuse of the 9-1-1 system for social or psychological problems which don’t require transport to or triage in an ED; and, lessening the need for repeat ED visits or readmissions. Interest in the CP model has substantially grown in recent years based on the belief that it may improve access to and quality of care while also reducing costs.
   
   Paramedics are presently trained to provide advanced life support services in an emergency setting or during inter-facility transfers. Current law limits paramedic scope of practice to emergency care in the prehospital environment and patients under the care of a paramedic are required to be delivered to an ED. The paramedic scope of practice in California is somewhat unique as compared to other licensed health professionals in that it refers to both a set of authorized skills/activities that EMS personnel are allowed to perform and the places and circumstances in which those skills/activities are allowed to be performed.
   
   Several other countries and states around the U.S., including North Carolina, Colorado, Minnesota, Maine, and Texas, have implemented variations of Community Paramedicine or a comparable Advanced Practice Paramedic program. A full Community Paramedic training curriculum approximately 200 hours in length has been developed by Community Healthcare Emergency Cooperative (a multistate and multinational collaborative) and the North Central EMS Institute in Minnesota. These programs have demonstrated that paramedics can be trained to safely and effectively perform an expanded role.

7. California CP Pilot Project. EMSA received approval from the Office of Statewide Health Planning and Development (OSHPD) to pilot Community Paramedicine in 12 sites across California. Beginning in January 2015, county medical director selected Paramedics began receiving specialized training that builds upon the training and skill sets of experienced paramedics to include patient assessment, clinical skills, and familiarity with the other healthcare providers and social services available in a local community. CPs will work under physician direction and approved patient care protocols to ensure patient safety while providing the right level of care for each patient. OSHPD and EMSA have convened a Statewide Advisory Committee to provide oversight of the pilot program to ensure patient safety. Pilot sites are scheduled to begin providing CP services in June 2015, the pilot sites include:
   
   

Lead Agency	Local EMS agency	Pilot Concepts
UCLA Center for Pre Hospital Care	Los Angeles	Alternate Destination
UCLA Center for Pre Hospital Care	Los Angeles	Post Hospital Discharge Follow Up
Orange County Fire Chief’s Assoc	Orange County	Alternate Destination
Butte County EMS	Sierra-Sacramento Valley EMS	Post Hospital Discharge Follow Up
Ventura County EMS Agency	Ventura	Directly Observed Treatment of TB
Ventura County EMS Agency	Ventura & Santa Barbara	Hospice Support
Alameda County EMS Agency	Alameda County	Post Hospital Discharge & Frequent 9-1-1 Callers
San Bernardino County Fire Dept	San Bernardino County	Post Hospital Discharge Follow Up
Carlsbad Fire Dept	San Diego	Alternate Destination
City of San Diego	San Diego	Frequent 9-1-1 Callers
Mountain Valley EMS	Stanislaus County	Alternate Destination Mental Health
Medic Ambulance	Solano County	Post Hospital Discharge Follow Up

3. SUPPORT. The California Fire Chiefs Association (CFCA), sponsor of this bill, writes in support that current law requires EMS providers when responding to 9-1-1 calls to deliver their patients to licensed EDs. CFCA states that patients suffering from serious medical conditions and those with only minor issues go through the same process and are delivered to the same type of facility; at the same time EDs are busier than ever, this means that EMS responders are spending more time waiting to offload patients at EDs and this bill seeks to help alleviate this problem by requiring the adoption of a methodology to keep track of wait times. CFCA indicates that it is vital that as EDs and EMS providers take on a larger role in our healthcare system that state statutory and regulatory frameworks are updated to reflect reality. The California Professional Firefighters (CPF) also write in support that this bill will establish an important first step in defining “wall time” within the context of reducing or altogether eliminating wall time in our EMS system. CPF further writes that while a patient waits to be admitted to the hospital, EMS personnel responsible for his or her care cannot respond to other emergency calls while waiting to transfer the patient. According to CPF, not only does this prevent a patient from receiving appropriate and immediate care, it poses a public safety risk by having fewer qualified EMS personnel available to respond to other emergencies.
   
   

4. OPPOSITION. The Riverside County Regional Medical Center and the Urban Counties Caucus both write in opposition to the prior version of this bill, that although reducing ambulance waiting times is an important issue, local EMS agencies are currently working on a project to try and address one facet of this issue and suggest a local solution over a statewide construct, which may not work in all counties.
   
   

5. RELATED LEGISLATION.
   
   

   1. AB 70 (Waldron) requires EMSA to report to the Legislature information on the effectiveness of the statewide EMS systems every five years instead of annually. AB 70 is pending in the Assembly Health Committee.
      
      

   2. AB 430 (Roger Hernández) requires local EMS agencies to commission an independent nonprofit organization or governmental entity to conduct a comprehensive assessment of their regional trauma system at least once every five years and submit the results to EMSA. Requires EMSA to develop a statewide trauma plan to address all aspects of a trauma care system and report to the Legislature the status of the development or implementation of the statewide trauma plan. AB 430 is currently on the Assembly Appropriations Suspense File.
      
      

   3. AB 1129 (Burke) requires an EMS provider, when collecting and submitting data with a local EMS agency, to use a system compatible with statewide and national standards, as specified, and include those data elements that are required by the local EMS agency. Prohibits a local EMS agency from mandating that an EMS provider use a specific system to collect and share this data. AB 1129 is pending on Assembly Third Reading.
      
      

6. PREVIOUS LEGISLATION.
   
   

   1. AB 1621 (Lowenthal and Rodriguez) would have required EMSA to develop a single, statewide standard for reporting prehospital emergency care in order to assess each EMS area or local EMS agency service area to determine the need for additional EMS services, coordination of EMS services, and the effectiveness of EMS. AB 1621 was held on the Senate Appropriations Suspense File.
      
      

   2. AB 1975 (Roger Hernández) would have required local EMS agencies to contract with the American College of Surgeons every five years to conduct a comprehensive assessment of the county trauma system. AB 1975 was held on the Assembly Appropriations Suspense File.
      
      

   3. AB 2702 (Nuñez), Chapter 288, Statutes of 2008, allows physicians providing services in a standby ED that was in existence January 1, 2007, in a hospital in Los Angeles County to receive reimbursement from Proposition 99 (Tobacco Tax and Health Protection Act of 1988) and Maddy EMS funds, as specified.
      
      

REGISTERED SUPPORT / OPPOSITION:

Support

California Fire Chiefs Association (sponsor)

California Professional Firefighters
Paramedics Plus

Opposition

California Medical Association (previous version)

County of San Diego Board of Supervisors (previous version)

Riverside County Regional Medical Center (previous version)

Urban Counties Caucus (previous version)

Analysis Prepared by: Patty Rodgers / HEALTH / (916) 319-2097