Existing law, the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act, establishes the Emergency Medical Services Authority, which is responsible for the coordination and integration of all state agencies concerning emergency medical services. Existing law requires the authority to develop planning and implementation guidelines for emergency medical services systems that addresses specified components, including data collection and evaluation. The act authorizes each county to establish an emergency medical services program under which the county is required to designate a local emergency medical services (EMS) agency. Existing law authorizes a local EMS agency to implement a trauma care system only if the system meets the minimum standards adopted by the authority, as prescribed. Existing law requires a local EMS agency that elects to implement a trauma care system to develop and submit a plan for that trauma care system to the authority in accordance with regulations adopted by the authority.

This bill would require a local EMS agency implementing a trauma care system, as part of the minimum standards, to, among other things, commission an independent nonprofit organization or governmental entity qualified to assess trauma systems to conduct a comprehensive regional assessment of equitability and access to its trauma system, and would require the assessment to be performed in conjunction with other local EMS agencies in that agencys region and the regional trauma coordinating committee (RTCC) established by the authority for that region. The bill would require the local EMS agencies to submit the results of each assessment to the authority. The bill would require that the assessments occur at least once every 5 years, but would authorize the RTCCs and the authority to determine, after the initial assessment, whether it would be proper for subsequent assessments to occur on a more frequent basis, as specified. The bill would authorize the 5 RTCCs to assess and provide recommendations to the local EMS agencies and the authority, and would require the local EMS agencies implementing a trauma care system to incorporate these recommendations into their respective trauma care plans.

This bill would require the authority to develop a statewide trauma plan that addresses all aspects of a trauma care system and would require the authority to report to the Legislature, by March 1, 2016, the status of the development or implementation of the statewide trauma plan.

Existing law, the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act, establishes the Emergency Medical Services Authority, which is responsible for the coordination and integration of all state agencies concerning emergency medical services. Existing law requires the authority to develop planning and implementation guidelines for emergency medical services systems that addresses specified components, including data collection and evaluation. The act authorizes each county to establish an emergency medical services program under which the county is required to designate a local emergency medical services (EMS) agency. Existing law authorizes a local EMS agency to implement a trauma care system only if the system meets the minimum standards adopted by the authority, as prescribed. Existing law requires a local EMS agency that elects to implement a trauma care system to develop and submit a plan for that trauma care system to the authority in accordance with regulations adopted by the authority.

This bill would require a local EMS agency implementing a trauma care system, as part of the minimum standards, to, among other things, commission an independent nonprofit organization or governmental entity qualified to assess trauma systems to conduct a comprehensive regional assessment of equitability and access to its trauma system, and would require the assessment to be performed in conjunction with other local EMS agencies in that agencys region and the regional trauma coordinating committee (RTCC) established by the authority for that region. The bill would require the local EMS agencies to submit the results of each assessment to the authority. The bill would require that the assessments occur at least once every 5 years, but would authorize the RTCCs and the authority to determine, after the initial assessment, whether it would be proper for subsequent assessments to occur on a more frequent basis, as specified. The bill would authorize the 5 RTCCs to assess and provide recommendations to the local EMS agencies and the authority, and would require the local EMS agencies implementing a trauma care system to incorporate these recommendations into their respective trauma care plans.

This bill would require the authority to develop a statewide trauma plan that addresses all aspects of a trauma care system and would require the authority to report to the Legislature, by March 1, 2016, the status of the development or implementation of the statewide trauma plan.

Date of Hearing: May 6, 2015

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Jimmy Gomez, Chair

ABPCA Bill Id:AB 430

Author:(Roger Hernández) – As Amended Ver:April 20, 2015

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

SUMMARY:

This bill:

1. Requires the Emergency Medical Services Authority (EMSA) to develop a statewide trauma plan that addresses specified threats by March 2016.

2. Requires local emergency medical services agency implementing a trauma care system to commission an independent regional assessment of equitability and access to its trauma system.

FISCAL EFFECT:

1. Costs to EMSA to contract for a consultant to modify their recently completed statewide trauma plan to address threats specified in the bill, estimated at $250,000 (GF).

2. Potential state-reimbursable mandate costs of more than $2 million GF every five years associated with a new requirement on local EMS agencies for comprehensive regional assessments. Additional staff costs in the same range may be incurred by local EMS agencies to support such assessments, but it is unclear whether these costs will be reimbursable.

COMMENTS:

1. Purpose. According to the author, this bill would create a new state standard for EMSA certification by requiring local EMSAs to commission a comprehensive assessment of their regional trauma system. The author states that this bill is a necessary response to the recent State Auditor report suggesting the need for better oversight in the spending and allocation of Los Angeles (L.A.) County's Measure B funds, and also suggests independent assessment would benefit EMS systems statewide.

2. Responsibilities for Trauma Care Systems. 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 minimum standards set by EMSA.

California has 33 local EMS agencies: seven regional multi-county systems and 25 single-county 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.

3. RTCCs. In 2008, EMSA defined five regions and created corresponding RTCCs composed of trauma system providers, local EMS agency staff, and trauma system stakeholders from within each region. The RTCCs serve in an advisory capacity to promote regional cooperation, enhance and develop best practices, assist with the analysis of regional data, and work collaboratively with the state and local EMS agencies to develop regional policies and protocols in support of the state trauma system.

4. L.A. County's Measure B. In order to maintain, expand, and improve the trauma system countywide, L.A. County approved Measure B in 2002. In recent years, concerns have been raised about the expenditure of Measure B funds and whether they are being equitably allocated throughout the county. A February 2014 State Auditor report recommended the L.A. County Board of Supervisors reinstate a defunct oversight committee, and that Measure B funds be used to engage the American College of Surgeons (ACS) to perform a comprehensive assessment of the trauma system.

5. Opposition. Local EMS agencies and counties oppose this bill, they indicate the current framework governing trauma care is transparent, accountable, and has served to support robust local EMS systems for decades. They believe this bill would upend this system by requiring local EMS agencies to incorporate RTCC recommendations into their trauma care plans while imposing additional mandates and costs. They argue that while they collaborate through RTCCs, local EMS agencies should not be forced to cede authority over system planning and design to these committees. They further explain that RTCCs are informal, voluntary committees that serve as a forum to share best practices for trauma care, but lack a standard structure or any function established in regulations.

6. Related Legislation. AB 70 (Waldron), pending in Assembly Health, changes the reporting requirement that EMSA report annually to the Legislature on the effectiveness of the statewide trauma system to once every five years.

7. Prior Legislation. AB 1975 (Hernández) of 2014 was similar to this bill, but also contained an appropriation for EMSA to create a data system, and was held on the Suspense File of this committee.

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

Date of Hearing: April 28, 2015

ASSEMBLY COMMITTEE ON HEALTH

Rob Bonta, Chair

ABPCA Bill Id:AB 430

Author:(Roger Hernández and Rodriguez) – As Amended Ver:April 20, 2015

SUBJECT: Trauma care systems.

SUMMARY: Requires local emergency medical services agencies (LEMSAs) 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 the California Emergency Medical Services Authority (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. Specifically, this bill:

1. Requires a LEMSA implementing a trauma care system, as part of the minimum standards for the implementation of a trauma care system, to do all of the following:
   
   
   

   1. Commission an independent nonprofit organization or governmental entity qualified to assess trauma systems to conduct an assessment at least once every five years of its trauma system in conjunction with other LEMSAs in the same region and with the regional trauma coordinating committee (RTCC);
      
      
      

   2. Submit the results of each assessment to EMSA at least once every five years. Allows the RTCC, along with EMSA, to determine if subsequent assessments are to occur on a more frequent basis depending on the outcomes of the initial assessment, as specified; and,
      
      
      

   3. Establish an oversight committee composed of representatives from county departments who have expertise in trauma care systems, as well as in bioterrorism preparedness programs, for the purpose of assisting, and investigating the feasibility of, health facilities in underserved areas serving as a trauma facility within the trauma care system. Requires the oversight committee to make recommendations and report on its activities to the LEMSA.
      
      
      

2. Allows RTCCs to assess and provide recommendations to the LEMSA and to EMSA. Requires the LEMSA implementing a trauma care system to incorporate these recommendations into their trauma care plans and submit these revised plans to EMSA for approval.
   
   
   

3. Requires EMSA to develop a statewide trauma plan that addresses all aspects of a trauma care system, including, but not limited to, a statewide plan for trauma in the case of bioterrorism, natural disasters, mass casualties, and access to trauma care for rural and urban communities.
   
   
   

4. Requires EMSA to report the findings on the status and development or implementation on the statewide trauma plan to the Legislature by March 31, 2016. Sunsets this requirement on March 31, 2020.

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 LEMSA responsible for planning and implementing an EMS system, which includes day-to-day EMS system operations.
   
   

3. Requires a LEMSA that elects to implement a trauma care system to develop and submit a plan to 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.

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

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, in 2002 Los Angeles (LA) County voters passed Measure B, an initiative to fund the trauma network countywide, maintain and expand the trauma system, provide emergency room services, and tackle bioterrorism. Measure B is a critical funding source to maintain, improve, and expand the region’s trauma system and ensure the rates of diversion and wait times in emergency rooms decrease in underserved communities. Last year, at the request of the author, the California State Auditor reported on deficiencies in the implementation of Measure B. The State Auditor concluded that LA County is currently lacking the ability to publicly demonstrate Measure B funds address the most pressing trauma and emergency room needs in the region. The Auditor recommends the establishment of an oversight committee and the commission of a comprehensive regional assessment.
   
   The author states the goal of this bill is to provide better accountability and transparency of Measure B funds in LA County and institute best practices for trauma systems statewide. The State Auditor found no evidence of a comprehensive assessment to evaluate whether the LA County Board of Supervisors (Board) has the best available data to make evidence-based decisions regarding the investment of Measure B resources. The author argues this bill will require the Board to reestablish the Measure B Oversight Committee, as it has not revisited its allocation of Measure B funds in over a decade. To ensure strong fiscal stewardship of the funds and ensure that the important trauma emergency services are being provided, LA County must revisit decades old information.
   
   

2. BACKGROUND.
   
   

   1. Model Trauma System Planning and Evaluation. According to the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration, a trauma system is a pre-planned, comprehensive, and coordinated statewide and local injury response network that includes all facilities with the capability to care for the injured. It is the system’s inclusiveness, or range of pre-planned trauma center and non-trauma center resource allocation, that offers the public a cost-effective plan for injury treatment. In such an effective system, trauma care delivery is organized through the entire spectrum of care delivery, from injury prevention to prehospital, hospital, and rehabilitative care delivery for injured persons. The system begins with a state’s authority to designate various levels of trauma and burn centers and through data collection and analysis processes, demonstrates its own effectiveness time and time again.
      
      According to the HHS Model Trauma System Planning and Evaluation, injury is a leading cause of death in the United States and continues to occur every day and in every state. The rates are not declining and the threat is magnified with the consideration of unexpected natural and man-made incidents. A primary strategy of the public health approach is to identify a problem based on data, devise and implement an intervention, and evaluate the outcome. These fundamental core functions of public health are applied to public health assessment, policy development, and evaluation mechanisms to ensure quality patient outcomes.
      
      Historically, trauma centers provided care to patients with major injuries and focused mostly on tertiary prevention. The trauma system, in contrast, should contribute to reducing the entire burden of injury in a state, region, or community. Therefore, it should integrate all three phases of injury prevention into planning and practice. Improving the injury health status of a community is far more complex and extensive than just ensuring good trauma care of injured patients. The population cared for in the trauma system is diverse, that is, with wide regional variation in age, ethnicity, and geography. To be most effective, injury prevention resources need to be targeted and customized to specific population groups. Only with the full mobilization of the community’s health care and public health resources, in concert with the trauma system, will injury prevention efforts be effective.
      
      The ultimate evaluation outcome of trauma system implementation is a reduction in morbidity and mortality. This goal can be accomplished through trauma system planning and implementation of process of care improvement, enhancement of system performance, use of evidence-based research, development and implementation of targeted injury prevention programs, and revisions to trauma system plans based on system assessments and data-based needs.
      
      

   2. 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. California has 33 LEMSAs: seven regional multi-county systems and 25 single-county agencies. The regional systems are usually comprised of small, rural, less-populated counties, and single-county systems generally exist in the larger and more urban counties. LEMSAs 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.
      
      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.
      
      

3. REGIONAL PLANNING. In 2008, EMSA defined five regions and created corresponding RTCCs composed of trauma system providers, LEMSA staff, and trauma system stakeholders from within each region. The RTCCs serve in an advisory capacity to promote regional cooperation, enhance and develop best practices, assist with the analysis of regional data, and work collaboratively with the state and LEMSAs to develop regional policies and protocols in support of the State Trauma System.
   
   

4. STATEWIDE TRAUMA PLAN. In 2005, Governor Schwarzenegger directed EMSA and the State Trauma Advisory Committee (STAC) to complete the statewide trauma care plan. EMSA published a planning document "California Statewide Trauma Planning: Assessment and Future Direction" in 2006, which analyzes the status of trauma care in the state and to make recommendations for a California Statewide Trauma System. Since that time, EMSA has been developing a Statewide Trauma Plan but has not yet approved a final plan. EMSA has stated that the STAC is reviewing the final draft of the State Trauma Plan.
   
   

5. LOS ANGELES COUNTY'S MEASURE B. In order to maintain and expand the trauma system countywide, to ensure the continued availability of EMS, and to respond effectively to biological terrorism, voters in LA County approved Measure B in 2002. With the passage of the measure, the LA Board of Supervisors implemented a parcel tax of $0.03 per square foot on generally all structural improvements, which it has increased over time. In fiscal year 2011-12, the measure generated more than $256 million in revenue.
   
   In recent years, concerns have been raised about the expenditure of Measure B funds and whether they are being equitably allocated throughout the county. Critics point to the fact that parts of the area, such as eastern San Gabriel Valley, are still lacking a trauma center. In 2013 the Joint Legislative Audit Committee approved an audit by the State Auditor to examine the spending of Measure B funds in LA County. Among other things, the State Auditor recommended that the LA County Board of Supervisors reinstate the Measure B oversight committee, which was dissolved in 2004. The Auditor also recommended that the LA County Board of Supervisors use Measure B funds to perform a comprehensive assessment, and to address any identified weaknesses in the trauma system. In response, the LA County Board of Supervisors stated that they had addressed the region's most pressing trauma needs by adding two new private trauma hospitals, adding 24/7 air medical transport services, and by reducing overall mortality rates in LA County since 2002.

6. OPPOSITION. The EMS Administrators Association of California and the EMS Medical Directors Association of California are strongly opposed to this bill. This opposition writes that currently, LEMSAs and their physician medical directors are responsible for planning, implementing, and evaluating the effectiveness of EMS trauma systems within their jurisdiction in accordance with current EMSA regulations. LEMSAs, with the oversight of EMSA and the Commission on EMS, currently perform objective and independent trauma planning and system evaluation. While there may be value on a case by case basis for a LEMSA to voluntarily choose to conduct an assessment, there exists no compelling argument to mandate a regional trauma system assessment for each region. The increase in EMS staff costs could surpass $100,000 a year in many counties. Local jurisdictions would have no choice but to pass along these costs to hospitals by increasing trauma center designation fees.
   
   The California State Association of Counties (CSAC) and the Rural County Representatives of California (RCRC), also in opposition, add that LEMSAs currently work closely with existing RTCCs, which are voluntary committees that primarily serve as a forum to share best practices for trauma care. By elevating the role and responsibility of volunteer RTCCs, this bill would usurp the proven ability of LEMSAs to effectively and impartially oversee local EMS systems. CSAC and RCRC contend that LEMSAs are currently required to develop and submit a local trauma care plan to EMSA each year. Those plans must enumerate the type, quality, and performance levels of each of the emergency services components that the local LEMSA oversees. This current framework is transparent, accountable, and has served to support robust local EMS systems for decades. CSAC states this bill would upend this system by increasing the role of the volunteer RTCCs and imposing additional mandates and costs on local LEMSAs.

7. RELATED LEGISLATION.

   1. AB 70 (Waldron) changes the reporting requirement that EMSA report annually to the Legislature on the effectiveness of the statewide trauma system to once every five years. AB 70 is currently pending hearing in the Assembly Health Committee.

   2. AB 503 (Rodriguez) allows a health facility to release patient-identifiable medical information to an EMS provider and to a LEMSA when specific data elements are requested for the purpose of quality assessment and improvement. Requires EMSA to develop minimum standards for the implementation of this data collection system. AB 503 is currently pending on the Assembly Floor.

   3. AB 1129 (Burke) requires an emergency medical care provider, when collecting and sharing data with a LEMSA, to use a system compatible with California Emergency Medical Services Information System and National Emergency Medical Services Information System standards, as specified. Prohibits a LEMSA from mandating that a provider use a specific system to collect and share this data. AB 1129 is currently pending hearing in the Assembly Health Committee.

8. PREVIOUS LEGISLATION.
   
   

   1. AB 1975 (Roger Hernández) of 2014 would have required LEMSAs 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 Suspense file in the Assembly Appropriations Committee.

   2. AB 1621 (Lowenthal and Rodriguez), also of 2014, would have required EMSA to develop the State Emergency Medical Services Data and Information System in order to assess each EMS area or LEMSAs 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 Suspense file in the Senate Appropriations Committee.

   3. SB 266 (Romero) of 2005 would have required EMSA to establish a trauma care advisory committee and required the committee to develop a statewide trauma care plan by January 1, 2007. SB 266 was vetoed by Governor Schwarzenegger, stating " I am directing EMSA, informed by its Trauma Advisory Committee, to complete its statewide trauma care plan and provide me recommendations by no later than June 1, 2006."

   4. AB 1988 (Diaz), Chapter 333, Statutes of 2002, requires EMSA to convene a task force to study the delivery and provision of EMS. Requires the task force, among other things, to develop a plan to ensure that all Californians are served by appropriate coverage areas for emergency and trauma services and that sufficient numbers of emergency departments and trauma centers exist to serve each area's population.

REGISTERED SUPPORT / OPPOSITION:

Support

None on file.

Opposition

California State Association of Counties

Emergency Medical Services Administrators Association of California

Emergency Medical Services Medical Directors Association of California

Rural County Representatives of California

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