Existing law, the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act, governs local emergency medical services (EMS) systems. The existing act establishes the Emergency Medical Services Authority (authority), which is responsible for the coordination and integration of all emergency medical services. Existing law authorizes each county to develop an emergency medical services program and requires a county that does so to designate a local EMS agency (LEMSA).

Existing law authorizes a LEMSA to adopt policies and procedures for calculating and reporting ambulance patient offload times. Existing law authorizes a LEMSA to develop and submit an emergency medical services system plan to the authority and requires the times and requires a LEMSA to annually submit its emergency medical services plan for the EMS area to the authority, according to EMS Systems, Standards, and Guidelines established by the authority.

This bill would make these authorizations this authorization mandatory. The bill would require an a LEMSA to include its annual budget and any exemptions from meeting 911 response times in the previous calendar year with its annual emergency medical services plan submission. The bill would also require LEMSAs and the authority to make the plans accessible on the LEMSAs and the authoritys internet websites within 30 days of approval by the authority. The bill would require the EMS Systems, Standards, and Guidelines to include a standardized list of exemptions from meeting 911 response times and would require a LEMSAs 911-response-time exemption to conform to the standardized list once the authority has established the list. require LEMSAs, to the extent they have established 911 response times for EMS providers, to include a list of exemptions from meeting 911 response times granted in the previous calendar year, if any, with their annual emergency medical services plan submission.

Existing law, the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act, governs local emergency medical services (EMS) systems. The existing act establishes the Emergency Medical Services Authority (authority), which is responsible for the coordination and integration of all emergency medical services. Existing law authorizes each county to develop an emergency medical services program and requires a county that does so to designate a local EMS agency (LEMSA).

Existing law authorizes a LEMSA to adopt policies and procedures for calculating and reporting ambulance patient offload times. Existing law authorizes a LEMSA to develop and submit an emergency medical services system plan to the authority and requires the LEMSA to annually submit its emergency medical services plan for the EMS area to the authority. authority, according to EMS Systems, Standards, and Guidelines established by the authority.

This bill would make these authorizations mandatory. The bill would require an LEMSA to include its annual budget and any exemptions from meeting 911 response times in the previous calendar year with its annual emergency medical services plan submission. The bill would also require LEMSAs and the authority to make the plans accessible on the LEMSAs and the authoritys internet websites within 30 days of approval by the authority. The bill would require the EMS Systems, Standards, and Guidelines to include a standardized list of exemptions from meeting 911 response times and would require a LEMSAs 911-response-time exemption to conform to the standardized list once the authority has established the list.

Existing law, the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act, governs local emergency medical services (EMS) systems. The existing act establishes the Emergency Medical Services Authority (EMSA), (authority), which is responsible for the coordination and integration of all emergency medical services. Existing law authorizes each county to develop an emergency medical services program and requires a county that does so to designate a local EMS agency (LEMSA). Among other duties, the LEMSA is responsible for implementation of advanced life support systems and limited advanced life support systems and for the monitoring of training programs.

Existing law, the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act, governs local emergency medical services (EMS) systems. The existing act establishes the Emergency Medical Services Authority (EMSA), which is responsible for the coordination and integration of all emergency medical services. Existing law authorizes each county to develop an emergency medical services program and requires a county that does so to designate a local EMS agency (LEMSA). Among other duties, the LEMSA is responsible for implementation of advanced life support systems and limited advanced life support systems and for the monitoring of training programs.

This bill would state the intent of the Legislature to enact legislation requiring increased LEMSA transparency to the EMSA.

SENATE COMMITTEE ON APPROPRIATIONS

Senator Anthony Portantino, Chair

2023 - 2024 Regular Session

AB 379 (Rodriguez) - Emergency medical services

Bill Summary:

AB 379 would, among other provisions, add requirements related to local emergency medical services plans.

Fiscal Impact:

The Emergency Medical Services Authority (EMSA) estimates ongoing General Fund costs of $418,000 for state administration.

Background:

Current law establishes the Emergency Medical Services (EMS) System and the Prehospital Emergency Medical Care Personnel Act to provide for a statewide system for EMS and establishes the EMSA which is responsible for the coordination and integration of all state activities concerning EMS. Current law authorizes counties to develop an EMS program and to designate a local EMS agency responsible for planning and implementing an EMS system.

Current law requires EMSA to develop planning and implementation guidelines for EMS systems which address the following components: manpower and training; communications; transportation; assessment of hospitals and critical care centers; system organization and management, data collection and evaluation; public information and education; and disaster response. Local EMS agencies annually submit an EMS plan for their area to EMSA.

Current law requires EMSA to develop a statewide standard methodology for the calculation and reporting by a local EMS agency of ambulance patient offload time (APOT). APOT is defined 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 department assumes responsibility for care of the patient. Current law authorizes a local EMS agency to adopt policies and procedures for calculating and reporting APOT.

Proposed Law:

Specific provisions of the bill would:

• Require the existing EMSA planning and implementation guidelines to include a list of standardized terminology for local EMS agencies to use when granting exemptions for 911 response times, as specified.
• Require, rather than permit, local EMS agencies to adopt policies and procedures for calculating and reporting APOT.
• Require EMSA to develop an audit tool to improve data accuracy of transfer of care with validation from hospitals and local EMS agencies.
• Require local EMS annual plans to include the local EMS agency’s annual budget and, to the extent they have established 911 response times for EMS providers, a list of exemptions from meeting 911 response times, if any.
• Require EMSA to approve or request changes to the proposed local EMS annual plans within 90 days of receipt and to make each local EMS plan submitted to them accessible on the internet website within 30 days of approval.

Related Legislation:

AB 40 (Rodriguez, 2022) would require, among other provisions, local EMS agencies to adopt an APOT standard. The bill is scheduled to be heard August 14, 2023 in this committee.

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SENATE COMMITTEE ON HEALTH

Senator Dr. Susan Talamantes Eggman, Chair

BILL NO: AB 379

SUBJECT: Emergency medical services

SUMMARY:

Requires local emergency medical services (EMS) agencies to post their annual plans that are approved by the state Emergency Medical Services Authority on their website, and requires these plans to include the local EMS agency’s annual budget and any exemptions from meeting 911 response times. Requires EMS system guidelines developed by the Emergency Medical Services Authority (EMSA) to include a standardized list of exemptions from meeting 911 response times. Requires local EMS agencies to adopt policies and procedures for calculating and reporting ambulance patient offload times, and to establish a process for hospitals and ambulance providers to review and validate the reported data.

Existing law:

1. Establishes the Warren-911-Emergency Assistance Act, which requires every public agency to have in operation a telephone service which automatically connects a person dialing the digits “911” to an established public safety answering point. Defines “public agency” to include the state, any city or county, or any public district that provides or has authority to provide firefighting, policy, ambulance, or other emergency services. Prohibits public agencies from delegating or subcontracting 911 dispatch services to a private entity, with limited exceptions for contracts that existed prior to the law that prohibited private entities from providing 911 dispatch. [GOV §53100, et seq.]
2. Requires every 911 system to include police, firefighting, and emergency medical and ambulance services. Requires every 911 system, in those areas in which a public safety agency provides ambulance emergency services, to include such public safety agencies. Permits 911 systems to incorporate private ambulance services. [GOV §53110]
3. Establishes the Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act (EMS Act) to provide for a statewide system for EMS, and establishes the Emergency Medical Services Authority (EMSA), which is responsible for the coordination and integration of all state activities concerning EMS, including the establishment of minimum standards, policies, and procedures. [HSC §1797, et seq.]
4. Establishes an 18-member Commission on EMS, within the California Health and Human Services Agency. 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. [HSC §1799, et seq.]
5. Requires EMSA to develop, and after approval by the Commission on EMS, adopt a statewide standard methodology for the calculation and reporting by a local EMS agency of ambulance patient offload time (APOT), using input from stakeholders, including, but not limited to, hospitals, local EMS agencies, and public and private EMS providers. [HSC §1797.120]
6. Defines APOT 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. [HSC §1797.120]
7. Permits a local EMS agency to adopt policies and procedures for calculating and reporting APOT, and requires a local EMS agency that adopts these policies and procedures to: a) use the statewide standard methodology for calculating and reporting APOT developed by EMSA; and, b) establish criteria for the reporting of, and quality assurance follow-up for, a “nonstandard patient offload time,” as defined. [HSC §1797.225]
8. Requires a local EMS agency to transmit APOT data quarterly to EMSA, consistent with policies and procedures established pursuant to 7) above. Requires EMSA, upon receipt of the quarterly data from local EMS agencies, to calculate APOT by local EMS agency jurisdiction and by each facility in their jurisdiction, and to make APOT reports twice per year to the Commission on EMS. [HSC §1797.123, §1797.228]
9. Requires EMSA to develop planning and implementation guidelines for EMS systems which address the following components: manpower and training; communications; transportation; assessment of hospitals and critical care centers; system organization and management, data collection and evaluation; public information and education; and, disaster response. [HSC §1797.103]
10. Requires EMSA to receive plans for the implementation of EMS systems from local EMS agencies, and to permit a local EMS agency to implement a plan unless EMSA determines that the plan does not effectively meet the needs of the persons served or is not consistent with applicable guidelines or regulations established by EMSA. Permits a local EMS agency to appeal a determination to the Commission on EMS. [HSC §1797.105]
11. 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. [HSC §1797.200, et seq.]
12. Requires local EMS agencies to annually submit an EMS plan for their area to EMSA, according to EMS Systems, Standards, and Guidelines established by EMSA. [HSC §1797.254]

This bill:

1. Requires EMSA to approve or request changes to EMS plans that are required to be submitted annually by local EMS agencies within 90 days of receipt. Requires local EMS plans to be made accessible on the local EMS agency’s website, and on EMSA’s website, within 30 days of approval by EMSA.
2. Requires EMSA to include a standardized list of exemptions from meeting 911 response times as part of their EMS Systems, Standards, and Guidelines.
3. Requires local EMS agencies, as part of the requirement to annually submit an EMS plan to EMSA, to include the local EMS agency’s budget and any exemptions from meeting 911 response times in the previous calendar year. Requires the 911 response time exemptions submitted as part of the annual EMS plan for the previous calendar year to conform to the standardized list established by EMSA pursuant to 2) above, once EMSA has established the list.
4. Requires, rather than permits, a local EMS agency to adopt policies and procedures for calculating and reporting APOT, and requires a local EMS agency to establish a process for hospitals and ambulance providers to review and validate the reported data, including arrival, transfer of care, and ambulance back-in-service times, and to dispute the reported data as well as a process to correct this data within 30 days.

FISCAL EFFECT:

According to the Assembly Appropriations Committee:

Minor and absorbable costs to EMSA to post specified information on its website.

Although this bill requires a local EMS agency to undertake specified duties, this bill does not create a state-mandated local program because a county is only required to have a local EMS agency if the county has an EMS program, and existing law does not require (only authorizes) a county to develop an EMS program. Thus, a county does not need to follow this bill’s requirements if the county does not have an EMS program.

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, local EMS agencies are responsible for planning, coordinating, and improving local emergency and medical response systems. Local EMS agencies mainly work to organize prehospital services. Local EMS agency plans lay out policies for system organization and management, staffing and training, communication, response and transportation for emergency services, facilities and critical care, data collection and system evaluation, public information and education, disaster medical response, and more. Maintaining timely 911 response times and efficient APOT is essential to ensuring that residents receive the medical care they need in a timely manner. By requiring local EMS agencies and EMSA to post approved plans on their websites, we can increase transparency for policymakers, stakeholders and residents who want to see how their emergency management officials are planning for their care. Current law states that local EMS agencies may establish policies and procedures for calculating and reporting APOT, but does not require it. Because APOT plays a pivotal role in how quickly EMS workers are able to respond to a 911 call, requiring local EMS agencies to establish these metrics is a critical component of emergency planning.
2. EMSA draft regulations on local EMS systems. One provision of this bill requires EMSA to approve, or seek changes to, the local EMS area plans that are required to be submitted to EMSA annually for approval within 90 days of receipt. These local EMS plans are supposed to be based on EMS Systems, Standards, and Guidelines that EMSA is required to establish. EMSA did develop several guidance documents in 1985 that were revised over the years, but they were never formally adopted as regulations. In 2019, the California Fire Chiefs Association challenged these guidelines as underground regulations. In response, EMSA certified that it would not use or enforce the documents, and subsequently began the process of promulgating regulations. In October of 2019, EMSA released draft regulations to adopt standards, policies, and procedures for the planning and implementation of local EMS systems. Many areas of the EMS Act would be affected by these regulations, including the competitive process a local EMS agency would have to follow in order to create an exclusive operating area. Among the many provisions proposed to govern the bidding process, these regulations proposed to explicitly prohibit subcontracting the primary provision of ambulance services by the bidder. The controversy over this subcontracting issue contributed to a decision by EMSA in August of 2020 not to proceed with these regulations. This issue also led to the passage of AB 389 (Grayson, Chapter 460, Statutes of 2021), which gave statutory authority for fire agencies to subcontract with private ambulance services. However, because the guidance documents that local EMS agencies have historically relied upon to develop their EMS plans can no longer be enforced due to the challenge that they were underground regulations, local EMS agencies are currently in a gray area of using the old guidance documents despite EMSAs inability to enforce them, since nothing else has been adopted to replace them, while EMSA develops a new regulatory package to provide standards, policies and procedures local EMS systems. According to the June 14, 2023, meeting of the Commission on EMS, which is required to review regulations developed by EMSA, a draft regulatory package is expected to be ready for review later this year.
3. Background on 911 response times and exemptions. There is no requirement in state law or regulations that first response or ambulance transport meet minimum 911 response times. In most local EMS areas, it is fire departments who arrive first to medical emergencies, but there is no universal or enforceable standard that fire departments respond to medical emergencies or how fast fire departments are required to arrive at the scene of a medical emergency. As part of the EMS planning, a local EMS agency may establish ambulance response times as part of a competitive process in creating an exclusive operating area (EOA). In practice, this approach to EMS planning has led to the imposition of response time standards for private ambulance companies in EOA agreements with local EMS agencies, while public fire department-based providers have no local EMS agency or external response time requirements. Many local EMS agencies use the guidelines established by the National Fire Protection Association to compare response time performance between contracted EOA ambulance services and fire departments. The NFPA response guidelines are as follows:
   1. Dispatch time for medical emergencies: 90 seconds for 90% of the calls (the time it takes for a 911 operator at a dispatch center to relay the call to a provider with the address/location);
   2. Turnout time: 60 seconds for 90% of calls (the time it takes from when the call comes to a provider for the crew to get into the vehicle and leave the station); and,
   3. Travel time: four minutes for 90% of calls for basic life support, and nine minutes for 90% of calls for advanced life support (meaning, a licensed paramedic is part of the crew rather than just an emergency medical technician for basic life support).

Local EMS agency agreements with response time requirements generally have a set of agreed upon “exemptions” from response time standards for occurrences outside the control of the provider. Examples of recognized exemptions include, but are not limited to, adverse weather such as fog or heavy rain, unexpected road closures, and notably when ambulances are captured at emergency departments waiting to transfer patients for care (APOT delays).

1. APOT reporting. Pursuant to AB 1223 (O’Donnell, Chapter 379, Statutes of 2015), EMSA developed standardized methods for data collection and reporting of APOT, and approved these standards in December of 2016. These APOT reporting standards established two reporting metrics (APOT-1 and APOT-2). APOT-1 is a measure of how many minutes it took to transfer care of 90% of the patients in the report (i.e., if there were 100 patients in a given APOT report, and they were sorted from the shortest APOT to the longest, the APOT-1 measure would be how long it took to transfer the 90^th patient). APOT-2 is a measure of the percentage of ambulance patients with an APOT within a 20 minute target, and the percentage that exceeded that target in reference to 60, 120, and 180 minute intervals. These reports are required to be stratified by hospital, with the number of patients transported to each hospital to provide context for the hospital reports. The reports are to be on a quarterly basis.
   
   Initially, APOT reporting was voluntary, but the Legislature passed AB 2961 (O’Donnell, Chapter 656, Statutes of 2018) to require a local EMS agency to report APOT to EMSA on a quarterly basis, and required EMSA to calculate APOT by jurisdiction and by each facility within a jurisdiction, and report this data to the Commission on EMS twice per year. According to a report on APOT delays, in December 2020, for purposes of evaluating APOT across the state, EMSA determined, in collaboration with EMS stakeholders, that 20 minutes is the maximum time any Californian transported to a hospital by ambulance should ever wait at any emergency department in the state before being transferred to a hospital bed. However, many local EMS agencies have established a standard offload time of 30 minutes. EMSA estimated in this report that statewide, an average of 28.26% of all transports exceeded 20 minutes. The report identified that the problem was severe in Sacramento County, Los Angeles County, and Alameda County, but was not a problem in Napa, Marin, Ventura, San Mateo, or Santa Barbara counties. Looking at more recent data, from 2022, many hospitals in severe areas are regularly scoring over an hour in APOT-1 (the time it takes to transfer care for the 90^th percentile patient). For example, in the Sacramento area for the month of October 2022: Kaiser Permanente in South Sacramento had 1498 offloads, and APOT-1 was 1:08:35; Mercy San Juan Medical Center had 1505 offloads, and APOT-1 was 1:29:34; Sutter Medical Center had 1386 offloads, and APOT-1 was 1:14:04; and, UC Davis Medical Center had 1310 offloads, and APOT-1 was 0:53:23.
   
2. Background on CEMSIS and capturing APOT data. According to EMSA, the California Emergency Medical Services Information System (CEMSIS) is a demonstration project for improving EMS data analysis across California. CEMSIS offers a secure, centralized data system for collecting data about individual EMS requests, patients treated at hospitals, and EMS provider organizations. CEMSIS uses the National Emergency Medical Services Information System (NEMSIS) standard for how patient care information resulting from a 911 call for emergency assistance is collected. EMSA states that 33 of California’s 34 local EMS agencies currently send a variety of local data collections to CEMSIS, and in return, these local agencies gain access to digital tools for running comprehensive reports on their own data at no cost. Only Los Angeles (LA) County EMS Agency is still in a testing phase, and EMSA states that it expects to start receiving LA County data through CEMSIS beginning on July 1 of this year. According to EMSA, it uses the data to develop and coordinate high quality emergency medical care in California through activities such as healthcare quality programs that monitor patient care outcomes, agency collaboration across jurisdictional boundaries, and public health surveillance.
   
   This bill includes a provision that requires local EMS agencies to establish a process for hospitals and ambulance providers to review and validate reported APOT data. However, a related bill this session by the same author, AB 40 (Rodriguez), includes a requirement that EMSA develop a requirement for CEMSIS to include an electronic signature for use between emergency department personnel at a receiving hospital and the EMS provider who is transporting the patient to the hospital that captures the points in time involved in APOT. When APOT times are captured by CEMSIS, the need to validate data should be diminished, as the tool used to capture this data will be uniform statewide. Additionally, AB 40 also contains a requirement that there be an “audit tool to improve data accuracy of transfer of care with validation from hospitals and local EMS agencies.”
3. Related legislation. AB 767 (Gipson) extends the sunset date of the Community Paramedicine or Triage to Alternate Destination Act of 2020, from January 1, 2024 to January 1, 2031, and adds short-term, post-discharge follow-up for persons recently discharged from a hospital due to a serious health condition to the list of program specialties that can be part of a community paramedicine program. AB 767 passed the Senate Health Committee by a vote of 11-0 on June 21, 2023.
   
   AB 40 (Rodriguez) requires EMSA to develop a system for an electronic signature for use between the emergency department and ambulance personnel that captures the points in time when a hospital receives notification of ambulance arrival and when transfer of care is executed for documentation of APOT. AB 40 requires EMSA to develop a statewide standard of 30 minutes, 90% of the time for APOT, and requires a general acute care hospital to develop an APOT reduction protocol, that addresses specified factors. Finally, AB 40 requires EMSA, on or after March 1, 2024, to monitor APOT for each facility that is required to report. AB 40 is set to be heard in this Committee on July 12, 2023.
   
   AB 716 (Boerner) limits the amount a health plan enrollee, insured, or uninsured person who receives services from a ground ambulance provider has to pay for services, prohibits the ground ambulance provider from billing more than the specified amount, and requires the health plan or insurer to directly reimburse a ground ambulance provider according to authorized reimbursement amounts, as specified. AB 716 is set to be heard in this Committee on July 5, 2023.
   
   AB 1168 provides the City of Oxnard, notwithstanding City of Oxnard v. County of Ventura, the right to administer or contract for prehospital EMS, establishes a process to determine who will provide prehospital EMS to the remaining portion of the exclusive operating area if the City of Oxnard exercises its right to provide prehospital EMS in the City, and clarifies going forward that a city or fire district providing prehospital EMS that enters into a joint powers of authority agreement (JPA) with a county will retain its rights to administer prehospital EMS if the city or fire district withdraws from the JPA. AB 1168 passed the Senate Health Committee by a vote of 10-0 on June 28, 2023.
   
4. Prior legislation. AB 389 (Grayson, Chapter 460, Statutes of 2021) permits a county to contract for emergency ambulance services with a fire agency that will provide those services, in whole or in part, through a written subcontract with a private ambulance service; and permits a fire agency to enter into a written subcontract with a private ambulance service for the purpose of contracting with a county.
   
   AB 1544 (Gipson, Chapter 138, Statutes of 2020) enacted the Community Paramedicine or Triage to Alternate Destination Act of 2019, which permits local emergency medical services agencies, with approval by EMSA, to develop programs to provide community paramedic or triage to alternate destination services in one of the following specialties: (1) providing directly observed tuberculosis therapy; (2) providing case management services to frequent emergency medical services users; (3) providing hospice services to treat patients in their homes; and, (4) providing patients with transport to an alternate destination, which can either be an authorized mental health facility, or an authorized sobering center. Sunsets the provisions of this bill on January 1, 2024.
   
   SB 438 (Hertzberg, Chapter 389, Statutes of 2019) prohibited a public agency from entering into a contract for 911 call processing regarding the dispatch of emergency response resources unless the contract is with another public agency, with specified exceptions.
   
   AB 2961 (O’Donnell, Chapter 656, Statutes of 2018) requires a local EMS agency to report APOT to EMSA on a quarterly basis, and requires EMSA to calculate APOT by jurisdiction and by each facility within a jurisdiction, and report this data to the Commission on EMS twice per year, and to submit a report to the Legislature by December 1, 2020.
   
   AB 1223 (O’Donnell, Chapter 379, Statutes of 2015) required EMSA to adopt a statewide standard methodology for the calculation and reporting by a local EMS agency of APOT, and permits local EMS agencies to adopt policies and procedures for calculating and reporting APOT using the statewide methodology.
   
   AB 1129 (Burke, Chapter 377, Statutes of 2015) requires an emergency medical care provider, when submitting data to a local EMS agency, to use an electronic health record system that is compatible with specified standards, and that includes those data elements that are required by the local EMS agency.
   
   AB 503 (Rodriguez, Chapter 362, Statutes of 2015) authorizes health facilities to release patient-identifiable medical information to an EMS provider and local EMS agency when specific data elements are requested for the purpose of quality assessment and improvement.
   
5. Letter of concern. The Emergency Medical Services Administrators of California (EMSAAC) submitted a letter of concern based on the provision in the bill requiring local EMS agencies to establish a process to review and validate APOT data, and on the provisions in the bill regarding exemptions for 911 response times. On the provision requiring local EMS agencies to establish a process to review and validate APOT data, EMSAAC states that the proposed language implies that this data is inaccurate to the extent that it requires regular correction from hospitals not involved in the legally required documentation of such data. EMSAAC states that while there may be infrequent and minor data errors due to unintentional documentation mistakes, these errors have been significantly reduced with the integration of computer aided dispatch systems and EMS electronic patient care report (ePCR) systems. EMSAAC states that the data elements involved are documented in a legal ePCR medical record that is required to be completed solely by EMS personnel, and any changes to this data would require the subsequent alteration of the legal medical record.
   
   With regard to the provisions regarding exemptions for 911 response times, EMSAAC states that local EMS agencies, unless specifically allowed as part of an exclusive operating area (EOA) agreement, do not have the legal ability to dictate or establish 911 response times for non-transport first responder agencies and therefore do not currently track or report on incidents where a non-transport first responder agency fails to meet their internally established 911 response time standards. Further, the internal establishment of these 911 response time standards by non-transport first responder agencies are usually guidelines with no specific consequence for failure to comply with them. EMSAAC states that some local EMS areas do not have established 911 response time criteria, whether it is for public or private ambulance transport providers. According to EMSAAC, ambulance transport EOA agreements, which have already been reviewed and approved by EMSA during the Request For Proposals (RFP) process, include multiple different area-specific valid exemptions for failing to meet established 911 ambulance response time. Further, since no scientific evidence currently exists to support the establishment of any specific 911 response time standard, many EOA agreements allow providers to offset response time standards and penalties if they are compliant with other established clinical care quality measures. Finally, EMSAAC states that because the specific reasons for failing to meet 911 response time standards are unique to each area, the development of a standardized list would be difficult.
   
6. Oppose unless amended. American Medical Response (AMR) is opposed to this bill based on the 911 response time exemptions, unless amended to also hold public agencies to response time standards, exemption reporting, and to establish a definition of a response time. According to AMR, the 911 exemption provisions intentionally target private ambulance operator’s response times with no accountability for the response times of public agencies which make up the majority of EMS providers in California. AMR states that this bill would require local EMS agencies to report 911 response time exemptions that are granted to private providers, and that because public providers do not have response time requirements, it would unfairly paint private providers as not meeting response times, when there is no comparable information for public providers. This creates a misleading double standard within the law. AMR states that to ensure adequate data collection, and fairness in application of the statute, public agencies should also be required to have response time compliance established by the county, which in turn would require them to seek exemptions for late calls. Finally, AMR states there should be a standard measurement or definition of a response time to ensure apples-to-apples comparisons.
7. Drafting concerns. As pointed out in the letter of concern from EMSAAC, the reasons for granting exemptions from 911 response times will vary based on the region of the state and geographic conditions. Additionally, not all local EMS agencies have established 911 response times, and therefore would not have any exemptions. The author may wish to consider an amendment to require local EMS agencies to include a standardized list of exemptions in their annual EMS plans that are submitted to EMSA, but only to the extent there are any. To accommodate an effort to standardize terminology throughout the state, which is the author’s stated intent, EMSA could be directed to develop standardized exemption terminology for common reasons for granting 911 response time exemptions, while making it clear that local EMS agencies could also grant exemptions that are not included in the standardized list. Finally, this bill includes a provision requiring a local EMS agency to establish a process for hospitals and ambulance providers to review and validate the reported APOT data. However, related legislation by this author to require EMSA to adopt a statewide APOT standard, AB 40 (Rodriguez), requires EMSA, rather than local EMS agencies, to establish an audit tool for APOT data with validation from hospitals and local EMS agencies. To avoid duplication, the author may wish to conform the data validation tool in this bill so that it matches the data validation in AB 40.

SUPPORT AND OPPOSITION:

Support: None received

Oppose: American Medical Response (unless amended)

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Date of Hearing: May 3, 2023

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Chris Holden, Chair

ABPCA Bill Id:AB 379

Author:(Rodriguez) – As Amended Ver:March 23, 2023

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

SUMMARY:

This bill requires a local emergency medical services agency (LEMSA) to develop specified policies and plans related to emergency medical services (EMS) and post the information online.

Specifically, this bill:

1. Requires, instead of authorizes, a LEMSA to adopt policies and procedures for calculating and reporting ambulance patient offload times (APOT).
2. Requires, instead of authorizes, a LEMSA to develop and submit an EMS system plan to the Emergency Medical Services Authority (EMSA). That LEMSA and EMSA must make each plan accessible on their respective internet websites within 30 days of the plan’s approval by EMSA.
3. Requires a LEMSA to make the annual EMS plan the LEMSA is already required to submit to EMSA accessible on the LEMSA’s internet website within 30 days of approval by EMSA. EMSA must also make each submitted plan available online within 30 days of approval.

FISCAL EFFECT:

1. Minor and absorbable costs to EMSA to post specified information on its website.
2. Although this bill requires a LEMSA to undertake specified duties, this bill does not create a state-mandated local program because a county is only required to have a LEMSA if the county has an EMS program, and existing law does not require (only authorizes) a county to develop an EMS program. Thus, a county does not need to follow this bill’s requirements if the county does not have an EMS program.

COMMENTS:

1. Purpose. According to the author:

Maintaining timely 911 response times and efficient APOT is essential to ensuring that residents receive the medical care they need in a timely manner. By requiring LEMSAs and EMSA to post approved plans on their websites, we can increase transparency for policymakers, stakeholders and residents who want to see how their emergency management officials are planning for their care.

1. LEMSAs. California has 34 LEMSAs (single county or multi-county regions) with an EMS system and plan. Essential functions performed by LEMSAs include coordinating prehospital and hospital services, certifying EMS field personnel, developing medical treatment protocols for local EMS service providers, and designating trauma centers. Existing law requires a LEMSA to annually submit its EMS plan, in accordance with EMSA’s EMS Systems, Standards, and Guidelines, to EMSA for approval. EMSA is currently undergoing the process to adopt these guidelines as regulations. According to the Assembly Emergency Management Committee’s analysis of this bill, “Based upon information available on EMSA’s and LEMSA’s internet websites, many EMS plans are not being updated on an annual basis and there are several instances of EMSA taking an unduly amount of time to approve such plans.” This bill requires each LEMSA to make its annually updated EMS plan accessible on its website within 30 days of approval by EMSA, which must also post the plan online in that timeframe.
2. APOT Standards. Each year, approximately 70,000 Californians wait over an hour on an ambulance gurney once they arrive at the hospital and before care is assumed by emergency department staff and the patient is moved to a hospital bed. APOT is the interval of time between when the patient arrives at the hospital and is transferred into the hospital’s care. AB 1223 (O’Donnell), Chapter 379, Statutes of 2015, and AB 2961 (O’Donnell), Chapter 656, Statutes of 2018, required EMSA to adopt a statewide standard methodology for calculation of APOT and calculate APOT by each facility within a jurisdiction. With stakeholder input, EMSA targeted 20 minutes as a maximum APOT, but concluded that, with only two years of data derived from disparate sources, it was premature to draw conclusions about what corrective measures are most practical and acceptable.

AB 1229 (Rodriguez), of the 2021-22 Legislative Session, would have required EMSA to convene a task force to evaluate and improve APOT delays, but was held on this committee’s suspense file. However, on November 1, 2021, the APOT Committee was established for key stakeholders across the state to provide advisory recommendations to the California Department of Public Health and EMSA on how to best mitigate APOT delays. The committee made 19 recommendations, including promulgation of a statewide standard of 20 minutes, 90% of the time, for APOT calculations of all LEMSAs

Existing law allows a LEMSA to adopt policies and procedures for calculating and reporting APOT using the statewide standard methodology. The adopted policy must include criteria for the reporting of, and quality assurance follow-up for, non-standard patient offload time (any delay past the 20 minute APOT guideline). This bill requires a LEMSA to adopt such policies and procedures. Although this bill does not require the APOT policy to be posted online, the author’s office notes that the policy is usually included as part of a LEMSA’s EMS plan, which this bill requires to be posted online. However, as discussed above, EMSA is still developing regulations for EMS plan content.

1. Related Legislation. AB 40 (Rodriguez), amongst other provisions, requires every LEMSA to develop a standard not to exceed 30 minutes, 90% of the time, for APOT and requires specified hospitals to develop an APOT reduction protocol by June 1, 2024. AB 40 is pending hearing in this committee.

Analysis Prepared by: Irene Ho / APPR. / (916) 319-2081

Date of Hearing: April 17, 2023

ASSEMBLY COMMITTEE ON EMERGENCY MANAGEMENT

Freddie Rodriguez, Chair

ABPCA Bill Id:AB 379 (

Author:Rodriguez) – As Amended Ver:March 23, 2023

SUBJECT: Emergency medical services

SUMMARY: Would require the California Emergency Medical Services Authority (EMSA) and Local Emergency Medical Services Authorities (LEMSAs) to post approved annual plans on their respective public websites. The bill would also require that LEMSAs adopt a procedure for calculating and reporting their ambulance patient offload times (APOT). Specifically, this bill:

1. Requires local emergency medical services agencies to adopt policies and procedures for calculating and reporting ambulance patient offload time, as defined.
2. Requires the local EMS agency, in each designated EMS area, to develop and submit a plan to the authority for an emergency medical services system according to EMSA guidelines.
3. Requires each local EMS agency to make EMS system plans accessible on the agency’s internet website within 30 days of approval by the authority.
4. Requires EMSA to make each local EMS agency’s EMS system plan accessible on EMSA’s internet website within 30 days of approving such plans.

EXISTING LAW:

1. Allows local emergency medical services (EMS) agencies to adopt policies and procedures for calculating and reporting ambulance patient offload time, as defined. (Health and Safety Code Section 1797.225)
2. Requires local EMS agencies that adopt such policies and procedures to, use the statewide standard methodology for calculating and reporting ambulance patient offload time developed by the authority and establish criteria for the reporting of, and quality assurance followup for, a nonstandard patient offload time. (Health and Safety Code Section 1797.225)
3. Allows a local EMS agency, in each designated EMS area, to develop and submit a plan to the authority for an emergency medical services system according to EMSA guidelines. (Health and Safety Code Section 1797.250)
4. Requires EMSA to develop planning and implementation guidelines for emergency medical services systems which address the following components: manpower and training; communications, transportation; assessment of hospitals and critical care centers; system organization and management; data collection and evaluation; public information and education; and disaster response. (Health and Safety Code Section 1797.103)
5. Requires local EMS agencies to annually submit an emergency medical services plan for the EMS area to the authority, according to EMS Systems, Standards, and Guidelines established by EMSA. (Health and Safety Code Section 1797.254)

FISCAL EFFECT: Unknown.

COMMENTS:

Purpose of the bill: According to the author, “Local Emergency Medical Services Authorities are responsible for planning, coordinating, and improving local emergency and medical response systems. LEMSAs mainly work to organize prehospital services. Local EMS plans lay out policies for system organization and management, staffing and training, communication, response and transportation for emergency services, facilities and critical care, data collection and system evaluation, public information and education, disaster medical response, and more.”

The author adds, “Maintaining timely 911 response times and efficient APOT is essential to ensuring that residents receive the medical care they need in a timely manner. By requiring LEMSAs and EMSA to post approved plans on their websites, we can increase transparency for policymakers, stakeholders and residents who want to see how their emergency management officials are planning for their care.”

“Current law states that LEMSAs may establish policies and procedures for calculating and reporting APOT, but does not require it. Because APOT plays a pivotal role in how quickly EMS workers are able to respond to a 911 call, requiring LEMSAs to establish these metrics is a critical component of emergency planning,” the author concludes.

Equity Impact: According to the author’s staff, “the lack of available emergency medical services resources in the community often leads to longer response times. Unfortunately, the most vulnerable are often times disproportionally impacted by a lack of response resources in a community. Greater transparency of local EMS plans will help those who seek to mitigate inequities in local EMS systems.”

The Emergency Medical Services Authority (EMSA): EMSA is charged with providing leadership in developing and implementing EMS systems throughout California and setting standards for the training and scope of practice of various levels of EMS personnel. The EMS Authority also has responsibility for promoting disaster medical preparedness throughout the state, and, when required, coordinating and supporting the state’s medical response to major disasters. According to EMSA, emergency and disaster medical services in California are rooted in the skills and commitment of the first responders, EMTs, nurses, physicians, and administrators who deliver care to the public and operate the system.

In California, day-to-day EMS system management is the responsibility of the local and regional EMS agencies. It is principally through these agencies that the EMS Authority works to promote quality EMS services statewide. EMS Authority staff also work closely with many local, state and federal agencies and private enterprises with emergency and/or disaster medical services roles and responsibilities.

Local EMS Agencies (LEMSAs): California's EMS Act authorizes each county to develop an EMS program and to designate a LEMSA that oversees the delivery of EMS within that geographic area. This level of governance allows for local control of emergency medical services that is desirable in a state as large and diverse as California. Essential functions performed by local EMS agencies include, among other things: planning, implementing, evaluating, and continually improving local EMS systems including prehospital services and relevant hospital services such as trauma and pediatrics; collaborating with other health officials to ensure a unified, coordinated approach in the delivery of health care; carrying out regulations relative to EMS systems; certifying, accrediting, and authorizing EMS field personnel; developing medical treatment protocols and policies for local EMS service providers (EMTs, paramedics, dispatchers); and designating trauma centers and other specialty care centers.

According to EMSA, “All 33 LEMSAs (single county or multi county regions) have developed an EMS system and plan, implement, and evaluate their EMS systems in accordance with HSC 1797.204. The LEMSAs submit their EMS plans to the Authority for approval. The LEMSAs, upon request, evaluate cities and fire districts for compliance with HSC 1797.201, and create exclusive operating areas pursuant to HSC 1797.224 where applicable. The procedures and provisions for carrying out the responsibilities noted above have been specified in state guidelines and county policies and procedures, and adhered to voluntarily over the years.

Status of EMSA planning and implementation guidelines: As noted above, Health and Safety Code 1797.103 requires EMSA to develop planning and implementation guidelines for EMS systems which address the following eight components: manpower and training; communications; transportation; assessment of hospitals and critical care centers; system organization and management; data collection and evaluation; public information and education; and disaster response.

In 1985, the Authority developed, and the Commission approved, EMS System Standards and Guidelines to provide guidance to LEMSAs in the planning, organization, management, and evaluation of local EMS systems, and to provide an evaluation and education mechanism for the Authority, elected officials, and interested parties. These standards and guidelines were revised over the ensuing years with input from EMS stakeholders and received approval from the Commission, but were never formally adopted as regulations. In 2012, EMSA formed a committee and invited affected stakeholder organizations to appoint a member to begin the process of updating the standards and drafting proposed regulations. Due to a lawsuit, the work of this Committee was suspended in 2015, but resumed again in late 2016.

In 2019, petitions were filed with the Office of Administrative Law asking for a determination as to whether three of EMSA’s documents related to Exclusive Operating Areas amounted to underground regulations. In response, the Authority certified and agreed that it would not use or enforce the documents. The Authority subsequently began the process of promulgating regulations to cover the guidelines authorized and required in accordance with Health and Safety Code Section 1797.103.

According to EMSA, “these regulations will provide clarity and specificity in the implementation of the EMS system standards and guidelines. The regulations will assist local governments in the implementation and maintenance of their EMS systems by providing clear and enforceable standards. The regulations will also provide the necessary resources for EMSA to effectively evaluate the local EMS systems in California in order to carry out its responsibilities for oversight of the EMS System to ensure protection of the public health and safety (HSC 1797.103).”

At the March 15, 2023 meeting of the California EMS Commission, EMSA reported that it was reviewing previously submitted comments and developing a new draft of updated regulations for annual EMS plans.

Annual LEMSA plans: Based upon information available on EMSA’s and LEMSA’s internet websites, many EMS plans are not being updated on an annual basis and there are several instances of EMSA taking an unduly amount of time to approve such plans. For example, according to EMSA:

1. Alameda County’s most recent EMS Plan for 2018 was submitted on November 18, 2019 and approved by EMSA on January 2, 2020. The next plan update was due on January 31, 2020.
2. Central California’s most recent EMS Plan for 2019 was submitted on September 12, 2019 and approved on February 1, 2022. The next plan update was due on December 31, 2022.
3. Los Angeles’s most recent EMS Plan for 2017 was submitted on June 27, 2018 and approved on July 23, 2018. The next plan update was due on July 31, 2019.
4. Riverside’s most recent EMS Plan for 2018 was submitted on November 28, 2018 and approved on March 7, 2019. The next plan update was due on March 31, 2020.
5. San Diego’s most recent EMS Plan for 2018 was submitted on June 28, 2019 and approved on October 14, 2021. The next plan update was due on October 14, 2022.
6. Solano’s most recent EMS Plan update for 2011 was approved on February 1, 2013. It was unclear on when this plan was originally submitted for approval, but the next update of the plan was due on February 1, 2014.

In letters approving local EMS plans, EMSA includes the following information:

1. When EMSA received the last full plan approval from the local EMS agency;
2. The years in which EMSA has previously received EMS Plan submissions;
3. A reminder of “Health and Safety Code (HSC) § 1797.254 states: "Local EMS agencies shall annually (emphasis added) submit an emergency medical services plan for the EMS area to the authority, according to EMS Systems, Standards, and Guidelines established by the authority"
4. The following statement: “The EMS Authority is responsible for the review of EMS Plans and for making a determination on the approval or disapproval of the plan, based on compliance with statute, regulations, and case law, consistent with HSC § 1797.105(b).”

Defining Ambulance Patient Offload Time (APOT) and Ambulance Patient Offload Delay (APOD): The Ambulance Patient Offload Time for each transported 9-1-1 patient is defined as the “interval between the arrival of an ambulance at an ED and the time that the patient is transferred to an ED gurney, bed, chair or other acceptable location and the ED assumes responsibility for care of the patient.” The Ambulance Patient Offload Delay is anything past the 20 minute guideline recommendation for APOT as provided by Emergency Medical Services Authority (EMSA). APOT is most commonly captured electronically in the patient care record from the recorded time on arrival at the hospital (defined as wheel stop at the location where the patient is off-loaded), to the time of the electronic signature of the triage nurse after the physical removal of the patient from the ambulance gurney.

Scope of the Problem: Ambulance patient offload delays have been a concern in the health care community for some time due to the potential impact on patient safety and quality of care. According to EMSA, each year, roughly 70,000 Californians wait over an hour on an ambulance gurney once they arrive at the hospital and before their care is assumed by emergency department staff and moved to a hospital bed.

In a 2020 report to the Legislature, EMSA notes that the number of transports to a given hospital seems to directly correlate to their APOT. More transport typically means longer wait times. Generally, rural counties and their hospitals have significantly lower APOT than urban counties and their hospitals.

During the COVID-19 pandemic, almost all local EMS agencies experienced less transport overall but saw an increase in APOT compared to the prior year as hospitals saw an increased number of patients being admitted. With stakeholder input, EMSA targeted 20 minutes as a maximum APOT, but concluded that, with only two years of data derived from disparate sources, it is still premature to draw conclusions about what corrective measures are most practical and acceptable.

Impact on Patient Care and Experience: When pre-hospital providers must wait to transfer care to the ED staff, it creates issues of patient safety. The paramedics or emergency medical technicians (EMTs) must continue to care for the patient they brought to the ED, rather than transferring the patient to the higher level of care within a hospital ED.

Waiting for an open ED bed may lead to delays in medication administration and failure to meet standard of care for various treatments. Delays in patient throughput in the ED decreases hospital cost efficacy and increases subsequent hospital stays, both of which are of concern to hospital and have negative financial impact.

According to the National Association of EMS Physicians (NAEMSP), offload delays lead to delays to definitive care, poor pain control, delayed time to antibiotics, increased morbidity, and possibly even mortality. Ultimately, there is a reasonable concern that ambulance offload delay will compromise patient safety.

During last year’s Emergency Management Committee hearing on wall times, a representative from the Sacramento Fire Department testified about an incident where a fire department paramedic was performing CPR on a patient with two ambulances at a hospital around the corner waiting to transfer patient care for more than an hour. The Fire Department ultimately needed an ambulance from a neighboring jurisdiction to respond from eight miles away and three cities over, because other resources weren’t available. The ambulance sent to the scene was the 20th pick in terms of distance but was the closest available resource.

Impact on EMS Systems: The ambulance unit and staff that are delayed in the ED are effectively out of service, decreasing advanced life support coverage in the community, which can increase response time for subsequent critical cases, including cardiac arrest and major trauma. ED delays of the EMS professionals back up the entire system; dispatch centers have increased task times and EMS supervisors spend their time in the hospital attempting to make their units available.

The compilation of these additional non-productive unit-hours are costly to the company and to the community, since readiness accounts for a large portion of the cost associated with ambulance coverage in a community, and ambulance contracts mandate maximal response times to critical calls.

Related legislation: AB 40 (Rodriguez) of this Session. Would require EMSA to, among other things, to adopt emergency regulations to develop an electronic signature for use between emergency department and emergency medical personnel, a statewide 20 minute standard for patient offload times, and an audit tool to improve the accuracy of such data. (Set to be heard in the Assembly Health Committee on April 18, 2023)

AB 55 (Rodriguez) of this Session. Would increase the Medi-Cal fee-for-service reimbursement rate for emergency medical transports, as specified. (Set to be heard in the Assembly Health Committee on April 18, 2023)

AB 296 (Rodriguez) of this Session. Establishes a 911 public education campaign within the California Office of Emergency Services. (Set to be heard by the Assembly Committee on Communications and Conveyance on April 19, 2023)

Prior legislation: AB 1770 (Rodriguez) of the 2021-2022 Session. Would have required the Emergency Medical Services Authority (EMSA), in collaboration with the California Office of Emergency Services (Cal OES), California Department of Public Health (CDPH), and other entities as specified, to establish several policies to reduce ambulance patient offload delays and protect patients from unnecessary and life-threatening impacts to their overall health outcomes. (Died in the Assembly Health Committee)

AB 1229 (Rodriguez) of the 2021-2022 Session. Would have required the Director of the California Emergency Services Authority (EMSA) to establish a task force to address ambulance patient offload delays. (Held in the Assembly Committee on Appropriations.)

AB 2961 (O’Donnell), Chapter 656, Statutes of 2018. Requires a local EMS agency to submit quarterly data to EMSA. Also required EMSA to submit a report to the Legislature on ambulance patient offload time and recommendations to reduce or eliminate ambulance patient offload time.

AB 503 (Rodriguez), Chapter 362, Statutes of 2015. Authorizes health facilities to release patient-identifiable medical information to an EMS provider and LEMSA when specific data elements are requested for the purpose of quality assessment and improvement.

AB 1129 (Burke), Chapter 377, Statutes of 2015, 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.

AB 1223 (O’Donnell), Chapter 379, Statutes of 2015. Authorizes a local EMS agency to adopt policies and procedures relating to ambulance patient offload time, as defined. Requires the authority to develop a statewide standard methodology for the calculation and reporting by a local EMS agency of ambulance patient offload times.

REGISTERED SUPPORT / OPPOSITION:

Support

None on file.

Opposition

None on file.

Analysis Prepared by: Mike Dayton / E.M. / (916) 319-3802