HomeMy WebLinkAboutMINUTES - 08011989 - 2.2 4
TO BOARD OFSUPERVISORS n,,,,
Fes'' Mark Finucane �.�Jl ltra
I Health Services Director
DATE: August 1, 1989 COuv
SUBJECT: County Service Area for Emergency Medical Services
(Measure "H" Implementation)
SPECIFIC REQUEST(S) OR RECCMMENDATION(S) a BACKGROUND AND JUSTIFICATION
RECOMMENDED ACTION
Approve Proposal and Service Plan to create a County Services Area (CSA) for Emergency
Medical Services as recommended by the Health Services Director.
FINANCIAL IMPACT
The establishment of a County Service Area for emergency medical services will enable
the Board to place annual assessments on real property to fund the cost of improvements
in the emergency medical services system. The actual assessments would be set by the
Board following creation of the CSA. Based upon the budget illustration contained in
the attached service plan, an assessment of $5.35 per benefit unit would raise
approximately $2,568,000 for FY 1990-91, $2,140,000 of which would be used to fund
service improvements. The remaining funds would be for administrative and collections
costs ($214,000) and a contingency reserve ($214,000).
BACKGROUND
On July 18, 1989 your Board directed staff to prepare for Board approval an application
to the Local Agency Formation Commission to establish a countywide CSA for emergency
medical services and authorized the Chair to invite each city council to adopt a
resolution to include its territory within the CSA. The attached Proposal and Service
Plan were prepared with input from various groups and organizations including the
Emergency Medical Care Committee, Fire Chiefs Association, Police Chiefs Association,
and Public Managers Association. A draft was reviewed at a public meeting held by the
Health Services Department on June 29, 1989. A final draft was reviewed and approved
by the Measure "H" Implementation Task Force on July 26, 1989.
Following approval by the Board, the Proposal and Service Plan will be distributed to
each city council and will be included as a part of the LAFCO application. In addition
to the Proposal and Service Plan each city will be provided with an account of the
benefits of the CSA pertaining to that jurisdiction. Copies of materials sent to the
cities will be provided to Board members.
CONTINUED ON ATTACHMENT] YES SIGNATURE' /
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
APPROVE OTHER
SIGNATUR S :
ACTION OF BOARD ON APPROVED AS RECOMMENDED A OTHER
VOTE OF SUPERVISORS
1 HEREBY CERTIFY THAT THIS IS A TRUE
�( UNANIMOUS (ABSENT r AND CORRECT COPY OF AN ACTION TAKEN
AYES: NOES: AND ENTERED ON THE MINUTES OF THE BOARD
ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN..
CC: Health Services Department ATTESTED _ AUG 1 1989
Emergency Medical Services --— ----
County Administrator PHIL BATCHELOR, CLERK OF THE BOARD OF
County Auditor /BUJ SUPERVISORS AND COUNTY ADMINISTRATOR
M382/1-83
BY_ (� •�/r/� �r.P...,� .DEPUTY
7/27/89
COUNTYWIDE EMERGENCY MEDICAL SERVICES BENEFIT ASSESSMENT
(Measure "H")
SUMMARY
Measure "H" - Countywide Emergency Medical Services
- Advisory measure passed by the
voters 71.6% countywide in November VOTER SUPPORT FOR nERSuRE °H"
1988. Couniyuideeh 71 .5
8rRiiuood ° J
- Provides for an annual countywide on�1O9
property assessment for improved ElDgtoa
Hercu es 7-
emergency medical services. Laigeata
MaSrMz 7C?2
- Assessment limited to $10.00 per pleaPi tsZn 5'qu 6b7� 7
residence or benefit unit, with a Ric"McR �r z
limit of $5.50 for the first year. �anan amao ° 6
o
unin�oraora�e 1 70.
- Would raise about $2.5 million at o 20 40 60 80 ICO
a $5.35 assessment rate.
percent
- Funds will be used for new services
and service enhancements, not for subvention of existing County costs.
Goal
- Reduce deaths and complications by improving the response and level of
care provided victims of medical emergencies.
Benefits
- More PARAMEDIC AMBULANCE UNITS stationed throughout the county to respond
to life-threatening and potentially life-threatening emergencies.
PARAMEDIC AMBULANCE response to ALL 9-1-1 medical emergencies.
Improved RESPONSE times to medical emergencies - 95 percent of
responses within 10 minutes for urbanized areas (including all
cities) .
- Improved AMBULANCE DISPATCHING.
Direct linkages between 9-1-1 medical/fire dispatch centers and the
ambulance dispatch center to REDUCE DISPATCHING DELAYS AND ERRORS.
- MEDICAL DISPATCHER TRAINING to improve PRIORITY SETTING and to enable
medical dispatchers to give PREARRIVAL INSTRUCTIONS to callers to initiate
critical lifesaving procedures prior to arrival of rescuers.
1
- DIRECT RADIO COMMUNICATIONS between responding FIRE and AMBULANCE units
to enable first responders to provide critical information to responding
paramedics (e.g. ; updated patient condition, revised location).
- Improved PARAMEDIC TO HOSPITAL COMMUNICATIONS to communicate with and
receive medical instructions from their base hospitals.
- Funding for a first responder EARLY DEFIBRILLATION program to benefit
heart attack victims.
- Improved medical FIRST RESPONDER TRAINING for firefighters.
- Funding to establish caches of first aid equipment and supplies to be
maintained by the fire services in COMMUNITIES throughout the county for
use in response to a DISASTER or. MULTICASUALTY incident.
Implementation of Measure "H"
Implementation of Measure "H" will require the cooperation of the County
and all of the cities. To establish a countywide County Service Area
(CSA) for emergency medical services, the following steps must be taken:
- Approval by Board of Supervisors and application to the Local Agency
Formation Commission (LAFCO) .
- Resolution by each city council to join the proposed CSA.
- Approval by LAFCO following a public hearing.
- Establishment of the CSA by the Board of Supervisors following a
public hearing.
Once the CSA is established, the budget and assessment rate would be
established annually by the Board of Supervisors.
Timing
- To begin implementing services by July 1, 1990, the CSA must be formally
established by December 31 , 1989.
- In order to meet this schedule, CITY COUNCIL RESOLUTIONS will need to be
passed during AUGUST and SEPTEMBER 1989. Consideration by LAFCO of the
completed application, including city resolutions, is planned for October
1989.
Oversight
An OVERSIGHT COMMITTEE will be established to provide ongoing advice to
the Health Services Department in budget preparation and program review.
This committee is proposed to include representatives from the Public
Managers' Association, Emergency Medical Care Committee, Fire Chiefs'
Association, Police Chiefs' Association, and East Bay Hospital Conference.
The Oversight Committee will participate in the ambulance proposal review
and selection process, including review of plans for the number paramedic
units and location of ambulance stations.
2
1
FIRST YEAR BUDGET ILLUSTRATION
PARAMEDIC SERVICE $ 1 ,600,000
Additional paramedic ambulance coverage 1 ,500,000
Additional base hospital coverage (4 zones) 100,000
MEDICAL FIRST RESPONDER SERVICE (Fire) 330,000
Early defibrillation program:
Purchase of automatic defibrillators and
related equipment 100,000
Defibrillation program training/coordination 90,000
EMT-I and related training/equipment/supplies 140,000
MEDICAL DISPATCH AND COMMUNICATIONS 210,000
Emergency medical dispatcher program
training/coordination 60,000
Enhancements at 9-1-1 medical dispatch
centers, (6 PSAP's) 100,000
EMS Communications Plan development 50,000
OPERATING BUDGET 2, 140,000
Administrative costs (10%) 214,000
Contingency reserve (10%) 2141000
TOTAL APPROPRIATION 2,568,000
ASSESSMENT RATE CALCULATION:
$2,568,000 / 480,349 benefit units = $5.35 per benefit unit
3
Comments on Budget Items
Subsidy for additional paramedic ambulance service. Estimated annual
subsidy cost for additional paramedic ambulance coverage. Actual subsidies will
be established following a competitive selection process conducted by the Health
Services Department and using a performance based Request for Proposal .
Base hospital services. Payments to base hospitals for additional cost
incurred for providing medical direction and quality assurance for an expanded
paramedic program.
Purchase of automatic defibrillators and related equipment. The total
equipment cost for implementing first responder defibrillation countywide is
estimated at $505,560 including 60 defibrillator units at $6,850 each, 5
training mannequins at $1 ,400 each, and 3 transcribers at $1 , 100 each.
Amortized at 8 percent over five years, this represents an annual cost of
approximately $100,000.
Defibrillation program training and coordination. Cost for a quarter-time
physician medical director and a full-time nurse trainer/coordinator to develop
and carry out first responder defibrillation training and required ongoing
monitoring.
Other medical training, equipment, and supplies. Funds budgeted under
this category will be used to reimburse fire services according to priorities
established only up to the amount budgeted. Priority will be for training
necessary for first responder personnel to qualify for EMT-I certification or
other EMS approved first responder certification and for purchase of first aid
supplies for multicasualty/disaster caches.
Emergency medical dispatcher program training and coordination. Cost of
a full-time coordinator/trainer to develop and carry out medical dispatcher
training and conduct appropriate monitoring.
Enhancements at 9-1-1 medical dispatch centers. Funds will be available
to existing fire/medical dispatch centers (Richmond, West Bay, Consolidated
Fire, Sheriff' s Dispatch, DRCC, and San Ramon Valley) for improvements in
ambu.lance dispatching.
EMS Communications Plan. Estimated cost for development of a long range
EMS communications plan including ambulance-to-hospital communications and
ambulance dispatch.
Administrative costs. Ten percent of the operating budget will be
allocated for additional administrative costs including overhead and collection
of fees.
Contingency reserve. A ten percent reserve will be maintained for
unanticipated program costs.
4
Table 1
AMBULANCE LOCATIONS
AIS Units BLS Units ALS Units BLS Units
(Paramedic) (FbIT-i) (Paramedic) (EMT-1)
Regional Ambulance: San Ramon Valley Fire:
Richmond 1 1 San Ramon 1 2
San Pablo 1 4 Danville 1 1
Pinole 1 1 Blackhawk 1
Martinez 1 2
Concord 1 2
Walnut Creek 1 2
Lafayette 1 2 Moraga Fire 1 1
Pittsburg 1 1
Antioch 1 1
Brentwood 1 -
TOTAL 13 22
Table 2
EMERGENCY AMBULANCE RESPONSES
Number Percent
Regional Ambulance 23,543 90
San Ramon Valley Fire 2,095 8
Moraga Fire 520 2
Total 31,501 100
Table 3
DEFICIENCIES IN EMERGENCY AMBULANCE COVERAGE
(Estimates based upon annual emergency responses in areas served by Regional Ambulance)
Number Percent
Countywide
Emergency Ambulance Responses 29,000 100
No paramedic ambulance 4,350 15
Response over 10 minutes 3,430 12
West County
Emergency Ambulance Responses 12,000 100
No paramedic ambulance 2,640 22
Response over 10 minutes 1,080 9
Central County
Emergency Ambulance Responses 10,000 100
No paramedic ambulance 900 9
Response over 10 minutes 1,600 16
East County
Emergency Ambulance Responses 7,000 100
No paramedic ambulance 840 12
Response over 10 minutes 700 10
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PARAMEDIC AMBULANCE COVERAGE
EXISTING PARAMEDIC UNITS
CIRCLES DEPICT APPROXIMATE t 'yam •+
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10 - MINUTE RESPONSE ZONES
CONTRA COSTA COUNTY
CALIFORNIA
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PARA•IEDIC AMBULANCE COVERAGE
PROPOSED COVERAGE (ILLUSTRATION ONLY) /
CIRCLES DEPICT APPROXIMATE
10 h11NUTE RESPONSE ZONES \ •, �
CONTRA COSTA COUNTY
CALIFORNIA
6
Contra Costa County Ballot Measure, November 8, 1988
MEASURE "H" - EMERGENCY MEDICAL SERVICES
(Advisory Measure)
Shall a Countywide Emergency Medical Services benefit assessment be
established to finance improvements in the emergency medical and trauma care
system including expanded countywide paramedic coverage; improved medical
communications and medical dispatcher training; and medical equipment,
supplies, and training for firefighter first responders, including training
and equipment for fire services electing to undertake a specialized program of
advanced cardiac care (defibrillation) ; said assessment to be limited to a
maximum assessment on real property of ten dollars annually for each single
family residence or benefit unit as defined in Resolution No. 88-500, a copy
of which is contained in the Voter Information Pamphlet, and said assessment
to be initially set at five dollars and fifty cents per benefit unit, subject
to review following a public hearing on the assignment of benefit units and
services to be financed, the public hearing and review to be conducted prior
to the initial assessment and annually thereafter?
7
S EMERGENCY MEDICAL CARE COMMITTEE
OF CONTRA COSTA COUNTY
EMERGENCY MEDICAL SERVICES
50 Glacier Drive
Martinez,California 94553-4822
(415) 646-4690
CONTRA COSTA COUNTY EMERGENCY MEDICAL CARE COMMITTEE
RESOLUTION SUPPORTING THE ESTABLISHMENT OF A
COUNTYWIDE COUNTY SERVICE AREA FOR
EMERGENCY MEDICAL SERVICES
WHEREAS. the Emergency Medical Care Committee (EMCC) has been established
by the Board of Supervisors as an advisory committee to the Board and to the
County Emergency Medical Services (EMS) Agency on matters relating to
emergency medical services ;
WHEREAS the voters of Contra Costa County passed by 71 .6 percent Measure
"H" , an advisory measure on the November 1988 countywide ballot, calling for
the establishment of a benefit assessment to finance improvements in the
emergency medical and trauma care system including expanded countywide
paramedic coverage, improved medical communications and medical diSpatcher
training, and medical equipment, supplies , and training for firefighter first
responders , including training and equipment for a first responder
defibrillation program;
WHEREAS the EMCC has developed and approved a plan of "Recommended EMS
System Priorities" to improve the level of emergency medical services ,
including improved paramedic ambulance service, emergency medical dispatch and
communications , first responder training and defibrillation, and overall EMS
system organization and management including support of the county trauma
system; and
WHEREAS the County Health Services Department, which is the Board
designated Local EMS Agency, has developed plans and proposals to form a
County Service Area for Emergency Medical Services ;
BE IT THEREFORE RESOLVED that the EMCC endorses the formation of a
countywide County Service Area for the purpose of establishing a benefit
assessment for emergency medical services as proposed in Measure "H" and that
the Board of Supervisors and each city council take the appropriate actions to
form the proposed County Service Area.
Passed Jul,/ 12 , 1989 AYES 16 NO 0 ABSTAIN 0
r
Attest. 1 F. - 1 - t •-L;
Mic ael E . Mickelberry
EMCC Chair \J
CONTRA COSTA COUNTY FIRE CHIEFS ASSOCIATION
RESOLUTION 89-02
WHEREAS the fire service in- Contra Costa County is a primary
provider of Emergency Medical and Rescue Services to the
citizens of Contra Costa County; and
WHEREAS the County Fire Chiefs Association recognizes the need to
improve emergency medical services by development of an organized
and coordinated EMS system in Contra Costa County; and
WHEREAS Contra Costa County has developed plans and proposals to
form an Emergency Medical Services District to mitigate
deficiencies in delivery of emergency medical services by improv-
ing ambulance response, first responder training and equipment,
communications and other needed EMS programs; and
WHEREAS the voters have overwhelmingly approved formation of an
independent Emergency Medical Services District in Contra Costa
County;
BE IT THEREFORE RESOLVED that the Contra Costa County Fire Chiefs
Association endorses the formation of an Emergency Medical Serv-
ices District as defined in Ballot Measure H and encourages all
City Councils in Contra Costa County to adopt resolutions to in-
clude their city in the Contra Costa County Emergency Medical
Services District.
----------------------------------------------------------------
I hereby certify that the foregoing
is a true and correct copy of a
resolution entered on the minutes
of the Contra Costa County Fire
Chiefs Association on this date.
___2LL2 L8 9 _ By:
Secreta y o the Contra Costa County
Fire Chiefs Association
o2. 1
CONTRA COSTA COUNTY
HEALTH SERVICES DEPARTMENT
EMERGENCY
MEDICAL
SERVICES
CSA EM-1
Proposal and Service Plan
To Create a County Service Area for
Emergency Medical Services
(Measure "H")
DRAFT
7/27/89
TABLE OF CONTENTS
Page
I. Purpose . . . . . . . . . . . . . . . . .•. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
II. Legal Basis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
M. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
IV. The Existing Emergency Medical Services System . . . . . . . . . . . . . . 3
V. Areas for Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
VI. Service Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Exhibit A
Measure "H" (Ballot Measure)
Exhibit B
EMCC Resolution of Endorsement and Recommended EMS System
Priorities
Exhibit C
County Fire Chiefs' Association Resolution of Endorsement
Recommendations on the Emergency Medical Services Benefit Assessment
Exhibit D
Budget Mustration
I. PURPOSE
The purpose of the proposed County Service Area (CSA)is to reduce deaths and complications
resulting from medical emergencies in Costra Costa County by making needed improvements in the
County's existing Emergency Medical Services System and to assure the continued availability of high
quality emergency medical and trauma care services throughout all parts of the County. In order to
accomplish this purpose, the CSA will assess fees on real property to fund:
-Ambulance subsidy costs necessary to assure availability of Advanced Life
Support (paramedic) ambulance service for timely response to all medical
emergencies.
-Improvements in the communications systems necessary to assure efficient
ambulance dispatching and hospital medical direction for paramedic units
in the field.
-Training for medical dispatchers in giving prearrival instructions and
recognizing the level of urgency for different medical emergencies.
-Specialized medical training and equipment for designated fust responders,
including a first responder early defibrillation program.
-Stockpiling caches of fust aid equipment and supplies to be maintained by
the fire services in communities throughout the county for use in response
to disasters and multicasualty incidents.
-Other improvements as may be needed from time to time in the countywide
emergency medical and trauma system.
II. LEGAL BASIS
The County Services Area Act(Government Code Sections 25210 et. seq.) allows a county board
of supervisors to create a county service area (CSA) for emergency medical services to include advanced
life support paramedic services and to finance the service area with a benefit assessment. The territory of
an incorporated city may be included within the CSA by a majority vote of the city council.
Authority for a county to establish an integrated emergency medical services system, including
advanced life support (ALS) paramedic services, is contained in the Emergency Medical Services Act
(Health and Safety Code Sections 1779 et. seq.). The Board of Supervisors in 1983 (Resolution #83/310)
designated the Health Services Department as the Local Emergency Medical Services Agency and the
County Health Officer as its Medical Director.
1
HI. BACKGROUND
In August 1988, the Board of Supervisors placed an advisory measure (Exhibit A)on the November
1988 countywide ballot to determine the support for a countywide emergency medical services benefit
assessment on real property, not to exceed $5.50 per benefit unit or single family residence for the first year
and not to exceed $10.00 annually thereafter. This action was taken in response to recommendations from
the County's Emergency Medical Care Committee, recommendations of a Board appointed Committee on
Funding County Programs, and in response to reported community concern over the lack of adequate
response in some areas to requests for emergency medical assistance received through the 9-1-1
emergency telephone system.
Specifically, Measure "H" asked voters if a countywide Emergency Medical Services benefit
assessment should be established to finance improvements in the emergency medical and trauma care
system including:
-Expanded countywide paramedic coverage,
-Improved medical communications and medical dispatcher training, and
-Medical equipment, supplies, and training for firefighter first responders,
including a specialized program of advanced cardiac care (first responder
early defibrillation).
The measure received the support and
endorsement of diverse political, medical, public VOTER SUPPORT FOR NERSURE "H"
safety, and taxpayer groups, including the American
Countywide 71 .5
Heart Association, County Taxpayers Association, Fn t i oc� 6'
8r ptuoo n
Alameda-Contra Costa Medical Society, County Fire to
^n� 8
Chiefs Association, Regional Ambulance Service, firnvtQ�e •?
eer
fighter associations, hospitals, as well as numerous EI
Hercur eos 7'
individual paramedics, public safety personnel,
tMartinnb� �z 7q
physicians, nurses, and public officials. Voter support r:na5a •2
countywide totaled 71.6 percent. Within every pleasI 15"�i1? 6Ey2,7
3:no
municipality in the county, voter support exceeded 66 SRicSmosS �f
percent. (See Figure 1.) San 3ame �, 1
uninco�ao�aie 7�
Following the election, an Implementation 0 20 40 60 80 100
Task Force was formed and the Board of Supervisors percent
directed the Health Services Department to proceed
with the steps necessary to implement Measure "H". Figure 1
Included on the Implementation Task Force were
representatives from the County Administrator's Office
and other County departments which would have involvement in establishment of the CSA,representatives
from the Public Managers' Association, the chief of Consolidated Fire, and the chair of the Emergency
Medical Care Committee. The County Emergency Medical Care Committee (EMCC) and the County Fire
Chiefs Association were asked by the Health Services Department to review EMS priorities and to submit
their recommendations to be used in development of the Measure "H"service plan. The recommendations
of the EMCC and the Fire Chiefs are contained in Exhibits B and C, respectively. Both organizations have
endorsed the formation of the proposed CSA and have urged the Board and city councils to take the
appropriate actions to form a countywide Emergency Medical Services District.
2
In addition to the close involvement of the Implementation Task Force, the EMCC, and the Fire
Chiefs Association in developing this proposal and service plan, the Health Services Department has made
presentations and sought input from the Mayors' Conference, the Public Managers Association, and the
Police Chiefs Association. Apublic meeting was held to provide an opportunity for all concerned individuals
to provide comment on the proposed CSA.
IV. THE EXISTING EMERGENCY MEDICAL SERVICES SYSTEM
The County's existing EMS system is administered by the Health Services Department as the
designated Local EMS Agency in accordance with the County Emergency Medical Service Plan; the County
Trauma System Plan; applicable State statutes and regulations; the County Ambulance Ordinance; County
contracts for emergency ambulance service, base hospital services, and trauma center services; and County
EMS policies, procedures, and protocols. The major components of the EMS system include:
-Communications, including 9-1-1 access, medical dispatch, and ambulance-
to-hospital communications.
-Medical fust responders - fire service or other public safety agency.
-Medical transport services, including ground and air ambulance.
-Base hospitals to provide medical direction to paramedics in the field.
-Hospital emergency facilities which receive patients transported by
ambulance.
-The trauma center, which provides definitive care to seriously injured
patients.
-Training facilities which provide training to prehospital care personnel.
-The Emergency Medical Care Committee (EMCC) appointed by the Board
of Supervisors to advise the EMS Agency and the Board on EMS matters.
-The local EMS Agency, which provides overall coordination and
administration of the system.
Emergency Medical Communications and Dispatch
EMS communications begins with the 9-1-1 system used by the public to report law enforcement,
fire,and medical emergencies. Nine-one-one calls in Contra.Costa County are answered by a local Public
Safety Answering Point (PSAP), usually a part of a local police or combined police/fire dispatch center.
Depending upon the jurisdiction, medical emergencies are either handled by the PSAP answering the call
or transferred to a secondary PSAP which handles fire and medical emergencies. An operator interrogates
3
the caller and, if there is a medical emergency, dispatches or requests dispatch of the appropriate medical
resources - usually a fire engine as fust responder and an ambulance. The six PSAP's or secondary
PSAP's which handle medical 9-1-1 calls for their respective jurisdictions are:
- Richmond Police Department
- West Bay Dispatch (Pinole Police)
- Sheriffs Dispatch Center (Comm-1)
- Consolidated Fire District
- Delta Regional Communications Center (East County)
- San Ramon Valley Fire District
These medical dispatch centers are responsible for interrogating the caller to determine the nature
and location of the medical emergency, dispatching a fust responder, and requesting the designated
ambulance provider to dispatch an ambulance. Except in Moraga, San Ramon Valley, and east County
areas served by DRCC,requests for an ambulance response are made by voice telephone from the medical
dispatch center to the ambulance company dispatch center which, in turn, dispatches the nearest available
ambulance by telephone or radio. (InMoraga and San Ramon Valley where ambulance service is provided
by the fire district, ambulance dispatch is handled directly by the medical dispatch center. In east County
areas served by DRCC,the ambulance request is handled through the DRCC computer with a terminal
located in the ambulance service dispatch center.) While most 9-1-1 dispatch centers have computer aided
dispatch systems which enable the dispatcher to "capture" the location of the call directly from the 9-1-1
system and transmit the call information directly to the appropriate fire station to initiate a fire response, the
ambulance dispatch must be initiated by a voice telephone call. This results in delays from a few seconds
up to several minutes, especially when multiple emergencies are being handled, and sometimes results in
dispatch errors when addresses are miscommunicated.
In many areas of the country, emergency medical dispatchers receive special training enabling them
to employ a system of PRIORITY DISPATCHING and PREARRIVAL INSTRUCTIONS. State
guidelines and County standards for emergency medical dispatching and dispatcher training have been
have been in effect since 1986. Under a system of priority dispatching, medical dispatchers are trained to
identify those 10 to 20 percent of emergency medical calls which are clearly non-life-threatening. These
requests need a prompt ambulance response to transport a patient to the hospital, but do not require the
full response of a fire first responder and paramedic-staffed ambulance. By identifying at the time of
dispatch those calls which do not need a fullfireand paramedic ambulance response, emergency resources
can be kept available to respond to potentially life-threatening emergencies.
Dispatchers trained in priority dispatching are often also trained in a program of providing callers
with prearrival instructions on how to assist the patient while waiting for help to arrive. These programs
have proven effective in directing often hysterical or frenzied callers to take such simple life saving steps as
repositioning the patient to open a blocked airway or administering abdominal thrusts on a chocking victim.
Of the six medical dispatch centers in Contra Costa County, only Consolidated Fire has implemented priority
dispatching and prearrival instructions.
Once the ambulance is en route to the medical emergency, the ambulance crew notifies Sheriff's
dispatch, which continues to track the ambulance as it arrives on the scene, leaves the scene en route to
the hospital, and arrives at the hospital. The MEDARS radio system operated by the County consists of
two channels - one for ambulances to communicate with Sheriffs Dispatch for tracking and one for
ambulances to communicate with hospitals. , A system of hilltop repeaters provides communications
capability throughout most areas of the County.
4
Ambulance-to-bospital communication is a vital component of emergency medical services and
serves two functions: prearrival notification to the hospital emergency department so that appropriate
medical personnel are ready to receive the patient; and communication between paramedics treating a
patient in the field and the base hospital physician or Mobile Intensive Care Nurse (MICN) to provide
medical direction in the care of the patient. While many urban counties have one radio channel for hospital
prearrival notification and up to 8 channels on the widely used MEDCOM radio system for paramedics to
receive directions from their base hospitals, in Contra Costa only a single radio channel is available for both
purposes. To meet the deficiencies of the radio system, all paramedic units are now equipped with cellular
telephones to make base hospital contact. The use of cellular telephones, however, has not provided a full
solution since access to the system cannot be assured.
Medical First Responders - Fire Service
In Contra Costa, as is the practice throughout most of California, fire service responds as the first
responder on most medical emergencies. In addition to their role in rescue and extrication, fire personnel
are trained to provide CPR and basic first aid. The rapid response capability of fire servicein most areas
enables fire personnel to initiate critical life-saving measures prior to the arrival of ambulance personnel.
When critically injured or ill patients are transported by ambulance, fire first responders frequently
accompany the patient in the ambulance to assist with management of the patient while en route to the
hospital. Fire personnel also decide when to initiate medical helicopter transport for critically injured
patients who would otherwise have excessive transport times to the trauma center or other medical facility.
While all fire personnel in California are required to have training in first aid and CPR, many fire
personnel receive training, either voluntarily or by departmental or agency requirement, to the EMT-Ilevel.
In Contra Costa, the EMCC has recognized .EMT-I level training as a goal for first responders, while also
recognizing the need to provide more flexible.training opportunities especially for agencies which rely
heavily on volunteer firefighters. Some .agencies in Contra Costa do require EMT-I certification and some
may provide an equivalent level of training; however, it is estimated that only about one-third of the county's
fire fighters are currently EMT-I certified.
One emergency care program that has become available to fire fust responders under recently
adopted State regulations is EARLY DEFIBRILLATION. With only a few hours of training, fust
responders can learn to use one of the newly developed automatic defibrillators. These are similar to
devices carried by paramedics to administer an electric shock to convert the nonprofusing rhythm of a heart
attack victim to a normal sinus rhythm. More limited in its application the defibrillator carried by a
paramedic, the automatic defibrillator is designed to monitor the patient and automatically deliver the
appropriate shock only when clearly indicated. By reducing the time from onset of cardiac £ibrillationuntil
defibrillation by four to six minutes (typically the difference in arrival times between fire and ambulance),
the mortality rate from witnessed heart attacks for which help is immediately summoned and CPR initiated
can be cut in half. Currently, in Contra Costa, only the Orinda Fire Protection District has established an
early defibrillation program. Other fire services, however, have expressed interest in undertaking such a
program.
Emergency Medical Transport - Ambulance Service
Simultaneously or immediately following fire dispatch, an emergency ambulance is dispatched to
every request for emergency medical assistance. Ambulances are staffed by two crew members - either
5
two paramedics trained and equipped to provide ADVANCED LIFE SUPPORT (ALS) or two EMT-I's
trained and equipped only to provide BASIC LIFE SUPPORT (BLS) level care. These ambulances
units are operated under contract with Contra Costa County by private or fire service providers in each of
five designated emergency response areas (ERA's). Current contractors are:
-Regional Ambulance Service serving ERA's I, II, and V covering
West/West-Central, East-Central, and East County, respectively.
-Moraga Fire Protection District serving ERA III covering the area of the
fire protection district.
-San Ramon Valley Fire Protection District serving ERA IV covering Alamo,
Danville, San Ramon, and the unincorporated areas of South County.
The emergency ambulance service contracts, which are awarded on a competitive basis, specify
minimum numbers of ambulance units which must be available for emergency response and require that
the contractor respond to 95 percent of emergency calls within 10 minutes for urban areas and 20 minutes
for designated rural areas. The contracts provide exclusive operating areas with respect to County-
dispatched calls, but provide no subsidy. In the areas served by Regional Ambulance Service and by San
Ramon Valley Fire, costs are borne in whole or in part by patient fees. Moraga Fire provides ambulance
service at no cost to the patient.
The level of ambulance service provided under the emergency contracts includes both advanced
life support (ALS) service provided by paramedic-staffed ambulance units and basic life support (BLS)
service provided by EMT-I staffed ambulance units. The distinction between AIS and BLS levels of
service is of critical importance. ALS service is provided by paramedics who have received some 1,000
hours of training and, operating under base hospital medical control, are able to bring much of the life-
saving capability of a hospital emergency department to the patient in the field. Paramedics can provide
electric shock to a.heart attack victim (defibrillation), intubate a nonbreathing patient to establish and
maintain an airway, surgically open a blocked airway, relieve an tension pneumothorax by needle
thoracotomy, apply medical anti-shock trousers to an accident victim with major blood loss, and administer
intravenous fluids and a wide selection of emergency drugs.
Paramedic programs must be approved by the County Emergency Medical Services Agency, which
is also responsible for certifying paramedic personnel, establishing the medical protocols under which
paramedics operate, and providing the overall medical direction and quality assurance.
BLS service, in contrast, is provided by EMT-I's who receive approximately 100 hours of training.
These personnel, who do not operate under base hospital medical control, are limited to "non-invasive"
emergency care including CPR. EMT-I's cannot administer drugs, cannot intubate, cannot apply medical
anti-shock trousers, cannot perform cricothyrotomy or needle thoracotomy, and, except under limited
circumstances and as part of a specially approved program, cannot defibrillate.
Currently, emergency ambulance service is provided by a combination of ALS and BLS units
stationed throughout the County as follows. Table 1 shows the locations of these units by city.
6
Table 1
AMBULANCE LOCATIONS
ALS Units BLS Units ALS Units BLS Units
(Paramedic) (EMT-I) (Paramedic) (EMT-I)
Regional Ambulance: San Ramon Valley Fire:
Richmond 1 1 San Ramon 1 2
San Pablo 1 4 Danville 1 1
Pinole 1 1 Blackhawk - 1
Martinez 1 2
Concord 1 2
Walnut Creek 1 2
Lafayette 1 2 Moraga Fire 1 1
Pittsburg 1 1
Antioch 1 1
Brentwood 1 -
TOTAL 13 22
All ALS (paramedic) units are dedicated to emergency response. BLS units operated by the fire
services are used for first response, providing patient transport only when a paramedic unit is not available
or when it is determined that paramedic level skills are not required. BLS units operated by Regional
Ambulance are used primarily for nonemergency transports (interhospital transfers, medical appointments,
discharges), but respond to medical emergencies when no nearby paramedic unit is available.
During 1988 there were some 31,158 requests for emergency ambulance response to life-
threatening or potentially life-threatening emergencies. (Table 2) Most of these requests, nearly 29,000,
were handled by Regional Ambulance with 10 dedicated ALS units and 16 BLS units used for both
emergency and nonemergency calls. San Ramon Valley Fire,with two ALS ambulance units and four BLS
units (used both for first response and transport of noncritical patients) responded to over 2,000 medical
emergencies; and Moraga Fire, with one ALS unit and one BLS unit, responded to over 500 medical
emergencies.
Table 2
EMERGENCY AMBULANCE RESPONSES
Number Percent
Regional Ambulance 28,543 90
San Ramon Valley Fire 2,095 8
Moraga Fire 520 2
Total 31,801 100
7
Approximately one-third of all emergency medical responses result in no patient transport. For the
most part, these involve potentially life-threatening incidents, such as reports of serious automobile
accidents, in which fortunately no one was injured. An additional one-third of emergency medical responses
involve transport of a patient who, while needing hospital attention, does not have a life-threatening or
potentially life-threatening condition. The remaining one-third - about 10,000 patients per year in Contra
Costa County - are transported to the hospital with serious medical conditions. These are the patients who
benefit from the provision of advanced life support treatment by paramedics on the scene and en route to
the hospital.
While paramedic ambulance service is available in all parts of Contra Costa County, the number of
paramedic units is not sufficient to provide timely paramedic response on all emergency medical responses.
Approximately 15 percent of all emergency medical responses are made by EMT-I-staffed BLS ambulance
units. Thus, some 4,770 emergency medical calls in 1988 did not receive a paramedic response; and, of
these, over 1,500 may have benefited from the advanced care that a paramedic could have provided.
Medical Helicopter Service
Medical helicopter transport is provided by four private air ambulance services approved by the
County EMS Agency and in accordance with procedures and protocols established by the EMS Agency.
Helicopter transport is usually initiated by the fire first responder for seriously injured trauma patients who
would otherwise have an excessively long ground transport time to the trauma center. Medical helicopter
response is requested through the 9-1-1 medical dispatch center and coordinated by the Sheriff's Dispatch
Center. All approved medical helicopters are staffed with a pilot and two medical attendants, including at
least one flight nurse or physician. All provide ALS level service. Once medical helicopter response is
requested, the nearest,available of the following helicopters is dispatched:
-CalStar (Hayward)
-MediFlight(Stockton, Modesto)
-LifeFlight(Stanford)
-LifeFlight(Davis)
These services are funded primarily by patient fees and do not receive public subsidy.
In addition to these medical helicopter services, the East Bay Regional Parks District and the
California Highway Patrol operate helicopters which, although not staffed or equipped to provide ALS level
service, are available for rescue and patient transport.
Base Hospitals
Base hospitals are designated by the County EMS Agency to provide medical direction to
paramedic units in each of four base hospital zones. Base hospitals are required to enter into contracts with
the County which specify hospital responsibilities for on-line and retrospective medical control and which
set forth special training and staffing responsibilities. For example, a base hospital must have on duty in the
emergency department at all times a specially trained and certified Mobile Intensive Care Nurse to provide
8
radio direction to paramedics. Each base hospital must conduct an ongoing quality assurance program to
monitor the ALS program within their base hospital zone and must provide a Base Hospital Nurse
Coordinator to administer the program and Base Hospital Liaison Physician to provide overall medical
direction. Base hospitals provide medical direction for all patients who receive ALS field care within their
respective zones, including patients who may be transported to the base hospital as well as patients who
are transported to other receiving hospitals. No subsidy is provided for base hospital service and base
hospitals cannot bill patients transported to other receiving hospitals..
Existing base zones and designated base hospitals include:
-Zone A(West County) - John Muir Medical Center
-Zone B (South Central County) - John Muir Medical Center
-Zone C (North Central County) - Mt.Diablo Hospital Medical Center
-Zone D (East County) - Los Medanos Community Hospital
Receiving Hospitals
Receiving hospitals include all hospitals licensed by the State to provide Basic Emergency Services
and other facilities which may be designated by the County EMS Agency to receive specified types of
patients. Hospitals with Basic Emergency Services in Contra Costa include Brookside, Doctors' of Pinole,
Merrithew Memorial, Mt. Diablo, Los Medanos Community, Delta Memorial, John Muir, and the Kaiser
Foundation Hospitals in Martinez and Walnut Creek. In addition, the Kaiser Foundation Hospital in
Richmond and the John Muir EmergiCenter, which do not provide Basic Emergency Services, are
designated to receive certain categories of patients. Patients may also be transported to Basic Emergency
hospitals in adjacent counties.
Trauma Center
In 1986, the County Trauma System was implemented with the designation of John Muir Medical
Center as the County's trauma center. In accordance with the County Trauma System Plan, field personnel
were trained in trauma triage criteria and directed to transport most seriously injured patients directly to the
trauma center. In accordance with the trauma center designation contract between John Muir and the
County, John Muir is required to meet special staffing, training, and facility standards in order to provide
care to injured patients. For example, the trauma center is required to maintain a trauma surgeon in house
24-hours a day and must dedicate one operating room to trauma. While John Muir is the only trauma
center within the County, pediatric trauma patients may be transported directly to Children's Hospital in
Oakland, which has been designated by Alameda County as a pediatric trauma center. The County EMS
Agency has also established a reciprocal agreement with Alameda County for transport of trauma patients
to an Alameda County trauma center when John Muir is temporarily unable to receive additional trauma
patients.
Because critically injured patients are transported relatively long distances past closer hospitals to
the trauma center, the County EMS Agency conducts a comprehensive monitoring program to assure the
maintenance of standards and provision of a high level of trauma care. The cost of trauma system
monitoring is funded through a an annual designation fee paid by the trauma center under the terms of its
contract with the County.
9
During FY 1987-88, emergency medical responders in consultation with base hospital personnel
evaluated 1,282 patients as serious or potentially serious trauma victims for whom trauma center treatment
was appropriate. Of these, 1,182 were transported to John Muir, and 57 to an out-of-county trauma center.
The remaining 100 were transported to a non-trauma center hospital, usually because their condition was
too severe to withstand the longer transport to the trauma center. It is estimated that during the trauma
system's first two years of operation, over 160 lives were saved. Countless others experienced improved
outcomes following treatment of their injuries. While the trauma system has been successful in reducing
deaths and disability from accidents, the longer patient transports to a trauma center remove ambulance
and fire units from service for longer periods then when patients were transported to the nearest hospital
emergency department.
Training Programs
Training programs to prepare prehospital care personnel for certification are approved by the Local
EMS Agency. Approved training programs in Contra Costa County include:
-Contra Costa College for EMT-I training;
-Los Medanos College for EMT-I and MICN training;
-Mt.Diablo Hospital Medical Center for MICN training; and
-Med Help,Inc., for EMT-I training.
There are currently no in-county training programs for paramedics.
Emergency Medical Care Committee
The Emergency Medical Care Committee (EMCC) is mandated by State statute and appointed by
the Board of Supervisors to provide oversight to the EMS system and to advise the Board and EMS Agency
on EMS issues. The EMCC is comprised of 20 members, including 5 citizen/consumer representatives
and one representative from each of the following agencies or organizations:
- California Highway Patrol
- Office of Emergency Services
- Fire Chiefs' Association
- Public Managers' Association
- Health Services Department
- Police Chiefs' Association
- Sheriff-Coroner's Communication Division
- Contra Costa Ambulance Providers
- American Red Cross
- Emergency Nurses' Association
- East Bay Hospital Conference
- Alameda-Contra Costa Medical Association
- Emergency Department Physicians
- Los Medanos College or Contra Costa College
- American Heart Association
10
Emer6ncy Medical Services Agency
The Health Services Department is the designated Local EMS Agency. The functions of the EMS
Agency are carried out by the EMS division of the Department. The EMS Agency is the lead agency for
emergency medical services within the County. Specifically, the EMS Agency responsibilities include:
-Developing the County Emergency Medical Services System Plan and the
County Trauma System Plan.
-Developing and administering contracts for emergency ambulance service,
base hospital services, and trauma center services.
-Approving prehospital advanced•• life support programs including
establishing field treatment protocols.
-Certifying prehospital care personnel (EMT-I's, paramedics, and MICN's)
and carrying out investigations and disciplinary actions related to
certification.
-Monitoring prehospital care, trauma care, and interfacility transfers.
-Reviewing and approving training programs for prehospital care personnel.
-Establishing plans for response to multi-casualty incidents and major
disasters.
-Providing staff services to the EMCC.
-Carrying out other activities in relation to the County's EMS system.
While not mandated by law, a county or multi-county
EMS agency must be designated for State approval of an LOCAL EMS AGENCY ORGANICAT ION
EMS System Plan. An approved EMS System Plan is a i Board or
statutory requirement for the operation of paramedic Superv1sor5
services, designation of exclusive operating areas for Emergency Medical •••••••••.•.I
emergency ambulance service, establishment of a trauma I Care Committee I
system, or approval of prehospital care training programs. ��
( Health Services I
Director
The EMS division is headed by the EMS Director Medical Director/
Healthand includes a total of four full-time professional staff, one I
half-time physician consultant, and two secretarial staff. In I(�Cc°linty
addition, the Department Medical Director/Health Officer is I "'S Staff: Oirecto,
the designated EMS Medical Director and has certain L
mandated responsibilities. The organizational structure of I Physician I EM Secretarial
the Local EMS Agency is shown in Figure 2. I I Consultant I Program Staff (2)
I 1 (0.5) I I Coordinator
I I
I Prehospital Care I r County Trauma
Coordinator Coordinator
(RM) (RN)
Figure 2
11
V. AREAS FOR IMPROVEMENT
Since Contra Costa County first established limited paramedic service in 1976, the county's
emergency medical service system has undergone many improvements within the limited scope of resources
available. Paramedic ambulance coverage has been expanded to include all areas of the county. A county
trauma system has been established. Firefighters in many areas have received EMT-I level training. A
system of medical helicopter service has been established. Certain components of the EMS system -
paramedic coverage, first responder training, medical dispatching - exist at higher levels in some areas of
the county than in other areas. If the county is to maintain a high standard for emergency medical
response for its residents wherever they may live, work, play, shop, or travel throughout the county, many
needed improvements must be made in the existing EMS system. The most important areas in which
improvements are currently needed include:
-paramedic ambulance coverage,
-medical dispatch and communications, and
-additional medical training and equipment for fire service personnel who are first
responders on medical emergencies.
Other deficiencies or areas for improvement also exist, and are identified in the EMS System Priorities
developed by the EMCC (Exhibit B) and in the County Fire Chiefs' recommendations regarding the
proposed EMS Benefit Assessment (Exhibit C).
Paramedic Ambulance Coverage
Deficiencies in paramedic ambulance coverage result in:
-An insufficient number of paramedic-staffed AIS ambulance units
necessitating the use of EMT-Istaffed BIS units for emergency response
when paramedic units are unavailable; and
-Insufficient ambulance coverage in peripheral areas of the county resulting
in response time over 10 minutes.
Existing emergency ambulance agreements, which are awarded through a competitive bidding
process based upon the highest level of service obtainable without subsidy, address ambulance coverage
standards in two ways. First, the contractors are required to maintain a specified number of ALS
(paramedic) and BLS (EMT-I) ambulance units available to respond to emergency calls. Second,
contractors are required to respond to 95 percent of emergency calls within their areas of responsibility
within 10 minutes (20 minutes for designated rural areas). The requirement for timely response may be
satisfied either by an ALS ambulance or BLS ambulance response. Thus, while paramedic service is
provided in all areas of the county, the requirement for timely response may result in a BLS ambulance
response when the ALS ambulance which would normally respond is responding to another emergency
call.
12
Figure 3 shows the locations of existing paramedic ambulance units circles depicting approximate
10-minute response zones. (Actual 10-minute response zones vary depending upon roads and traffic
conditions.)
N
r
7,
�'PA''-ED!C A112ULA7CE CT!EPAGE
CIRCIE3 ENCT APR0Xjr1A7:
10 i'!AlrE P_E"0:1SE ZME7
CONTRA COSTA COUNTY
CALIFORNIA
Figure 3
Table 3 shows, for each region of the County, the annual number of emergency ambulance
responses, the number which do receive an ALS (paramedic) level ambulance response, and the number
for which the ambulance response (ALS or BLS) was over 10 minutes.
Countywide during 1988, approximately 4,700 (15 percent) out of some 31,000 emergency medical
requests received only a BLS ambulance response. Based upon existing paramedic response data,
approximately 36 percent of all ambulance responses result in transport of a patient needing ALS level
skills. Thus, it can be estimated that during 1988 some 1,700 city and county residents (15 percent of the
4,700 who received only a BLS ambulance response) failed to receive needed ALS level skills.
13
Table 3
DEFICIENCIES IN EMERGENCY AMBULANCE COVERAGE
(Estimates based upon annual emergency responses in areas served by Regional Ambulance)
Number Percent
Countywide
Emergency Ambulance Responses 29,000 100
No paramedic ambulance 4,350 15
Response over 10 minutes 3,430 12
West County
Emergency Ambulance Responses 12,000 100
No paramedic ambulance 2,640 22
Response over 10 minutes 1,080 9
Central County
Emergency Ambulance Responses 10,000 100
No paramedic ambulance 900 9
Response over 10 minutes 1,600 16
East County
Emergency Ambulance Responses 7,000 100
No paramedic ambulance 840 12
Response over 10 minutes 700 10
EMS Communications and Dispatch
Five major areas of deficiency exist in the EMS communications and dispatch system:
-First,the existing MEDARS system is antiquated and provides insufficient
capacity for paramedic-to-hospital communications.
-Second, in most areas of the county, requests for emergency ambulance
service must be relayed by voice telephone from the 9-1-1 PSAP to the
ambulance company dispatch center. This results in delay and occasional
error in ambulance dispatch. While the average time required relaying
dispatch information by voice telephone is only about a minute, delays of
14
several minutes may occur when dispatchers are handling multiple
emergencies.
-Third, medical dispatchers in five of the six 9-1-1 medical dispatch centers
are not trained to the level recommended in the State Emergency Medical
Services Authority Guidelines for Medical Dispatching.
-Fourth, in those areas of the County with private ambulance service, an
adequate public agency backup system does not exist to handle ambulance
dispatch in the event that the company dispatch center is for any reason
unable to function.
-Fifth,most private ambulance units are not able to communicate while en
route to a medical emergency directly with fire first responder units already
on the scene.
MEDARS. The limitations in the County's MEDARS radio system have been recognized for years
and have been the subject of recommendations by the EMCC and the Health Services Department. Radio
equipment is antiquated, the system is not compatible with the MEDCOM system used for paramedic
communications in most areas of the county, and the two available channels do not provide sufficient
capacity for ambulance tracking and ambulance-to-hospital communications. A 1985 proposal submitted
by Motorola Corporation recommended installation of a $1.1 million MEDCOM system for Contra Costa
County. This proposal was never funded, and subsequent changes in communications technology suggest
that the County's EMS communications needs be carefully reassessed before making a commitment to a
new communications system. In the meantime, the introduction of cellular telephone technology has taken
some of the load off the MEDARS radio system for ambulance-to-hospital communication.
Computer Linkages. When an emergency call is answered by a 9-1-1 public safety answering
point, the caller's telephone number and address are automatically displayed on 9-1-1 terminal. This
information is confirmed by the medical dispatcher and "captured" onto the dispatch computer for
transmission to the fust responder. The request for an ambulance, however, must be relayed by voice
telephone from the 9-1-1 medical dispatcher to the ambulance company dispatcher. The ambulance
company dispatcher, in turn, re-enters the dispatch information into the ambulance company dispatch
computer. The technology exits to transfer the dispatch information directly to the ambulance company
computer. Relaying the information by voice results in delays and introduces errors.
Medical Dispatcher Training. State standards have been set for the training of Emergency Medical
Dispatchers to provide pre-arrival instructions and to prioritize emergency medical calls to distinguish those
calls which may need immediate first responder and paramedic ambulance response from those for which
a reasonable prompt ambulance response is clearly all that is needed. Pre-arrival instructions have been
shown to save lives by involving the composed professional voice of the dispatcher in providing basic first
aid instructions to the caller. Priority dispatching, when appropriately used, conserves resources by
reducing unnecessary responses of fire and paramedic units, thereby enhancing availability for emergency
calls.
Backup Dispatch Capability. Emergency ambulance service is a vital public service, and dispatch
capability is a key part in the ability to provide this service. Currently, all emergency ambulance calls are
tracked by Sheriff's dispatch. This is accomplished by requiring ambulance units to report to Sheriffs
dispatch by radio when responding on a call. Sheriff's dispatch does not know of an emergency request
received at one of the other 9-1-1 dispatch centers until the responding ambulance unit reports. Nor does
Sheriff's dispatch monitor the availability status of ambulance units.
15
Ambulance-to-Fire Communication. Two common situations arise in which an ambulance unit en
route to a medical emergency can benefit from direct communication capability with a fire first responder
unit already on the scene. With direct communication capability, an on scene fire unit can radio directions
to the ambulance to find a difficult or changed patient location and can provide the ambulance crew details
of the patient's condition which may prepare the ambulance crew to initiate treatment more quickly upon
their arrival.
First Responder Services
Rapid Response to Cardiac Emergencies -(Early Defibrillation). Paramedic service was initially
developed out of the need to bring advanced life support directly to the scene of victims of cardiac
emergencies. Itwas found that lives could be saved by training ambulance technicians to hook up a patient
to a device capable of transmitting a electrocardiogram (EKG)to a base hospital and to use another device
to administer an electric shock (defibrillation). With additional training, these technicians could learn to
interpret many EKG's themselves, thus removing reliance upon the capability of transmitting the EKG by
radio. Paramedics were trained in the administration of special cardiac drugs to stabilize the patient
following defibrillation and were trained and equipped to deal with other life-threatening emergencies as well.
While the development of paramedic service brought a major advancement to the care of cardiac
emergencies, many patients were still being lost because defibrillation came too late. First responders, often
arriving within three to five minutes of the onset of an emergency, could only provide CPR while waiting for
the paramedics to arrive. Recently, however, a new device has been developed known as an "automatic
defibrillator." Under regulations approved by the State, a fust responder with only a few hours of training
can learn to defibrillate a patient with an automatic defibrillator. The device uses a computer to measure
the patient's heart rhythm and, if indicated, automatically delivers the appropriate shock. By reducing the
time to defibrillation from twelve minutes to six.minutes, it is estimated that a countywide early defibrillation
program could save as many as 40 to 100 lives annually.
EMT-I Training. Although EMT-I level training for first responders has long been recognized as a
goal in the county, it is estimated that only about one-third of the county's firefighters are currently certified
to this level of training.
Disaster First Aid Caches. While fire and ambulance units are well stocked to treat several victims
at the scene of an emergency, first aid supplies may be quickly exhausted in the event of a disaster or
major multicasualty incident. Fire services in many areas of California have developed systems of
stockpiling backboards, oxygen, and other fust aid supplies commonly used by both fire and ambulance
personnel in caches which can easily be transported to the scene of a major emergency. Disaster caches
are designed to be easily transported by fire units and include equipment and supplies in routine use which
is familiar to responders and which can be rotated to avoid deterioration.
Other Areas for Improvement
While paramedic ambulance coverage, EMS communications, and fust responder defibrillation are
the major areas identified for improving the EMS system in Contra Costa County, recommendations by the
EMCC and by the County Fire Chiefs Association identify other areas as well. These include:
16
Establishment of an EMS data system for monitoring system performance;
Provision of training to medical responders in treatment of victims of
hazardous materials incidents;
-Reduced reliance on firefighters to provide patient assistance en route to
the hospital;
-Disaster and multicasualty preparedness;
-Public education; and
-Communicable disease prevention.
17
VI. SERVICE PLAN
The services to be provided under the proposed CSA include the following:
-Additional paramedic ambulance units necessary to provide response to
all life-threatening medical emergencies and to improve the response to
peripheral areas of the County.
-Replacement or upgrading of the existing EMS radio communications
system.
-Improved dispatching, including medical dispatcher training and computer
linkages between 9-1-1 medical dispatch centers, a central public safety
dispatch, and ambulance provider dispatch centers.
-Funding for fust responder defibrillation programs to provide rapid
response to persons with cardiac emergencies.
-Additional medical training and equipment for fire first responders.
-Caches of fust aid equipment to be maintained by fire services throughout
the county for use in disasters or major multicasualty incidents.
County Service Area funding will be used to fund new services and service enhancements, including
an allocation of ten percent of the operating budget to cover additional administrative costs which will be
incurred. A fust year budget illustration is shown in Exhibit D.
Administration of the Proposed County Service Area
The proposed County Service Area will be administered by the Health Services Department under
the governing authority of the County Board of Supervisors. The Health Services Director will appoint an
Oversight Committee to assist in ongoing program planning and monitoring and to advise the Department
on preparation of the annual budget for the CSA. The Oversight Committee will include a representative
nominated by each of the following:
- Public Managers' Association
- Fire Chiefs' Association
- Police Chiefs' Association
- East Bay Hospital Conference
- Emergency Medical Care Committee (2 consumer members)
Paramedic Ambulance Service
Ambulance coverage under the CSA will continue to be provided by ambulance services under
contract to the County with contracts awarded through a competitive process. A Request for Proposal
(RFP)will be issued for emergency ambulance services in each of the areas currently served by Regional
Ambulance Service, Moraga Fire Protection District, and San Ramon Valley Fire Protection District,
respectively. The RFP will set standards for emergency ambulance response which must be met by the
18
contractors. These standards will include paramedic-staffed ambulance response to all life threatening or
potentially life threatening emergencies and response within 10 minutes to 95 percent of emergency calls
within each city and the unincorporated urbanized area of the county. Additionally,in order to determine
the feasibility of achieving 8 minute paramedic ambulance response times as recommended by the EMCC,
bidders will be asked to submit a separate bid for an 8 minute response standard.
In preparing the RFP, attention will be given both to improving ambulance response times in areas
such as El Cerrito/Kensington, Crockett/Rodeo, Clayton, Orinda, and the east County areas outside the
immediate Antioch, Pittsburg, and Brentwood areas and to providing more paramedic coverage to the
higher call volume areas of west and central County. While the actual number and locations of paramedic
ambulances will be determined in response to the RFP, it is estimated that at least five or six additional
units are required to meet peek demand and that two to three of these will need to be 24-hour/7-day per
week units to achieve response time standards.
Figure 4 provides an illustration of how paramedic ambulance coverage might be improved using
five additional paramedic units. (Compare with Figure 1 showing existing paramedic ambulance coverage.)
The actual ambulance coverage plan, including the locations of ambulance stations, will be determined by
each successful ambulance bidders based upon the their proposals submitted in response to the RFP.
Regardless of the proposed coverage plan, however, a successful bidder will be required to station
paramedic-staffed ambulances in sufficient numbers and appropriate locations to meet contract response
standards.
The Health Services Department will conduct an ambulance selection process with the goal of
selecting the most qualified providers to assure a high quality of ambulance service for Contra Costa
County. The Oversight Committee (including city, police, fire, hospital, and EMCC representation as
described above) will participate in the proposal review and selection process, including review of plans for
the location of ambulance stations.
In addition to paramedic coverage and response time requirements, ambulance services will be
required to provide appropriate staff to transport critical trauma patients from areas over 20 minutes from
the trauma center without firefighter assistance en route to the hospital.
19
'AA 7
3
_J
-4
PARWIVIC COVEUC:
'ROPCSEJ CIISRAG' t LLU S T I AT 01! 0;'L
CIRCLES PE C' AFFROXI:IATE
10 - MINUTE RESPONSE ZUES
CONTRA COSTA COUNTY
CALIFORNIA
Figure 4
EMS Radio Communications System
Itis well recognized that the existing EMS radio communications system must undergo major
upgrading or replacement. While an earlier review process resulted in a recommendation for replacement
of the 2-channel MEDARS system with a 10-channel MEDCOM system, rapid changes in radio
communication technology suggest that options be reexamined. Therefore, an EMS communications plan
will be developed during the firs't year of operation of the CSA, with purchase of new equipment scheduled
to begin during the second year.
Improved Dispatching
The communications plan developed during the first year will include review of the system of
ambulance dispatch. However, certain improvements in the existing system may be undertaken without
completion of such a plan. These include, for example, establishing computer data linkages from existing
9-1-1 medical dispatch centers to the Sheriffs dispatch and ambulance company dispatch centers and
developing a medical dispatcher training program to be made available to the 9-1-1 medical dispatch
centers.
20
First Responder Defibrillation
A program will be established to provide training, equipment, and required monitoring for fire
services electing to implement early defibrillation services. The program will include a physician medical
director; a mobile intensive care nurse to provide training, monitoring, and program coordination; and funds
for acquisition of automatic defibrillator and related equipment.
First Responder Medical Training, Equipment, and Supplies
Funds budgeted for additional fust responder medical training, equipment, and supplies will be
used to reimburse fire services for the costs of providing training necessary to qualify personnel for
certification as EMT-I's or other EMS approved first responder certification and to purchase medical
equipment and supplies to enhance first responder medical response, including equipment and supplies to
be stockpiled in caches for use in disasters and multicasualty incidents. Funds may be used to the extent
available to reimburse for other approved medical training, and purchase of approved medical equipment
and supplies including equipment and supplies used to prevent the spread of communicable disease.
Local EMS Agency
The EMS Agency is responsible for coordinating, administering, and monitoring the EMS system.
County Service Area funding will be used for additional services provided through the EMS Agency.
21
Exhibit A
Measure "H"(Ballot Measure)
EXHIBIT A
Contra Costa County Ballot Measure, November 8, 1988
MEASURE "H" - EMERGENCY MEDICAL SERVICES
(Advisory Measure)
Shall a Countywide Emergency Medical Services benefit assessment be
established to finance improvements in the emergency medical and trauma care
system including expanded countywide paramedic coverage; improved medical
communications and medical dispatcher training; and medical equipment,
supplies, and training for firefighter first responders, including training
and equipment for fire services electing to undertake a specialized program of
advanced cardiac care (defibrillation); said assessment to be limited to a
maximum assessment on real property of ten dollars annually for each single
family residence or benefit unit as defined in Resolution No. 88-500, a copy
of which is contained in the Voter Information Pamphlet, and said assessment
to be initially set at five dollars and fifty cents per benefit unit, subject
to review following a public hearing on the assignment of benefit units and
services to be financed, the public hearing and review to -be conducted prior
to the initial assessment and annually thereafter?
Argument in Favor of
MEASURE "H" - EMERGENCY MEDICAL SERVICES
A "YES" vote on MEASURE "H" may save your life! A "YES" vote on
MEASURE "H" urges the Board of Supervisors and city councils to assure that
enough paramedics are available for all emergency calls and to provide a
means to make needed improvements in our emergency medical services._
Emergency medical services are designed to provide rapid lifesaving response
to victims of heart attacks, serious injuries, and other life threatening
medical emergencies. Paramedics, under medical direction from hospital
emergency doctors and nurses, bring advanced medical skills, equipment, and
drug therapy directly to the emergency scene. Right now there are not enough
paramedic units to respond to many emergency calls. ONE OUT OF SIX 9-1-1
CALLS FOR EMERGENCY MEDICAL HELP DOES NOT RECEIVE A PARAMEDIC RESPONSE.
The radio system paramedics rely on to receive on-scene medical
direction is old and cannot handle the existing number of emergency calls.
Medical dispatchers need to be trained to assist 9-1-1 callers waiting for
help to arrive. Firefighters who are first responders to emergency medical
incidents need to be trained to the recommended Emergency Medical Technician-I
level and need to be trained and equipped with advanced lifesaving equipment
approved by the State for use by first responders prior to arrival of
paramedics.
For less than 34 per day per household, a "YES" vote on MEASURE "H"
will:
- Add needed paramedic units,
- Provide medical training and equipment for firefighters,
- Upgrade emergency medical communications and dispatch, and
- Ensure a high level of trauma care throughout the county.
Please vote "YES" on MEASURE "H" and make Contra Costa County a better
and safer place for all of us to work, play, and LIVE.
s/ Michael E. Mickelberry, Chairman
Contra Costa County Emergency Medical Care Committee
s/ Gregory A. Rhodes, M.D. , Chairman
Emergency Committee, Alameda-Contra Costa Medical Association
Past Chairman, Contra Costa County Emergency Medical Care Committee
s/ Timothy A. Carlton, M.D. , President
American Heart Association, Contra Costa County Chapter
s/ Allen Sebransky, M.D.
Surgeon
s/ Lyla Cromer
Health Sciences Educator
THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIrORNIA
August 9, 1988
Adopted this Order on by the fulluvving vote:
AYES: Supervisors Powers, Fanden, McPeak, Torlakson
NOES: None
ABSENT: None
ABSTAIN: Supervisor Schroder
Resolution Number 88/500
SUBJECT: EMERGENCY MEDICAL SERVICES
WHEREAS, this Board of Supervisors proposes to establish, with the con-
currence of each city council, a County Service Area for the provision
of paramedic service, trauma care, and other emergency medical services
on a county-wide basis; and
WHEREAS, a county may levy an assessment upon each property within a .
service area to pay for cost of the services; and each assessment may
be determined by apportioning the total cost of the service, not other-
wise offset by other available revenue, to each property in proportion
to the estimated benefits to be received by each property from the
service; and
WHEREAS, a special advisory election will be held to determine whether
this Board of Supervisors should undertake the formation of an emergency
medical servies area and the levy of an assessment; and
WHEREAS, a schedule of benefit units reflecting the degree to which
different kinds of properties according to use would benefit from the
service has been established, and the estimated dollar.value of the
benefit unit necessary to defray the cost of the service has been set
at five dollars and fifty cents per unit.
NOW, THEREFORE, BE IT RESOLVED that this Board of Supervisors adopts the
attached Schedule of Benefit Units (Exhibit A) for the different kinds
of properties within the County as a guideline for purposes of the
advisory election, to be held on November 8, 1988.
j BE IT FURTHER RESOLVED that the Schedule of Benefit Units for different
kinds of property and the cost of emergency medical services provided
be reviewed following a public hearing to be conducted prior to any
initial assessment and annually, thereafter; but that the maximum
dollar value of each benefit unit shall in no event exceed ten dollars
annually.
1herebyCertify that this laatrue and concleopyof
Rn action taken and entered on the minutes of the
Board of Supervisors on the data shown.
ATTESTED: August 9, 1988
PHIL BATCHELOR,Clerk of the Board
Of Supervisors and County Administrator
By ,� Deputy
Orig. Dept.:
cc: Elections
County Administrator
Health Services
County Counsel
THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CA!_It'011111A
Adopted this Order on , by the Iulluwing vole:
AYES:
NOES:
ASSENT:
ABSTAIN:
Resolution Number 0 0
SUBJECT: EMERGENCY MEDICAL SERVICES
WHEREAS, this Board of Supervisors proposes to establish, with the con-
currence of each city council, a County Service Area for the provision
of paramedic service, trauma care, and other emergency medical services
on a county-wide basis; and
WHEREAS , a county may levy an assessment upon each property within a
service area to pay for cost of the services; and each assessment may
be determined by apportioning the total cost of the service, not other-
wise offset by other available revenue, to each property in proportion
to the estimated benefits to be received by each property from the
service; and
WHEREAS, a special advisory election will be held to determine whether
this Board of Supervisors should undertake the formation of an emergency
medical servies area and the levy of an assessment; and
WHEREAS, a schedule of benefit :units reflecting the degree to which
different kinds of properties according to use would benefit from the
service has been established, and the estimated dollar value of the
benefit unit necessary to defray the cost of the service has been set
at five dollars and fifty cents per unit.
NOW, THEREFORE, BE IT RESOLVED that this Board of Supervisors adopts the
attached Schedule of Benefit Units (Exhibit A) for the different kinds
of properties within the County as a guideline for purposes of the
advisory election.
BE IT FURTHER RESOLVED that the Schedule of Benefit Units for different
kinds of property and the cost of emergency medical services provided
be reviewed following a public hearing to be conducted prior to any
initial assessment and annually, thereafter; but that the maximum
dollar value of each benefit unit shall in no event exceed ten dollars
annually.
SCHEDULE OF BENEFIT UNITS
CATEGORY OF PROPERTY BENEFIT UNITS
CODE DESCRIPTION ASSIGNED
RESIDENTIAL:
10 Vacant, unbuildable0*
11 Single Family, 1 Res on 1 Site & Duets with
out common Areas 1
12 Single Family, 1 Res on 2 or more sites 1
13 Single Family, 2 or more res. on 1 or more sites 2*
14 Single family on other than single family land 1
15 Miscellaneous improvements, 1 site 1
16 Misc. Imps on 2 or more sites; includes trees &
vines 1
17 Vacant, 1 site (includes PUD sites) 0 . 5
18 Vacant, 2 or more sites 0. 5
19 SFR; Det. w/common area (normal subdiv. type PUD)
Duets w/common area
MULTIPLE:
20 Vacant 0. 5
21 Duplex 2
22 triplex 3
23 Fourplex 4
24 Combinations ; e.g. , single and a double, etc. 3
25 Apartments , 5-12 units , inclusive 5
26 Apartments , 13-24 units, inclusive 13
27 Apartments , 25-59 units, inclusive 25
28 Apartments , 60 units or more 60
29 Attached PUD' s, Cluster Homes, Co-ops , Condos ,
Townhouses, etc. 1
COMMERCIAL:
30 Vacant 0. 5
31 Commercial Stores (not supermarkets) 3
32 Small Grocery Stores (Mom & Pop, 7-11,Quick Stop 3
33 Office Buildings 3
34 Medical: Dental 25
35 Service Stations; car washes ; Bulk plants 3
36 Garages 3
37 Community Facilities: Recreational: Swim Pool
Assn. 6
38 Golf Courses 6
39 Bowling Alleys 6
40 Boat harbors 8
41 Supermarkets (not in shopping centers) 5
42 Shopping Centers (all pcls incl. vac for
future shop center) 15
43 Financial Bldgs (ins. & Title Cos . Banks & S&L 3
44 Motels , Hotels, and Mobile Home Parks 10
45 Theatres 3
46 Drive-In Restaurants (Hamburger, Taco, etc. 6
47 Restaurants (not drive-in; inside service only) 8
48 Multiple & Commercial; Miscellaneously improved 8
49 New Car Auto Agencies 3
INDUSTRIAL
50 Vacant Land (not part of Industrial Park or P & D) 0 . 5
51 Industrial Park (with or without structures) 40
52 Research & Development, with or without structures 3
53 Light Industrial 20.
54 Heavy Industrial 500
55 Mini-Warehouse (Public Storage) 3
56 Misc. Imps. , including T&V on Light or Heavy Indust. 3
LAND
61 Rural, Res. Improved; lA up to 10A 1
62 Rural, with or without Misc. Structures IA up to 10A 1
63 Urban Acreage 10A up to 40A 1
64 Urban Acreage, 40A and over 2
65 Orchards; Vineyards; Row Crops ; Irr.Past. ; Irr.Past
10A up to 40A 1
66 Orachards ; Vineyards; Row Crops ; Irr.Past. ; 40A and
over 2
67 Dry Farming, Grazing & Pasturing 10A up to 40A 1
68 Dry Farming, Grazing and Pasturing, 40A and over 2
69 Agricultural Preserves 1
INSTITUTIONAL:
70 Convalescent Hospitals & Rest Homes 50
71 Churches 1
72 Schools, public or private, with or without
improvements 1
73 Hospitals with or without improvements 100
74 Cemeteries ; Mortuaries 1
75 Fraternal and Service Organizations 1
76 Retirement Housing Complex 25
77 Cultural Uses (Libraries) 1
78 Parks and Playgrounds 8
79 Government-owned, with or w/out bldgs (Fed, State ,
City, BART, etc. ) 1 0*
MISCELLANEOUS:
80 Mineral Rights (Productive/Non-Productive) 0
81 Private Roads 16/�5 0*
82 Pipelines and Canals 4
83 State Board Assessed Pcls . 0*
84 Utilities with or w/out bldgs. (not assessed by
state Bd. ) 1
85 Public and Private Parking l
86 Taxable Municipally-Owned Property l
87 . Common Areas pcls. in PUD' s; e.g. , Open Spaces ,
Rec. Facilities 0*
88 Mobilehome 1
89 Other; Split Pcls. in diff. Tax Code Areas l 0*
99 Awaiting Assignment 1
* Adjustments 7/89
Exhibit B
Contra Costa Emergency Medical Care Committee
Resolution of Endorsement and
Recommended EMS System Priorities
. EMERGENCY MEDICAL CARE COMMITTEE
OF CONTRA COSTA COUNTY
EMERGENCY MEDICAL SERVICES
50 Glac;er Drive
Martinez,California 94553-4822
(415) 646-4690
CONTRA COSTA COUNTY EMERGENCY MEDICAL CARE COMMITTEE
RESOLUTION SUPPORTING THE ESTABLISHMENT OF A
COUNTYWIDE COUNTY SERVICE AREA FOR
EMERGENCY MEDICAL SERVICES
WHEREAS. the Emergency Medical Care Committee (EMCC) has been established
by the Board of Supervisors as an advisory committee to the Board and to the
County Emergency Medical Services (EMS) Agency on matters relating to
emergency medical services;
WHEREAS the voters of Contra Costa County passed by 71.6 percent Measure
"H" , an advisory measure on the November 1988 countywide ballot, calling for
the establishment of a benefit assessment to finance improvements in the
emergency medical and trauma care system including expanded countywide
paramedic coverage, improved medical communications and medical dispatcher
training , and medical equipment, supplies , and training for firefighter first
responders, including training and equipment for a first responder
defibrillation program;
WHEREAS the EMCC has developed and approved a plan of "Recommended EMS
System Priorities" to improve the level of emergency medical services ,
including improved paramedic ambulance service, emergency medical dispatch and
communications , first responder training and defibrillation, and overall EMS
system organization and management including support of the county trauma
system; and
WHEREAS the County Health Services Department, which is the Board
designated Local EMS Agency, has developed plans and proposals to form a
County Service Area for Emergency Medical Services;
BE IT THEREFORE RESOLVED that the EMCC endorses the formation of a
countywide County Service Area for the purpose of establishing a benefit
assessment for emergency medical services as proposed in Measure "H" and that
the Board of Supervisors and each city council take the appropriate actions to
form the proposed County Service Area.
Passed July 12 , 1989 AYES 16 NO 0 ABSTAIN 0
r
Attest\' ) ) �• �� - fzY . L
Mic ael E . Mickelberry
EMCC Chair \ `'1
Approved by EMCC 4/12/89 EXHIBIT B
4/3/89
CONTRA COSTA COUNTY EMERGENCY MEDICAL CARE COMMITTEE
EMS Priorities Subcommittee
Recommended EMS System Priorities
A. SYSTEM ORGANIZATION AND MANAGEMENT
1. Implement a countywide EMS service area as approved by the voters
with the passage of Measure "H" in the November 1988 election.
Comment: In November 1988 the voters of Contra Costa County
approved by 71.6 percent Measure °H", an advisory measure calling
for the establishment of an countywide service area to assess
annual fees on real property for the purpose of financing
improvements in the County's emergency medical service system,
including:
- increased paramedic ambulance coverage;
- upgrading the EMS communication system;
- providing specialized medical training and equipment
to first responders, including an early defibrillation
program; and
- assuring the continued viability of the trauma system.
It is estimated that a fee of $5.50 per benefit unit would raise
about $2.5 million in the first year.
2. Expand existing EMS data systems to establish a general pre-
hospital data system including ambulance response and prehospital
care for trauma and nontrauma patients.
Comment: The existing EMS data systems do not provide data
necessary to evaluate overall system response to 9-1-1 calls or
details of prehospital care necessary to evaluate patient
treatment protocols. An EMS data system should be capable of
tracking ambulance response from the time a call is received until
the patient is at the hospital and should record pertinent details
of prehospital care.
B. COMMUNICATIONS AND DISPATCH
1. Improve the paramedic-to-hospital communication system to handle
the existing call volume and the anticipated increases resulting
from expanded paramedic service.
Comment: The existing L-19 radio channel is insufficient to handle
present call volumes and does not provide countywide coverage.
While the use of cellular telephones by paramedics has alleviated
some of the problems that- have existed, there needs to be
established a system for medical communication between paramedics
and base hospitals which will support multiple simultaneous
transmissions, provides coverage to all parts of the county, and
is available on a priority basis to provide medical direction to
paramedics.
2. Establish a system for direct communication between ambulance
and first responder units responding to medical emergencies.
Comment: In most areas of the County, responding ambulance units
and first responders do not share a common radio channel . A
common radio channel would enable a first responder on the scene
of a medical emergency to provide updated patient information to
the responding ambulance unit as well as provide directions for
difficult to find locations.
3. Implement systemwide priority dispatching to include pre-
arrival instructions.
Comment: The EMCC has adopted standards for priority dispatching
which, where adopted, help assure the availability of resources to
handle life-threatening emergencies. Under a system of priority
dispatching, dispatchers are trained to identify certain
situations in which a basic life support (EMT-I staffed) ambulance
may be safely responded in lieu of a full fire first response and
paramedic ambulance response. Medical dispatchers may be further
trained to give simple pre-arrival instructions which may enable a
caller to control bleeding or open an airway in a non-breathing
patient while help is en route.
4. Improve the efficiency of the existing ambulance dispatch system
by providing direct computer linkages between the 9-1-1 answering
points and the ambulance dispatching agency.
Comment: In most areas of the County, emergency ambulance
requests must be relayed by voice telephone from the 9-1-1
answering point to the private ambulance service which dispatches
the call. This adds time to the ambulance dispatch process and
allows for the introduction of errors in reporting locations.
- 2 -
Direct computer linkages would enable the ambulance dispatch
center(s) to receive information on the call simultaneously with
the first responder and without introduction of errors. '
5. Establish the capability at Sheriff's dispatch to monitor ambulance
status and response times and to serve as a backup ambulance
dispatch facility countywide.
Comment: Currently, ambulance service is provided throughout most
of the County by a private ambulance company. Regional-Ambulance
dispatches emergency medical calls received from 9-1-1 answering
points and county communications centers in Contra Costa and
Alameda Counties through a state of the art dispatch center in
Fremont. While this system works well , the County should should
have the capability of on-line monitoring of the status of the
ambulance system and the capability of taking over ambulance
dispatch in the event of an emergency or other situation in which
the private provider could not perform this service.
C. AMBULANCE SERVICE
1. Provide paramedic-staffed ambulance response to all 9-1-1
requests involving life-threatening or potentially life-
threatening medical emergencies.
Comment: Paramedic:staffed ambulance units, operating under base
hospital medical control , bring most of the lifesaving
capabilities of a hospital emergency room directly to the scene of
medical emergencies. Basic life support (EMT-I staffed) ambulance
units, on the other hand, are capable only of providing first aid.
Advanced life support treatment may be delayed 15 to 30 minutes
until the patient can be transported to a hospital emergency
department. Currently, paramedics are able to handle only about
70 percent of all 9-1-1 medical emergency requests.
2. Establish an 8 minute ambulance response standard for urban
areas of the county and reasonable response standards for rural
areas.
Comment: The existing County standard for ambulance response in
urban areas is 10 minutes. Ambulance contractors are currently
required to respond to 95 percent of Code 3 emergency calls in the
designated urban areas within 10 minutes of dispatch. However,
the time required for dispatch, including relay of the request
from the 9-1-1 answering point, adds an additional minute or two
under normal circumstances to overall response time. Reducing the
ambulance response time response time to 8 minutes, would result
in achieving overall response times within 10 minutes for most
calls.
- 3 -
C. FIRE SERVICE
1. Establish first responder standards specifying first responder
responsibilities to help assure a standardized system-wide
response to medical emergencies.
Comment: First responders standards, including a first responder
patient form, should be developed with the cooperation of fire
services in order assure coordinated response of all agencies and
to provide consistent documentation of prehospital patient care.
2. Train and certify first responders to the EMT-I level.
Comment: EMT-I is recognized as the optimal level of training for
first responders in California.
3. Implement early defibrillation countywide.
Comment: The benefits of early defibrillation in reducing
mortality and morbidity due to cardiac failure have been well
established. With the development of automatic defibrillators and
l the adoption of State standards permitting use of these devices by
EMT-I 's and other public safety personnel, it is appropriate to
begin equipping and training first responders to perform
defibrillation.
4. Recognize the need to provide flexible first responder training
opportunities to accommodate the needs of volunteer fire personnel .
Comment: Volunteer fire services face a particularly difficult
problem in meeting training standards established for professional
fire personnel. It may be unrealistic, for example, for a
volunteer fire service to require EMT-I training. Flexible
training opportunities need to be made available to areas which
must rely on volunteer first responders.
D. HOSPITALS
1. Assure continued operation of the trauma system.
Comment: Since its beginning in June 1986, the County's trauma
system has demonstrated its success in reducing trauma deaths. In
many areas of California, however, trauma systems are struggling
against mounting costs and loss due to uncompensated care, and
several trauma centers have, in fact, closed as a result of
financial loses. While this has not been been a problem for
Contra Costa County, it is important that the status of the trauma
- 4 -
system be monitored and that the County be prepared to take
appropriate steps to assure the continuation of the trauma system
should such steps become necessary.
2. Continue to monitor and evaluate base hospital performance.
Comment: Base hospitals play a key role in the operation of the
prehospital care system - directing patient care and triage,
monitoring the performance of paramedics in providing patient
care, and in providing continuing education for prehospital care
personnel. Maintaining high base hospital standards is key to
maintaining a high overall standard for patient care within the
County's EMS system.
3. Continue oversight of interfacility transfers in accordance
with the County Transfer Guidelines.
Comment: Under Transfer Guidelines adopted by the Board of
Supervisors in December 1987, the EMS Agency has established a
process to review interhospital patient transfers. This process
is designed to assure that patients are not transferred for
nonmedical reason without being appropriately stabilized and that
all transfers follow an approved process to assure that the
t receiving hospital is able to accept the patient, that necessary
patient records are sent, and that the mode of transport is
appropriate to the patient's condition. While many of the
requirements of the County's Transfer Guidelines have subsequently
been incorporated into State and federal legislation, the review
process established by the County continues to serve an important
function in assuring that standards are routinely met.
E. DISASTER RESPONSE
1. Assure that new personnel are oriented to the County's Multi-
Casualty Response Plan.
Comment: Because multicasualty incidents are infrequent events,
new personnel may not become familiar with relevant policies and
procedures unless special steps are taken to assure that all
personnel are appropriately oriented.
2. Undertake a program to conduct periodic multi-casualty exercises.
Comment: Because multicasualty incidents are infrequent events,
it is unrealistic to expect personnel to be familiar with the
roles they may be expected to play in a multicasualty incident if
they have not at least been exposed to simulated incidents as a
part of periodic exercises.
- 5 -
Exhibit C
Contra Costa Fire Chiefs' Association
Resolution of Endorsement and
Recommendations on the Emergency Medical Services Benefit Assessment
CONTRA COSTA COUNTY FIRE CHIEFS ASSOCIATION
RESOLUTION 89-02
WHEREAS the fire service in' Contra Costa County is a primary
provider of Emergency Medical and Rescue Services .to the
citizens of Contra Costa County; and
WHEREAS the County Fire Chiefs Association recognizes the need to
improve emergency medical services by development of an organized
and coordinated EMS system in Contra Costa County; and
WHEREAS Contra Costa County has developed plans and proposals to
form an Emergency Medical Services District to mitigate
deficiencies in delivery of emergency medical services by improv-
ing ambulance response, first responder training and equipment,
communications and other needed EMS programs; and
WHEREAS the voters have overwhelmingly approved formation of an
independent Emergency Medical Services District in Contra Costa
County;
BE IT THEREFORE RESOLVED that the Contra Costa County Fire Chiefs
Association endorses the formation of an Emergency Medical Serv-
ices District as defined in Ballot Measure H and encourages all
City Councils in Contra Costa County to adopt resolutions to in-
clude their city in the Contra Costa County Emergency Medical
Services District.
----------------------------------------------------------------
I hereby certify that the foregoing
is a true and correct copy of a
resolution entered on the minutes
of the Contra Costa County Fire
Chiefs Association on this
date.
_7/12/89 By: L &4�1-
Se6reta y off the Contra Costa County
Fire Chiefs Association
J
EXHIBIT C
(Approved by County Fire Chiefs, Association 5/3/89
TO: Members--Contra Costa County Fire Chief ' s Association
FROM: Fire Chief ' s Emergency Medical Service Committee
SUBJECT: Emergency Medical Services Benefit Assessment
DATE: April 25, 1989
A. Background
On November 29, 1988, the Board of Supervisors approved the
development of an Emergency Medical Services Program to upgrade
paramedic, communications and other emergency medical services
countywide and requested that the County Administrator report
back with a time table for implementation. This was in
response to Measure "H" , an advisory measure passed by the
voters in the November 1988 election by 71.6 percent county-
wide. Placing this on the ballot as an advisory measure was a
means to provide an indication of countywide support to the
Board of Supervisors and each City Council. The measure calls
for the formation of 'a countywide service area for the purpose
of assessing fees on real property to finance improvements in
the County' s emergency medical service system. The funds will
be used principally for:
• increasing the number of paramedic units available to
respond to emergency calls;
• upgrading the communications system used for dispatching
paramedics and for paramedics to receive medical direction
from their base hospitals;
• providing specialized medical training and equipment to
firefighters who are first responders on medical
emergencies, such training and equipment to include early
defibrillation; and
• assuring the continued viability of the County's trauma
system.
B. Implementation:
Implementation of the proposed EMS district requires that the
Board of Supervisors make application to LAFCO to approve
formation of a county service area. The following activities
need to occur prior to submission of this application:
• appoint implementation task force
• develop service plan and budget
--for increased paramedic ambulance coverage
--for first responder services (training and equipment
t, including defibrillation)
--for emergency medical services communications
• review of service plan by Fire Chief' s Association, Police
Chief ' s Association and other relevant organizations
• review of service plan by Emergency Medical Care Committee
• public hearing on draft service plan
• presentation to Public Managers Association
• presentation to Mayors ' Conference
• Board approval of service plan
• resolution of intent to from county service area
• invitation to cities to join county service area
• city councils pass resolutions to join county service area
If funding obtained through the proposed Emergency Medical
Services assessment is to be used to fund activities -of county-
wide benefit, it is necessary that the cities consent to
inclusion. Inclusions of the cities requires a resolution from
each city council requesting that its territory be joined in
the county service area. The timing of Measure "H" implementa-
tion is further affected by statutory provision which require
that the county service area be established by January 1st of
the year for which an assessment is levied.
C. Recommendations
The Fire Chief ' s Emergency Medical Service Committee reviewed
the action taken by the County Board of Supervisors to
establish a countywide Emergency Medical System Benefit Assess-
ment as presented to the voters as an advisory measure in the
November 8 , 1988 election.
It is the consensus of--the Committee that funds received from a
benefit assessment for use in the County Emergency Medical
System are needed to assist in the improvement of the total
system. Funding could also be used to off-set the increased
costs to fire departments for providing emergency medical
services.
The Committee submits for your consideration the following
recommendations:
1. Formally endorse the proposed EMS benefit assessment and
urge the cities to join the County Service Area.
2. Request the Health Services Director to establish 1) a
multi-discipline planning/funding committee; and 2) a
procedure that would provide for a yearly process of
evaluating the on-going and changing needs of the emergency
medical service system and how assessment funds would be
utilized.
3 . Request the Health Services Director to allow representa-
tion from the Fire Chief ' s Association to serve on the
Planning/Budget Committee.
• 4 . Request the Local EMS Agency (EMS Office) to establish the
( minimal service level including knowledge, skills and
treatment protocols considered necessary for fire
departments to function as first-in responder within the
County Emergency Medical Service System.
D. Funding Considerations
The Emergency Medical Service Committee recognized that voter
approval of Proposition "H" was based on a limited number of
items for which funding would principally be used. Considering
that the assessment would be a continuous yearly source of
funding, the Committee identifed the following items for fund-
ing. Items are ranked in priority of selection and may
duplicate some of the items listed in Proposition H.
1. Plan, develop and purchase the necessary equipment to
provide for an improved County Medical Communication System
(ambulance-hospital) .
2. Reimbursement (equipment and personnel costs) for any
county first responder training required by the County
Emergency Medical Service System.
3 . Reimbursement for defibrillators and training costs
required to implement and operate a first responder
( defibrillator program for fire departments interested in
providing this service.
4. Subsidizing to the-.ambulance provider under contract to the
County so that:
a. all areas of the county will be guaranteed an ALS
ambulance response to incidents 95% of the time
b. ALS ambulance staff will be increased to eliminate the
need for firefighters in ambulances for transportation
when the fire department is an area remote from the
Trauma Center and reduce the need for firefighters in
ambulances in high response areas
5. Subsidize any additional pre-hospital emergency medical
training (equipment and personnel costs) undertaken by a
fire department that exceeds what is required by State Code
for the service level of EMS provided.
6a. Develop and implement a countywide priority dispatch system
including the use of pre-arrival instructions.
6b. Develop and administer training to all pre-hospital care
providers on procedure care of casualties exposed to
hazardous materials.
6c. Develop a system of two-way communications to allow para-
medic ambulances under County contract to talk with
responding or on-scene fire units.
6d. Provide for contingency funding available to all depart-
ments for communicable disease prevention through
equipment, immunization, etc.
7 . Develop and place throughout the County emergency care
supplies and equipment caches for use during multi-casualty
or disaster type incidents.
8a. Develop and administer a coordinated and continuous public
education program for the citizens that will emphasize:
a. what is an emergency
b. immediate first aid
c. how to utilize the EMS system
8b. Full or partial reimbursement of non-reusable emergency
care supplies that are not compensated for through patient
or insurance billing and for damaged or lost reusable
emergency care equipment
9. Develop and administer training to law enforcement agencies
on EMS operations.
E. Needs/Concerns
In the process of surveying County fire departments, the
Committee also identified other EMS concerns or needs that may
not require funding. They are listed in priority of concern:
1. A standardized method to assure the return of fire
department emergency care equipment from hospital emergency
j departments.
2 . The need to bring first responders into the ALS or base
station educational-process.
3 . Improved procedures and coordination of advanced life
support helicopter use within County.
4a. Establishment of fire department co-operative purchasing of
emergency care supplies and equipment to reduce costs.
4b. Development of a method of stabilizing firefighters in
ambulances who administer chest compression on cardiac
arrest patients during transportation.
5. Recognition of testing by County EMS, training with
ambulance companies and training by or with local hospitals
for satisfying continuing education requirements.
6. Development of equipment standards where applicable to
allow for an equipment exchange between the private
ambulance contractor and fixe departments.
7. The development of foreign and sign language quick reference
cards for all response units.
Exhibit D
Budget Illustration
A . V
FIRST YEAR BUDGET ILLUSTRATION
PARAMEDIC SERVICE $ 1 ,600,000
Additional paramedic ambulance coverage 1 ,500,000
Additional base hospital coverage (4 zones) 100,000
MEDICAL FIRST RESPONDER SERVICE (Fire) 330,000
Early defibrillation program:
Purchase of automatic defibrillators and
related equipment 100,000
Defibrillation program training/coordination 90,000
EMT-I and related training/equipment/supplies 140,000
MEDICAL DISPATCH AND COMMUNICATIONS 210,000
Emergency medical dispatcher program
training/coordination 60,000
Enhancements at 9-1-1 medical dispatch
centers (6 PSAP' s) 100,000
EMS Communications Plan development 50,000
OPERATING BUDGET 2,140,000
Administrative costs (10%) 214,000
Contingency reserve (10%) 214,000
TOTAL APPROPRIATION 2,568,000
ASSESSMENT RATE CALCULATION:
$2,568,000 / 480,349 benefit units = $5.35 per benefit unit
Comments on Budget Items
Subsidy for additional paramedic ambulance service. Estimated annual
subsidy cost for additional paramedic ambulance coverage. Actual subsidies will
be established following a competitive selection process conducted by the Health
Services Department and using a performance based Request for Proposal .
Base hospital services. Payments to base hospitals for additional cost
incurred for providing medical direction and quality assurance for an expanded
paramedic program.
Purchase of automatic defibrillators and related equipment. The total
equipment cost for implementing first responder defibrillation countywide is
estimated at $505,560 including 60 defibrillator units at $6,850 each, 5
training mannequins at $1,400 each, and 3 transcribers at $1 ,100 each.
Amortized at 8 percent over five years, this represents an annual cost of
approximately $100,000.
Defibrillation program training and coordination. Cost for a quarter-time
physician medical director and a full-time nurse trainer/coordinator to develop
and carry out first responder defibrillation training and required ongoing
monitoring.
Other medical training, equipment, and supplies. Funds budgeted under
this category will be used to reimburse fire services according to priorities
established only up to the amount budgeted. Priority will be for training
necessary for first responder personnel to qualify for EMT-I certification or
other EMS approved first responder certification and for purchase of first aid
supplies for multicasualty/disaster caches.
Emergency medical dispatcher program training and coordination. Cost of
a full-time coordinator/trainer to develop and carry out medical dispatcher
training and conduct appropriate monitoring.
Enhancements at 9-1-1 medical dispatch centers. Funds will be available
to existing fire/medical dispatch centers (Richmond, West Bay, Consolidated
Fire, Sheriff's Dispatch, DRCC, and San Ramon Valley) for improvements in
ambulance dispatching.
EMS Communications Plan. Estimated cost for development of a long range
EMS communications plan including ambulance-to-hospital communications and
ambulance dispatch.
Administrative costs. Ten percent of the operating budget will be
allocated for additional administrative costs including overhead and collection
of fees.
Contingency reserve. A ten percent reserve will be maintained for
unanticipated program costs.
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