HomeMy WebLinkAboutMINUTES - 08212012 - FPD SD.4RECOMMENDATION(S):
ACCEPT a report on the Evolution of the Fire Service and The Relationship of Fire First Response to Emergency
Medical Services.
FISCAL IMPACT:
No Impact
BACKGROUND:
Recently, a number of questions have been raised regarding the service delivery model for fire protection and
emergency medical services. The fire service has evolved over the years and accepted a broader mission of
community protection. An integrated system provides the highest level of protection, patient care, and service to the
public. Additionally, an all-hazards response system provides added value to the public for resources that are required
to be in place for fire protection.
CONSEQUENCE OF NEGATIVE ACTION:
The report will not be accepted.
CHILDREN'S IMPACT STATEMENT:
No Impact
APPROVE OTHER
RECOMMENDATION OF CNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
Action of Board On: 08/21/2012 APPROVED AS RECOMMENDED OTHER
Clerks Notes:
VOTE OF SUPERVISORS
AYE:John Gioia, Director
Candace Andersen,
Director
Mary N. Piepho, Director
Karen Mitchoff, Director
Federal D. Glover, Director
Contact: Daryl Louder,
925-941-3500
I hereby certify that this is a true and correct copy of an action taken and entered on the minutes of the Board
of Supervisors on the date shown.
ATTESTED: August 21, 2012
David Twa, County Administrator and Clerk of the Board of Supervisors
By: June Mc Huen, Deputy
cc: Daryl Louder
SD. 4
To:Contra Costa County Fire Protection District Board of Directors
From:Daryl L. Louder, Chief, Contra Costa County Fire Protection District
Date:August 21, 2012
Contra
Costa
County
Subject:Evolution of the Fire Service
ATTACHMENTS
The Relationship of First Response to EMS
The Evolution of the Fire Service
1
Emergency Medical Services Agency
August 8, 2012
Report to the Local Agency Formation Commission
The Relationship of Fire First Response to Emergency Medical Services
On September 26, 2011, the Contra Costa Emergency Medical Services (EMS) Agency submitted a report
to LAFCO on the accomplishments and challenges facing the EMS System. Since then the EMS agency
has become actively involved in mitigating consequences of fire station closures in East Contra Costa
County and is concerned about the potential erosion of fire first response countywide. In preparation
for the August 8, 2012 LAFCO meeting the EMS Agency has been requested to submit the following
report.
The Challenge
Fire services play a vital role in providing an engine “first response” to 9‐1‐1 medical emergencies. In
some areas (Moraga‐Orinda and San Ramon Valley) fire services also provide emergency ambulance
response. In other areas of Contra Costa County, emergency ambulance response to 9‐1‐1 calls is
provided by a private company, American Medical Response (AMR). The Contra Costa EMS Agency, a
division of Contra Costa Health Services, is charged with overall coordination of the EMS system and
administration of ambulance service contracts, as well as contracts with fire services providing
paramedic service and with hospitals providing specialized emergency service. With significant
budgetary pressures currently affecting nearly all public sector entities, Contra Costa County has already
been impacted by cutbacks in fire service in some areas, and may see more cutbacks in service in the
months ahead. Fire station closures mean fewer fire engines available for medical first response. The
purpose of this document is to discuss the structure of the EMS system and the potential impacts of fire
station closures.
The EMS System at Work and the Role of First Responders
When a medically‐related 9‐1‐1 call occurs in Contra Costa, the call is routed to one of three designated
fire/medical dispatch centers located at Contra Costa County Fire, San Ramon Valley Fire, and Richmond
Police. There, specially‐trained dispatchers systematically assess the medical needs based on
information the caller provides, assigns a dispatch priority to the call, dispatches the appropriate EMS
resources and may provide emergency first aid directions to the caller. A typical emergency call receives
a fire engine first response and an ambulance, both dispatched immediately with lights and siren (Code
3). In some cases, where the dispatcher determines the call is less urgent and less complex, an
ambulance alone may be dispatched without lights and siren.
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All emergency ambulances and most fire first responder units are staffed with at least one paramedic‐
trained crewmember.1 Other crewmembers are trained at the Emergency Medical Technician I (EMT‐I)
level. All responders, whether paramedic or EMT‐I, are trained and equipped to perform most
immediately needed life‐saving first aid measures such as controlling bleeding, opening and maintaining
an airway, providing cardio‐pulmonary resuscitation (CPR), and performing cardiac defibrillation. Only
paramedics can administer drugs and perform certain other advanced medical procedures.
Fire first responders typically arrive 2‐5 minutes before an ambulance, but, depending on the location of
the call and the location of the responding units, that interval can be 10 minutes or more. While a few
minutes difference in response times do not affect the outcome for most patients, in certain critical
cases – cardiac arrest, breathing difficulty, profuse bleeding – minutes, or even seconds, can make a
difference in saving a life or avoiding serious complications. Fire first‐responders provide emergency
treatment on scene until care can be transferred to the ambulance crew, continue to assist in patient
care when needed both on the scene and, in some cases, en route to the hospital. Importantly, fire first
responders provide scene management, safety oversight, and rescue services (e.g., extricating patients
from motor vehicle accidents). When patients require transport by helicopter (most often critical
trauma patients), fire responders are required to manage the landing site. Fire personnel have all
hazard capabilities not easily duplicated or replaced by other personnel.
While fire resources generally are station‐based, AMR ambulance resources are “dynamically” deployed.
Using a system known as “system status management,” ambulance units are moved to predefined post
locations based on system status (number of units available) at any given time. Thus, when one
ambulance is dispatched to a call, one or more other ambulance units may be moved to best cover the
area. The goal is to post to locations where the best response times can be achieved for the next
expected calls based on history, time of day, and day of week. While this system maximizes use of
available resources, it does not provide the depth of resources generally associated with the fire
services.
Potential Patient Care Impacts of Reductions in Fire Service Resources
Ambulance response time is unaffected by the changes in fire first response as emergency ambulance
response time requirements are set by County contract. First responder response times are obviously
affected in those areas where a fire station closure increases the response time from the next closest
station. Additionally, first responder response times may be negatively impacted in all areas when the
engine from the closest station is occupied on another call. Where first responder response times are
delayed, critical interventions needed in the early stages of some calls may be delayed and, in the most
serious cases, treatment delays may affect patient outcome. Also, transport times (time from 9‐1‐1 call
1 In areas without paramedic first response (East Contra Costa County Fire, Richmond, Crockett‐Carquinez Fire), the County
through its ambulance contract has required AMR to provide additional ambulance units or single‐paramedic‐staffed non‐
transporting “Quick Response Vehicles” to respond with the fire first responders.
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until patient arrival at hospital) may be negatively impacted when the ambulance crew is required to
spend more time treating the patient on the scene due to the delayed arrival of the first responder.
Disaster and Multi-Casualty Events
Contra Costa County, like many communities in the Bay Area, has hazards related to industry,
transportation, flood and wildfire, as well as urban and rural demographics. The Contra Costa EMS
Agency plays a role in supporting emergency operations as part of a system of strong ”all hazards”
emergency response. Although large‐scale emergency events occur infrequently, they predictably
require numerous fire, ambulance and hospital resources to rapidly respond, triage, treat and transport
victims. In these scenarios the importance of having an adequate first response capability to effectively
mitigate these risks cannot be minimized. The “all hazard” capabilities of the fire services are part of the
county’s critical infrastructure to respond to a mass casualty event or disaster.
EMS Agency Role and Changes in Fire First Response
Fire first response is provided by the county’s six fire districts and three municipal fire departments and
is supported primarily through local funding. Each of these services through its governing body,
determines the level of service to be provided. The EMS Agency works in collaboration with Fire‐EMS
and Ambulance provider agencies to support a coordinated system of patient care pursuant to Section
1797.103 of the California Health and Safety Code.
Measure H Support for Fire First Responders and Fire Paramedic First Response
In 1988, a countywide ballot measure (Measure H aka CSA‐EM‐1) enabled the Board of Supervisors
(BOS) to establish an annual parcel charge ($10 for a single family residence) to pay for enhancements to
the County EMS system, including providing increased paramedic availability. From 1989‐2004 this
funding was primarily used to provide more paramedic ambulance availability.
In 2004 a County EMS system redesign plan was approved by the Board of Supervisors and since then
Measure H funding has been used to subsidize the added cost of providing fire first responder
paramedic service. The available Measure H funding has enabled the County to provide an annual
subsidy of $30,000 for paramedic‐staffed fire engines. Since 2004 the majority of Measure H funding
has been used to support Fire‐EMS paramedic programs.
Measure H partially offsets the added cost to a fire service to upgrade its first responder units to the
paramedic level, but, obviously, represents a small fraction of the actual cost of maintaining a station. In
areas without paramedic engines, the County has provided additional paramedic coverage through
AMR. In Emergency Response Zone A (Richmond) this is accomplished with AMR providing dual
paramedic ambulances and in Emergency Response Zone E (East County) by providing single medic
Quick Response Vehicles (QRVs) co‐located with fire to provide a level of paramedic first response.
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These accommodations were instituted in 2004 to provide an “equitable level” of prehospital care to all
communities.
In 2010 the Contra Costa BOS approved a provision to preserve Measure H paramedic first response
funding for fire agencies faced with “browning out or closing” fire stations due to budgetary constraints.
Under this provision fire agencies continue to receive their same level of paramedic engine funding as
long as “paramedic first response service” continues to the affected community. As the fire agencies
are forced to reduce “paramedic engines,” funding for paramedic first response may be affected under
the current paramedic first responder fund requirements. The EMS Agency believes that funding to
preserve fire first response, regardless of level, is a priority for the Contra Costa EMS system.
Other Support for Fire First Response from Measure H
Measure H funds directly support the practice of medicine by prehospital personnel with the goal of
improving patient outcome throughout the EMS System. Examples of fire agency support include:
1. Prehospital equipment, such as Automated External Defibrillators (AEDs), 12‐lead (ECG)
transmission‐capable cardiac monitors, cardiac compression devices and mass casualty
equipment.
2. Contra Costa Fire‐EMS Training Consortium competency programs including patient care
simulators that mimic real‐life physiologic response to life threatening conditions.
3. Implementation of electronic prehospital patient data systems providing appropriate oversight
of patient care to support improved outcomes in cardiac arrest, stroke, heart attack, and other
conditions.
4. Fire‐EMS clinical personnel responsible for agency level oversight of paramedic and EMT
clinical performance required to support systems of care, e.g. Trauma, Stroke, STEMI and
Cardiac Arrest.
5. Computer‐aided dispatch upgrades and “smart” integrated dispatch automated programs
supporting appropriate matching of resources to patient condition including bystander CPR, e.g.
Emergency Medical Dispatch2, PulsePoint3.
Summary:
The coordinated response of fire and ambulance services is an essential partnership in the care of 9‐1‐1
patients. The EMS Agency will continue to work with each fire service to achieve optimal integration
2 Emergency Medical Dispatch (EMD) is a standardized dispatch interview approach to 9‐1‐1 medical calls consistent with
national dispatching standards.
3 PulsePoint is a dispatch linked GPS smartphone enabled application that advises bystanders trained in CPR where the nearest
AED is located and advises them that they are near cardiac arrest victim.
5
and coordination of first responder and emergency ambulance service, but the level of fire first response
is determined by the governing bodies of each fire service. The Contra Costa EMS Agency does not
control the funding, configuration or response capability of fire first‐responder services and does not
have the resources to fill gaps that may result from cutbacks to fire services. Although 9‐1‐1
ambulance response times are NOT impacted by these changes, ambulance service cannot duplicate
fire first response times or activities. Contra Costa EMS continues to carefully monitor EMS response
and patient care as the capabilities of fire first response change.
At the same time emergency medical care is entering a period of dramatic change that requires the EMS
system to “fully integrate” with the health care system to reduce cost and improve patient outcomes.
Partnerships will include not only hospitals but health information systems, Accountable Care
Organizations (ACOs), and Patient Safety Organizations (PSOs). EMS‐Health Care integration will provide
extraordinary enhancements in emergency care and opportunities for interested provider agencies to
innovate using trained prehospital professionals. Examples include:
1. The current EMS System Trauma, STEMI, Stroke, Cardiac Arrest and HeartSafe programs.
2. Linking dispatch agencies to nurse call centers to better match patient need to resources.
3. The use of community paramedics to support in‐home programs to prevent injuries, provide
health maintenance, monitor medically fragile or discharged patients reducing the volume and
cost of preventable emergencies.
4. Integrated health information record systems to support coordinated care between the field
and the emergency department.
5. EMS provider agency and ACO partnerships to reduce or prevent hospital re‐admissions.
6. Implementation of new pre‐hospital care roles, e.g. Advanced EMT, Community paramedic.
7. Innovative programs to help support populations who use the EMS system because access to
care is otherwise not available.
8. Creation of potential new revenue streams to support EMS providers interested in pursuing
hospital and ACO partnerships.
Contra Costa EMS System provider agencies are all well positioned to partner with health care system
providers to support efficient, safe and evidence‐based patient care in this new environment. The EMS
Agency is committed to working collaboratively within the capabilities of the community to help support
these opportunities and fulfill its mission.
1940’s –1950’s –Fire Suppression“Brute Force” Rescue1960’s –Firefighters Provide First AidAmbulance transport provided by Funeral Homes, Hospitals, Private CompaniesRescue limited to simple tools and techniques
1970’s ‐Pre‐Hospital Care ‐Facilitated by U.S. Department of Transportation:Advance First AidEmergency Medical TechniciansParamedics
Integrated Response System –“The confluence of public safety, public health, and the medical system.”Pre‐hospital –Advanced training and interventionTransport (Ground and Air)Emergency RoomTrauma CentersAdvancement in rescue equipment, procedures, and training.
Transition to “All‐Hazards” OrganizationsEnhanced –ProfessionalismEducationTechnologyScience/DataEmerging FieldsHazardous MaterialsEnvironmental Protection
The 1990’sUrban Search and RescueConfined SpaceTrench RescueBuilding Collapse RescueHigh Angle Rope RescueSwift Water RescueContinued advancement with technology, training, and procedures.
Response to TerrorismCommunity Threat ReductionEmergency Preparedness and Emergency ManagementNational Incident Management SystemNational Response Framework12‐Lead EKG, STEMI and Stroke CentersPublic Health Threats ‐Pandemics
EMS System Design (2004)High Performance▪Dispatch‐Fire First Response‐Transport‐Hospital▪Advanced Life Support Paramedic▪Coordinated patient care teamsHigh Reliability▪Rapid response and transport to definitive care ▪Optimized within local capabilitiesHigh Trust▪Commitment to Patient Safety’▪Evidence‐based
Basic Life Support is Fundamental Medical CareCritical Link in the Chain of SurvivalImportance of Multi‐Agency Teamwork911 Use ‐How would it change without first response?
Full integration with Health CareTrauma, STEMI, Stroke, Cardiac Arrest Dispatch‐Nurse Call Center PartnershipsLinked medical record systemsNew pre‐hospital care rolesCommunity ParamedicAdvanced EMTEMS and Accountable Care Organizations (ACOs)Strategic Hospital/Health Plan partnerships Potential new revenue streams
Respond to the diverse threats facing the community.Enhanced protection and service to the publicStrong efforts to prevent and prepareEmphasis on professionalism, education, training, science/data, technology, and best practices.“Added value” for the public