HomeMy WebLinkAboutMINUTES - 08052014 - D.7RECOMMENDATION(S):
RECEIVE EMS Director and Medical Director and EMS Agency staff preliminary recommendations associated with
the EMS System Modernization Study, and upcoming emergency ambulance procurement for Emergency Response
Areas (ERA) I, II and V. The following recommendations for RFP do not apply to emergency ambulance services
provided by Moraga-Orinda Fire Protection District in ERA III and San Ramon Fire Protection District in ERA IV.
APPROVE Ambulance RFP (Request for Proposal) Preparation Process and Timeline.
1. EMS Agency will support transparency in the competitive process by posting all RFP materials, bids and review
documents on the Contra Costa EMS website at http://cchealth.org/ems/system-review.php#simpleContained8
a. Timeline and all related documents will be posted on the web as soon as available.
b. Mechanisms for ongoing public comment will be available throughout the process via email, fax or mail.
2. Solicit a panel of neutral, qualified out of county RFP reviewers to objectively score each RFP submission as part
of a fair, transparent competitive process.
a. The search for review panel members will be conducted by Fitch and Associates LLC and submitted to the Board
of Supervisors (BOS).
b.
APPROVE OTHER
RECOMMENDATION OF CNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
Action of Board On: 08/05/2014 APPROVED AS RECOMMENDED OTHER
Clerks Notes:
VOTE OF SUPERVISORS
AYE:John Gioia, District I Supervisor
Candace Andersen, District II
Supervisor
Mary N. Piepho, District III
Supervisor
Karen Mitchoff, District IV
Supervisor
Federal D. Glover, District V
Supervisor
Contact: Patricia Frost,
646-4690
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 5, 2014
David Twa, County Administrator and Clerk of the Board of Supervisors
By: June McHuen, Deputy
cc: Pat Frost, T Scott, C Rucker
D.7
To:Board of Supervisors
From:William Walker, M.D., Health Services Director
Date:August 5, 2014
Contra
Costa
County
Subject:EMS (Emergency Medical Services) Agency Staff Recommendations for the Preparation of Emergency Ambulance
Request for Proposal (RFP) for Emergency Resp
RECOMMENDATION(S): (CONT'D)
The five member review panel to consist of EMS Agency Directors, Fire Chiefs, and/or EMS System clinical and
ambulance service delivery experts.
3. Prepare the RFP in partnership with EMS System stakeholders, potential bidders and health system providers in
a day long consultant facilitated workshop to be held in early September 2014, to be followed by BOS review of
stakeholder recommendations.
a. An open transparent RFP preparation process with strong stakeholder engagement will assure local community
and EMS System needs are met.
b. The RFP development workshop will be designed and facilitated to assure that local knowledge and expertise is
incorporated into RFP specifications and scoring criteria.
4. Conduct the procurement process in accordance with the following approximate timeline (2015 dates are
subject to final 2015 Board Schedule for Calendar Year 2015):
a. Workshop to draft RFP with stakeholders September Early TBD, 2014
b. Board RFP workshop Review September TBD, 2014
c. Draft RFP to EMS Agency November 3, 2014
d. Draft RFP to BOS for approval December 9, 2014
e. RFP to California State EMS Authority for Approval December 10, 2014
f. Final RFP to BOS for Approval January/Feb TBD - 2015
g. RFP Released to Bidders February 18, 2015
h. Proposer’s Conference March 4, 2015
i. Proposals Due April 15, 2015
j. Review Panel Evaluation Period April-May TBD, 2015
k. Recommendation of Review Panel to EMS Agency May TBD, 2015
l. EMS Agency Recommendation to BOS Intent to Award June TBD, 2015
m. Final Contract Preparation Period June-Aug TBD 2015
n. Final Contract Approved by BOS Sept TBD, 2015
o. New Contract Start January 1, 2016
AUTHORIZE the Health Services Director and EMS (Emergency Medical Services) Agency to prepare a request
for proposal (RFP) for emergency ambulance services for Emergency Response Areas (ERA) I, II, V with no
County subsidy and submit the Final RFP to the Board for approval by January/Feb 2015.
APPROVE minimum credentials and qualifications for emergency ambulance RFP candidates.
1. Demonstrate ability to provide Advanced Life Support (paramedic) ambulance service.
2. Demonstrated ability to meet performance based response time standards.
3. Commitment to cooperate with a county effort to develop single uniform emergency medical dispatch services.
4. Demonstrated ability to provide a high level of clinical competency and performance at advanced life support
level.
5. Demonstrated financial strength and stability.
6. Demonstrate ability in EMS ambulance flexible deployment, management and clinical quality improvement
processes.
AUTHORIZE the EMS Agency to incorporate the following features and changes based on recommendations
from the Fitch EMS Modernization report:
1. A five year performance based competitive contract for emergency ambulance services at no cost to the county
with an option for a 5 year extension to include the ability to cooperate with a -single uniform emergency medical
dispatch and other mobile health services.
2. Proposers will be required to employ whatever level of effort is necessary to achieve the clinical, response time,
quality improvement, customer satisfaction and other performance results required by the EMS System
specifications.
3. Support the integration of operational and electronic patient care data systems consistent with state and federal
privacy and protection laws.
4. Assist to develop and provide expanded mobile health care services in partnership with health system providers.
5. Pending additional urban, suburban and rural demand analysis, the urban Response Areas will be modified
consistent with the EMS study demand analysis resulting in shorter response times for those newly designated
urban areas.
6. Paramedic Quick Response Vehicles (QRVs) will be eliminated
a. In 2004, QRVs were created to provide a paramedic response within 10 minutes.
b. EMTs scope of practice has increased in the last ten years.
c. Rapid first medical response is competently managed by all fire agencies responsible at both the EMT and
Paramedic service levels. This function should not be duplicated by ambulance service provider.
d. Expansion of urban response zones will improve ambulance response for affected areas.
7. RFP may lengthen response times ONLY in the designated urban areas commensurate with a verified similar
decrease in dispatch times not to exceed 60 seconds, pending further modeling of demand analysis by the Fitch
consultants.
a. Improvements in emergency medical dispatch processing may improve first responder and ambulance
deployment up to 1 or more minutes based on Fitch EMS Study.
b. Response times for non-critical patient conditions can be modified using a medical priority dispatch process
when properly used under medical control and oversight to assure patient safety.
8. The EMS system response times should be based on supporting the needs of the patient. Minimum emergency
ALS ambulance staffing will be standardized in all response areas to one EMT (Emergency Medical Technician)
and one paramedic consistent with EMS science, local experience for medical efficacy and cost/benefit utilization.
9. Require future ambulance service provider to dedicate adequate staff, resources for patient safety, quality
improvement, data management, technology integration and transparent performance reporting to support a
coordinated EMS System of Care for ambulance response, Trauma, STEMI, Stroke, Cardiac Arrest and other
EMS System programs that may evolve in the future.
10. Require provider to dedicate resources for Community Outreach including HeartSafe communities, injury
prevention, education and training supporting CPR (Cardiopulmonary resuscitation) in communities and schools,
AED (automated external defibrillation), Stroke, Heart Attack and Cardiac Arrest.
a. Prevention and early recognition are essential to improving survival.
b. Bystanders and HeartSafe communities are part of the chain of survival for cardiac arrest, heart attack and
stroke.
c. Bystander CPR and early defibrillation are known to be the important factors supporting long term meaningful
survival.
11. Require bariatric capable ambulances to support community demands.
12. Require a performance based review program for consumer billing complaints with options for extended
payment and compassionate care in coordination with the Contra Costa County HICAP (Health Insurance
Counseling and Advocacy Program).
13. Incorporate the ACCMA recommendation to utilize a clinical advisory body to review RFP recommendations
related to community paramedicine, treat and no transport, medical priority dispatch and alternative destination to
ensure patient care is not compromised.
14. Require that county costs for contract management and quality oversight be supported.
FISCAL IMPACT:
No general fund impact. It is intended that ambulance services obtained under the upcoming procurement be 100%
supported through user fees and insurance without County subsidy.
BACKGROUND:
Background:
The Contra Costa EMS system is a high performance, collaborative network of public safety, fire, transport, and
The Contra Costa EMS system is a high performance, collaborative network of public safety, fire, transport, and
emergency hospital personnel committed to improving patient outcomes. The EMS system serves all regardless
of ability to pay, every hour of the day, 365 days a year. In 2013, the Contra Costa EMS system responded to
over 80,000 9-1-1 calls for medical assistance with 7-13% associated with critical or “life and death” events. At
the same time EMS is known to be the most costly way for individuals to access emergency department care.
In 2004 the Contra Costa Board of Supervisors approved the first EMS System Design supporting the
development of paramedic first response, advanced life support enhancements, emergency communication and
dispatch. Prior to 2004 the County had paid over $ 2.5 million of Measure H (CSA-EM1) funds annually for
emergency ambulance services. After 2004, emergency ambulance services have been exclusively supported by
revenue from patient co-pays and medical insurance reimbursement. Measure H funds used previously to
provide an ambulance provider subsidy were re-allocated to support fire first medical response.
The Contra Costa Board of Supervisors received the Fitch & Associates EMS Modernization Project Report on
June 3, 2014. The full report with accompanying public comment is posted on the Contra Costa EMS Website at:
Fitch EMS Study final report: http://cchealth.org/ems/pdf/2014-EMS-System-Modernization-Study.pdf
Fitch EMS Study Public Comment and Consultant Response:
http://cchealth.org/ems/pdf/2014-EMS-System-Modernization-Study-Public-Comments.pdf
Changes associated with health care reform, downturns in local economies and increased costs associated with
the practice of pre-hospital medicine have created new fiscal challenges. The Fitch EMS study reported on
Contra Costa EMS System current capabilities, increased needs for ambulance service in both East County
associated with population growth and West County due to pending closure of Doctor’s Medical Center. The
report described trends in operational costs and utilization affecting all EMS System stakeholders. Fitch
consultants identified numerous measures to improve EMS System efficiency and reduce cost while maintaining
high quality patient care that could be incorporated in the upcoming ambulance procurement process.
Based on the findings in the Fitch EMS Study, it is the EMS Agency’s recommendation that selected efficiencies
are implemented and resources be redirected to assure an effective level of EMS service delivery throughout the
county. Any savings associated with efficiencies should be exclusively used to support a fiscally sound,
accountable, safe and high quality emergency ambulance service. The Fitch EMS Modernization Report
identified efficiencies consistent with EMS industry standards, EMS science and based on the following
priorities:
Safe, quality patient care1.
A consistent level of fiscally sustainable ambulance service delivery throughout the county2.
Value driven operational and clinical ambulance performance3.
A commitment to support a single uniform accredited emergency medical dispatch capability designed to
support medically controlled deployment of EMS system resources based on the patient condition.
4.
Value driven EMS Systems use the best available empirical and scientific evidence to provide optimal
deployment of resources to meet patient care needs, within the fiscal capabilities of the communities served.
While long term solutions will be determined by policy makers, in the short term RFP efforts should reduce cost
for the county while redirecting savings by optimizing flexibility in EMS service delivery.
The Importance of a Neutral Out-of-County RFP Expert Review Panel
Neutrality is critical to the ambulance procurement review process to attract and maximize the number of
qualified bidders participating in the process. Potential RFP candidates consider the following top areas when
determining their bidding efforts and interest:
Preparation of the RFP: If RFP content is considered to bias the RFP towards one entity or another
interested candidate may elect not to bid or may challenge the process.
1.
Scoring & weighting of review criteria: If the review criteria, scoring or weighting benefits one entity,2.
interested candidates may elect not to bid or may challenge the process.
Who is on the review panel: If the panel is perceived as biased in any way, interested candidates may elect
not to bid or may challenge the process.
3.
Supports an acquisition process to deliver on a timely basis, the best value service to the customer, while
maintaining the public’s trust and fulfilling public policy objectives.
4.
Promotes competition between contractors who have a successful past performance or who demonstrate a
superior ability to perform.
5.
A neutral review by out-of-county technical experts supports a confidential, fair and unbiased review of
candidate bids based on the merits of their bids. The proposal itself tells the review not only “what” will be
accomplished, but “how” it will be accomplished and assures local service requirements will be met.
For these reasons the EMS Agency staff recommends that a neutral out-of-county review panel of technical
experts in emergency ambulance service be used. In a recent informal survey of Bay Area and Northern
California EMS Agencies in July 2014, the use of qualified out-of-county and out-of state RFP reviewers was
the most common practice over the last three years.
Full Day Transparent RFP Development Workshop
Due to the importance of the emergency ambulance RFP and EMS system changes being considered, the EMS
Agency is recommending a consultant facilitated workshop for RFP development to capture local knowledge
and expertise to be incorporated into RFP. The RFP will specify “what” will be accomplished, but “how” it will
be accomplished while assuring local service requirements are met.
Workshop Purpose: Is to convene local experts in identifying the issues and components of the EMS system
and it operations to be addressed in the upcoming RFP. Invitees/participants would include: Potential Bidders,
Health System Representatives, System Stakeholders, Medical Community, elected and other local jurisdictional
staff. A separate supervisor briefing will be provided to review recommendations from workshop - after the RFP
preparation workshop is completed. Workshop Concepts to be included:
Goal of RFP Preparation: To attract multiple qualified bidders to submit proposals that provide services to the
County through a fair and objective competitive process.
Safety Net provisions1.
Performance requirements2.
General legal provision3.
Procurement process/timeline4.
Description of Public and Stakeholder Process Associated with EMS Modernization Study
During the Fitch EMS Modernization Study the numerous stakeholder meetings, public meetings and written
public comment was summarized and addressed as part of the EMS study. This included over 25 written
comments from EMS System stakeholders including recommendations on the upcoming ambulance
procurement. Comment was received by the Town of Danville, Supervisor field representatives, consumers,
Emergency Medical Care Committee (EMCC), Alameda and Contra Costa Medical Association (ACCMA),
City of Brentwood, Hospital Council of Northern and Central California, Emergency and Non-Emergency
ambulance providers, Contra Costa Taxpayers Association, Local 1230, Kaiser Permanente, LAFCO, San
Ramon Valley Fire, Contra Costa Executive Chiefs, City of Richmond Police Chief, John Muir Health, EMS
Agency Director and Medical Director. The EMCC hosted a public hearing on March 3, 2014 and conducted a
special EMCC meeting open to the public on July 17, 2014. During that meeting the EMCC passed a motion
recommending that a member of the EMCC serve on the RFP review panel and that minimum qualifications for
RFP candidates do not restrict local providers from becoming a bidder. (see supporting documents for letter)
The EMCC, in their letter dated April 28, 2014, submitted the following recommendations for the next
ambulance contract including several points to improve service delivery. (Fitch EMS Study Public Comment
document page 9)
Single point ordering for Fire and Ambulance response1.
GPS tracking2.
Common communications3.
Integration of BLS transports for Alpha, Beta and some Charlie levels4.
Utilization of ALS transports for higher Charlie, Delta and Echo levels5.
Utilization of Fire First Responders for higher Charlie, Delta and Echo Levels6.
Level 0 (zero) will trigger BLS transports responding to higher Charlie, Delta and Echo level incidents
with Fire First Responders.
7.
Utilization of BLS transport for 5150 without external factors i.e. drugs or alcohol.8.
Allowance for Police Officers to transport 5150 (if staffing allows) without external factors, i.e. drugs or
alcohol.
9.
Allowance of dispatch centers to directly contact a BLS provider for 5150 transports in accordance with
ambulance zone agreements for providing service in Contra Costa County
10.
Not increase response time, as suggested but utilize available resources by real-time tracking.11.
Common ePCR (electronic patient care record) for data gathering.12.
Distribution of ePCR in a depository for access by receiving hospitals to eliminate the fax transmissions.13.
The ACCMA submitted a letter of comment on May 5, 2014 (Fitch EMS Study Public Comment document page
30) stating that “The report had many worthy recommendations especially those that are supported by empirical
evidence” including recommendations for one minute extension of response times, flexible deployment of
existing paramedic personnel with support for use of BLS level responders. Their letter also expressed concern
about the economic and political feasibility of consolidated medical dispatch and added the following
recommendations:
More efforts to focus on continuous process improvement using LEAN and Six Sigma techniques to
expand EMS capacity.
1.
Utilize clinical advisory body to review recommendations related to the report’s recommendations for
community paramedicine, treat and release, medical priority dispatch and alternative destination to ensure
patient care is not compromised.
2.
Evaluate the magnitude of possible inappropriate use of 911 by some schools and nursing homes3.
Request public comment on RFP for emergency transport services with mechanisms for the medical
community, other stakeholders and the public to provide feedback on the appropriateness of changes
before they are implemented, again using a clinical committee of community physicians and other
clinicians as described in their letter.
4.
The Hospital Council comment letter concurred with the following Fitch report recommendations related to
future ambulance procurement:
Consolidated medical communications into a single center1.
Exploration of dispatch referrals to advice nurse lines or other agencies and providers to reduce
unnecessary emergency department visits and avoidable hospital readmissions.
2.
Interest in utilizing emergency care workforce for novel ways to improve health outcomes supporting
clinical integration and coordination of care.
3.
Their letter also recommended the need to improve availability of intra-facility ambulance transport and
that the sharing of health information & data was a worthy one, but required compliance with state and
federal law in order to ensure all necessary protections related to patient privacy and consent are in place.
With any public reporting of data by the Contra Costa EMS to allow hospital ample opportunity to review
and correct prior to publication.
4.
Fire Executive Chiefs comment letter (Fitch EMS Study Public Comment document page 42) of May 6, 2014,
expressed the following concerns associated with the report findings and recommendations: The intent of
Measure H and distribution of funds.
Concerns were raised regarding inadequacies in the data system platform (First Watch) and need for a
more comprehensive health information exchange analysis.
1.
Comments on use and reliability of medical priority dispatch system for EMS deployment.2.
Concern over extending response times and its impact on patient care.3.
Comments that the Advanced EMT role discussion in the report lacked supporting data.4.
Comment that “the report bypasses community or local agency expectations of service levels regardless of
category (BLS, ALS, transport), and assumes regional benefits.”
5.
Other key feedback related to the Fitch Study was from the Richmond City Manager Comment (Fitch EMS
Study Public Comment document page 47) who expressed concern regarding extending response times and
believed it would negatively affect their community and stated they did not support consolidated dispatch. The
complete compendium of public comment is available at
http://cchealth.org/ems/pdf/2014-EMS-System-Modernization-Study-Public-Comments.pdf
CONSEQUENCE OF NEGATIVE ACTION:
Opportunities to achieve financial savings, improve patient outcome and ambulance deployment, as well as
explore alternative service delivery models to enhance and support the EMS System would not occur.
Procurement of replacement emergency ambulance services for emergency response areas I, II and V will not
occur by the required deadlines.
CHILDREN'S IMPACT STATEMENT:
Approximately 8-10% of EMS system services are provided to children.
CLERK'S ADDENDUM
Speakers: Dan Colbath, Firefighters' Local 1230; Fire Captain Gil Guerrero; Vincent Wells, President
Firefighters' Local 1230; Jeff Carman, Chief Contra Costa Fire Protection District; Erik Rohde, General
Manager, American Medical Response; Paige Meyer, Executive Fire Chiefs of Contra Costa County.
ADOPTED the recommendations with the following modifications and additions: The neutral review panel will
have one member who is a resident of Contra Costa County; the word 'demonstrated' will be changed to
'demonstrate' in all occurrances; the EMS Director will work with County Counsel on appropriate methods to
have public participation on the stakeholders' meeting; and the County Administrators Office will schedule
and prepare a Board Order for the Board of Supervisors to acquire input from the Executive Chiefs of the Fire
Protection Districts.
ATTACHMENTS
CCEMS BOS RFP
EMCC and Executive
EMS System Opt
Opt Prehospital
Map
Map of Emergency Response Areas I, II and V, Associated with Request for Ambulance
Services RFP response areas are limited to ERA I, II and V and exclude emergency
ambulance services provided by Moraga-Orinda Fire Protection District in ERA III and
San Ramon Fire Protection District in ERA IV.
Contra Costa EMS Staff Recommendations
Preparation of Emergency Ambulance Request for Proposal (RFP)
EMERGENCY RESPONSE AREAS (ERA) I, II, V
Addressing the Need for Strategic EMS Service
Patricia Frost RN, MS, PNP-BC
Director Emergency Medical Services 1
EMS System Modernization
EMS System Review Purpose
EMS system flexibility
Enhance value for the patient
EMS/health care partnerships
Optimize systems of care
Support fiscal sustainability
Assure patient safety
Support patient care innovation
2
FITCH EMS MODERNIZATION STUDY
Identified strategic short
and long term options to
improve efficiency, expand
funding and reallocate
resources
3
54661
57008
60097 60671
61567
50000
52000
54000
56000
58000
60000
62000
64000
2009 2010 2011 2012 2013
Fitch Findings: Demand Has Increased
2009-2013
>12 % volume increase
2013
63% Government Payers
18.9% No Insurance
1.8% HMOs & VA
15.6% Private Payers
4
MORE URBAN AMBULANCE HOURS NEEDED
Fitch Report Page 13
5
FACING CONTINUED FISCAL LIMITATIONS
AND CORRECTIVE ACTION RECOMMENDED
Important EMS system trends
Decreasing revenue
Decreasing reimbursement
Increased call volume
Increasing costs of medical service delivery
Increased unfunded statutory mandates
Stakeholder fiscal constraints
County subsidies for ambulance service could be needed in the future if costs are not addressed
Fitch Report Page 81
6
CONTRA COSTA EMS SYSTEM UNDER FORCED CHANGE
FIRE STATIONS CLOSURES
MEDICAL CONTROL: DEPLOYMENT FOR MOST VULNERABLE
Contra Costa has lost
approximately 20% of it’s fire
stations since 2009 requiring
ambulance deployment
modifications
7
WEST COUNTY & THE EMS SYSTEM
CHANGES FUNDAMENTALS OF RFP
Risk
DMC
FULL IMPACT YET UNKNOWN
Increased Out of County EMS Transports
Abaris projected 2 million in added cost
Increased time on task, volume & ambulance hours
Countywide & regional effects
8
“EMS study findings
should be used in
upcoming ambulance RFP
to optimize the Contra
Costa EMS system”
EMS SYSTEM RE-DESIGN
9
EXPAND WHAT ENHANCES SURVIVAL
DISPATCH, CPR, AED, BLS, SYSTEMS OF CARE
Bystanders (CPR and AEDs)
Dispatched Aided CPR (bystander instruction)
Fire EMS (EMT, Paramedic)
Law Enforcement (AEDs)
HeartSafe Communities (CPR, PAD, Schools)
10
“CARE BEGINS WHEN THE CALL TAKES PLACE”
Institute for Healthcare Improvement July 24, 2014
“The Very First Responder In Any Emergency”
Optimal Medical Priority Dispatch Essential
11
PATIENT CENTERED EMS SERVICE
12
Reliable timely medical
transportation +
comfort required.
Safe to create EMS
service options for
appropriate patients
Rapid Response
+ Advanced Life
Support +
Systems of Care
Required
First
Responder
Hospital and
Intervention Home
Medical First
Response
NFPA
Goal 8 minutes
Systems of Care Management
Ambulance Medical
Response
Industry Standard is
12 minutes Urban
Dispatch Aided
Medical
Response NFPA
Goal 90 sec
EMS is Part of the Continuum of Health Care
The best patient outcomes depend on
Early Recognition + EMS + Systems of Care
Trauma, STEMI, Stroke, Cardiac Arrest
13 NFPA: National Fire Protection Agency Recommended EMS Standard
Dispatch
Paramedic
Transport
Unit Released &
Available
Partner
with
Health
Care
PATIENT FOCUSED OVERSIGHT
EMS/HEALTH CARE PARTNERSHIP
Provider Level Tools
Data Systems Promoting Improved EMS & Community Health Outcomes
Health Information Exchange
Focused on Patient Safety
Coordinated Field to Hospital Operations
EMS System Efficiencies
Performance Based
Informed Public Policy
Reporting Transparency
RELIES ON ROBUST QUALITY DATA SYSTEMS
14
THE EMS AGENCY RECOMMENDS
“A VALUE DRIVEN EMS SYSTEM”
Safe high quality pre-hospital patient care
Strong clinical, quality and operational oversight
Based on best available clinical & scientific evidence
Strengthened by engaged physician clinical advisors
Patient focused EMS deployment
Fiscally responsible
Flexible alternative service delivery models
Respect for first responder service levels
Incubator for future partnerships with hospitals & health plans
15
REQUEST FOR PROPOSAL (RFP) PROCESS
Timeline
Aggressive…we need to get this underway
New California State EMSA approval process
RFP Public Process & Transparency
All Documents on Website
EMS Stakeholder RFP Development Workshop
RFP determines what is to be accomplished and how
Incorporates community and stakeholder knowledge and expertise
Neutral Qualified Out-of-County Review Panel
Attracts more qualified RFP candidates
Assures Fair Competitive Process
Minimum Credentials
Ability to Perform
Duration
5 year with option for 5 year extension
16
REQUEST FOR PROPOSAL TIMELINES
Workshop to draft RFP with stakeholders September Early TBD, 2014
Board RFP Workshop Review September TBD, 2014
Draft RFP to EMS Agency November 3, 2014
Draft RFP to BOS for approval December 9, 2014
RFP to California State EMS Authority for Approval December 10, 2014
Final RFP to BOS for Approval January/Feb TBD 2015
RFP Released to Bidders February 18, 2015
Proposer’s Conference March 4, 2015
Proposals Due April 15, 2015
Review Panel Evaluation Period April/May TBD, 2015
Recommendation of Review Panel to EMS Agency May TBD, 2015
EMS Agency Recommendation to BOS Intent to Award June TBD, 2015
Final Contract Preparation Period June-Aug TBD 2015
Final Contract Approved by BOS Sept TBD, 2015
New Contract Start January 1, 2016
17
A FAIR, OPEN, COMPETITIVE PROCESS
18
http://cchealth.org/ems/system-review.php#simpleContained8
FOR INFORMATION
Patricia Frost, EMS Director
Contra Costa Emergency Medical Services
www.cccems.org
925 646-4690
19
1
EMERGENCY MEDICAL CARE COMMITTEE
CONTRA COSTA COUNTY
Chair
Darrell Lee
Contra Costa Fire Chiefs’
Association
1st Vice Chair
John Speakman
District II
2nd Vice Chair
Gary Napper
Public Managers’ Association
Executive Committee
Ross Fay
Air Medical Transportation
Provider
Executive Committee
Andy Swartzell
Contra Costa Fire Chiefs’
Association
July 23, 2014
Honorable Board of Supervisors
County of Contra Costa
651 Pine Street, 1st Floor
Martinez, CA 94553
Re: Motions from EMCC regarding considerations for next Ambulance
Request for Proposal
Dear Chair Mitchoff and County Supervisors:
The EMCC held a special meeting on July 17, 2014 to hear a presentation on
EMS Optimization, proposed key components and features based on the Fitch
EMS System Study, update on the process for requirements and considerations
criteria for the next ambulance contract.
BACKGROUND
A staff report was being presented to the Board of Supervisors in July and the
EMCC members wanted to provide input prior to the presentation. The EMCC
was informed of the presentation and had concerns over the recommendations
for the next ambulance request for proposal contract.
The EMCC approved the following motions to be included in the next EMS
Agency staff report on Ambulance Request For Proposal:
1. Allow local first responder and fire agencies to be part of the bidding
process.
2. Allow a member of the EMCC to hold a seat on the bidding review
panel (proposed panel was outside of Contra Costa County).
Sincerely,
Signed letter submitted to Clerk of the BOS
Darrell Lee
Chairperson, EMCC
cc: John Speakman, 1st Vice Chairperson
Gary Napper, 2nd Vice Chairperson
Ross Fay, Executive Committee Member
Andy Swartzell, Executive Committee Member
Email received from Executive Fire Chiefs to Dr. Walker and County EMS 7/25/2014 4:22PM
EMS of the Future: What is the role of ALS?
EMS and Outcomes
In the last 15 years, there has been ongoing interest in better defining the benefits of EMS, particularly
whether or not Advanced Life Support (i.e. care provided by a Paramedic) improves outcomes when
compared to an EMT Basic, who has a much more limited scope of practice.
It is important to define “outcomes” in order to accurately determine the effectiveness of the care
provided by an EMS system.
Two of the most valuable outcomes to measure for EMS are mortality and “neurologically intact”
survival. These two measures represent the effectiveness of EMS to not only save lives, but also to save
“quality” of life.
Time until treatment for emergent conditions, such as status epilepticus, anaphylaxis and severe
hypoglycemia are also important outcomes to measure, as it is understood that these conditions
progress quickly toward serious disability or death if treatment is delayed.
While not necessarily life threatening, early relief of pain and suffering using analgesia and antiemetics,
are also key outcomes to measure in an EMS system.
OPALS Study- Respiratory Distress
During the last 10 years, we have begun to see the results of quality studies in EMS confirming the
effectiveness of ALS care. As mentioned in the recent CoCo EMS document, the OPALS study from
Canada showed significant reduction in mortality with ALS care provided to patients with CHF, COPD,
pneumonia and asthma. The primary ALS treatments provided by the paramedics in this study were
Lasix, albuterol, nitroglycerin and intubation.
Most importantly, in the OPALS study that demonstrated lives saved by ALS, the time to arrival from call
received was 7.1 minutes. The OPALS study demonstrated not only that ALS paramedics save lives, but
that early ALS is a key factor.
OPALS Study- Cardiac Arrest
In another study by the OPALS group, ALS demonstrated a powerful impact on increasing survivors of
cardiac arrest. However, the number of neurologically intact survivors was not increased, which was the
key outcome. There are several concerns, however, with applying the results of this older study to
modern EMS systems. When the study was performed over 10 years ago, there was no use of
therapeutic hypothermia, there was a low rate of bystander CPR, and the paramedics used were newly
trained, having worked only as EMT-Basics in the system prior to starting the study.
Many EMS experts believe that the OPALS Cardiac Arrest study would have also shown an increase in
neurologically intact survivors were it to be repeated today in a more mature ALS system. Furthermore,
the OPALS investigators themselves concluded “Our study does not address the value of advanced-life-
support programs in urban communities that have high rates of CPR by bystanders or very rapid
advanced-life-support responders.” Dr. Eisenberg of Seattle/King County’s Medic One program ,
renowned for their cardiac arrest survival rate above 50%, concurs and after studying his own system
has concluded that paramedics “dramatically improved survival rates” beyond that which had been
achieved by BLS alone.1
A key fact is that the rate of survival for VF arrest in the OPALS cardiac arrest study was only 15.5%2.
The results in this case suggest that the system studied was underperforming, likely due to the fact that
it was a brand new ALS system.
Most importantly, over the last 4 years, the survival rate for VF cardiac arrest in the Contra Costa Fire
Protection district has been 30%, double the survival rate of the OPALS study.3
Benefits of Early ALS (ALS delivered in less than 10 minutes)
The next question, perhaps even more critical, is not whether ALS is effective, but how important is it to
deliver ALS quickly?
Some examples of time sensitive conditions generally accepted to benefit from interventions in an
immediate fashion are cardiac arrest, respiratory distress, anaphylaxis, status epilepticus, severe
hypoglycemia, and severe pain. Of these conditions, with few exceptions, it is very difficult to ethically
study outcomes related to delaying ALS care.
Because it is apparent that brain and heart may be damaged irreversibly within 5-15 minutes of
experiencing impaired blood flow or oxygen, it would be impossible to find a group of patients willing to
consent to a study that would delay ALS care that could stop their seizure, relieve their airway
obstruction, or reverse their severe allergic reaction. Therefore high quality, randomized outcomes-
based studies on such conditions would be unethical to perform.
Early ALS is also a fundamental component of a successful prehospital STEMI and Stroke program. Both
programs rely on rapid ALS assessment, including 12 lead EKG utilization and exclusion of hypoglycemia
to determine the appropriate destination. As mentioned previously, when 5-15 minutes of ischemia is
enough to cause irreversible tissue loss, minutes truly matter in the care of these patients. Lengthening
the prehospital interval to the delivery of ALS assessment in these cases flies in the face of what we
know to be best practice.
As mentioned previously, however, a large study of patients with respiratory distress (OPALS) did in fact
demonstrate an increase in lives saved by two paramedics responding to provide ALS, on average, in 7.1
minutes.4 Since there had never been ALS care in the community, the study simply looked at the deaths
occurring when BLS was the only care provided, and then looked at the number of lives saved after
introducing the ALS system.
In the case of cardiac arrest, recent studies have demonstrated that intravenous or intraosseous
epinephrine delivered within 5-10 minutes of cardiac arrest in patients with asystole or PEA significantly
improves neurologically intact survival.5 Another recent study found a profound beneficial effect on
neurological survival with the early (5 minutes) delivery of a combination of epinephrine, vasopressin
and steroids.6,7 With each passing minute, the chance of neurologically intact survival decreases, in a
fashion very similar to defibrillation or CPR. These new studies suggest the need to consider an addition
to the earliest chain of cardiac arrest survival, and that the best cardiac arrest outcomes will need early
CPR, defibrillation, and medications. The American Heart Association may make recommendations
about this option in its next release.
Intubation, an ALS procedure whose efficacy has often been questioned in the prehospital setting was
recently demonstrated to show improved short term outcome from cardiac arrest, as well as improved
survival to hospital discharge with satisfactory neurological outcome.
In a 2004 study in Seattle/King County, 46% of those intubated early survived, compared to only 23 % of
those intubated later.8
A more recent 2010 study again showed that an ET placement resulted in a higher incidence of
sustained return of circulation, although the study did not look at longer term outcomes and
neurological survival.9
The most recent study of intubation in 2012 had the most impressive results of all: The intubated group
had a statistically significant survival to hospital discharge with satisfactory neurological status of 4.7%,
compared to 3.9% in the patients managed with only supraglottic airways. (King, Combi and LMA) These
studies raise questions about the emphasis on BLS airway management seen in many systems, including
ours. In light of the growing number of survivors from cardiac arrest, in whom aspiration in the
prehospital environment is more likely to affect long term outcome, it appears that an endotracheal
tube placed effectively without interrupting defibrillation and CPR, and used with low volumes and rates
may be another way to further improve cardiac arrest outcomes.10
Summary
1. Early ALS improves outcomes in respiratory distress (7.1 minutes to scene in OPALS)
2. Early ALS improves outcomes in pain and suffering via analgesia and antiemetics (pain and
nausea relief is self-evident)
3. Early ALS may improve outcomes in cardiac arrest through early epinephrine, as well as
meticulous endotracheal intubation of cardiac arrests (due to airway protection and prevention
of aspiration pneumonia in survivors)
4. ALS in Contra Costa has matured far beyond that shown in the OPALS cardiac arrest study, and
the survival rate in the largest district of our county is nearly triple the rate shown in OPALS-
this is an “apples and oranges” comparison.
5. Early ALS is presumed beneficial in seizures, severe hypoglycemia and anaphylaxis, based on the
pathophysiology of these conditions.
6. Early ALS is beneficial (7.5 minutes to scene) in achieving the cardiac arrest survival in Seattle,
one of the top in the nation.
7. Early ALS is necessary for an optimized prehospital STEMI and Stroke program, as our emphasis
shifts from D2N (door to needle) times, to a focus on E2N (EMS to needle) times. Rapid ALS
arrival will be a major part of keeping these times short.
References:
1Resuscitate, MS Eisenberg 2nd edition 2013
2N Engl J Med 2007 May 24; 356(21):2156-64. Table 3 Stiell IG et al:
Advanced Life Support for out-of-hospital cardiac arrest
3CARES Database Contra Costa County, analyzed 7/18/2014
4N Engl J Med 2007 May 24; 356(21):2156-64. Table 2 Stiell IG et al:
Advanced Life Support for out-of-hospital respiratory distress
5BMJ. 2014 May 20 Donnino MW et al: Nakahara S et al: Time to administration
of epinephrine and outcome after in-hospital cardiac arrest with non-
shockable rhythms: retrospective analysis of large in-hospital data registry
6Acad Emerg Med 2012 Jul; 19(7):782-92 Association between timing of
epinephrine administration and intact neurologic survival following out-of-
hospital cardiac arrest in Japan: a population-based prospective
observational study
7JAMA 2013 Jul; 17; 301(3):270-9 Mentzelopoulos SD et al Vasopressin, steroids
and epinephrine and neurologically favorable survival after in-hospital
cardiac arrest: a randomized clinical trial
8 Prehosp Emerg Care. 2004 Oct-Dec; 8(4):394-9Shy BD et al. Time to intubation
and survival in prehospital cardiac arrest.
9J Anesth. 2010 Oct; 24(5):716-25.
Takei Y et al: Tracheal intubation by paramedics under limited indication
criteria may improve the short-term outcome of out-of-hospital cardiac
arrests with noncardiac origin.
10Resuscitation. 2012 Sep;83(9):1061-6.
Wang HE Endotracheal intubation versus supraglottic airway insertion in out-
of-hospital cardiac arrest.
Joseph Barger, MD
Medical Director
Contra Costa EMS
1
Prior EMS System Development
Initial paramedic program started in 1977 with a few paramedic-staffed ambulances
Most ambulances were Basic Life Support (EMT-staffed).
Fire departments were either EMT or First Aid/Public Safety
Increasing paramedic staffing in 911 ambulances with full paramedic staffing approximately 5 years ago.
Fire first responders all became EMT-level, subsequently several fire departments developed paramedic first responder programs
2
Current 9-1-1 System Staffing
9-1-1 Transport
AMR, San Ramon Valley Fire and Moraga Orinda Fire provide paramedic staffing on all ambulances
Fire First Responders
Paramedic: Contra Costa County Fire, Pinole Fire, Rodeo-Hercules Fire and El Cerrito Fire (SRVF and M-O)
EMT: Richmond Fire, Crockett-Carquinez Fire and East Contra Costa Fire
Other System Features
Quick response vehicles (single paramedic) provide first-responder paramedic services to Crockett and East County areas
In Richmond, more rapid response times requirements to provide earlier paramedic care
3
Advanced Life Support Studies
OPALS Studies from Ottawa, Canada are the most prominent studies to look at what interventions modify outcomes
Before and After ALS implementation studies:
Trauma – ALS care had no effect and in fact may have worsened outcome
Cardiac Arrest – ALS care had no effect on outcome but rapid defibrillation (a BLS skill) did increase survival
Respiratory Distress – Improvement in mortality with ALS Care
○Postulated use of beta-agonist medication like Albuterol, use of nitroglycerin, and use of positive pressure ventilation
4
First-Responder Paramedics
In the absence of evidence, there are
likely clinical conditions in which minutes
count in which First-Responder ALS
may be useful
Seizure control with midazolam
○stopping seizures faster is felt to improve
outcomes
Anaphylaxis
○delay in treatment is associated with
increased mortality
Treatment of hypoglycemia
5
First-Responder Paramedics
in Contra Costa
QRV (outside of Brentwood) – few critical interventions – 4-5 treatments per month (half are Albuterol)
First-Responder Fire – most interventions occur is slightly earlier time frame than can be provided by ambulance paramedics
Critical time-sensitive ALS interventions occur on 2-4% of calls though some of these interventions do occur after ambulance arrival – most are albuterol
Critical BLS Interventions – Defibrillation, oxygen, airway and ventilation support, hemorrhage control (Cardiac Arrest, Critical Trauma, Respiratory Distress)
6
Complementary Function versus
Duplication of Service
First-responder paramedics can provide
care earlier in some areas where
ambulance saturation is lower (distant from
hospitals)
Examples: Clayton, Rossmoor, Bay Point, El
Cerrito, Rodeo (not complete list)
More duplication in denser urban/suburban
areas
Questionable benefit and high cost in very
low volume areas
Examples: Rural East County
7
Other Important Paramedic Care
Assessment
Symptom Relief
pain, nausea, shortness of breath
12-Lead ECG for STEMI, Stroke
Assessments
8
Infrastructure
Medical Control
Supervision
Training
○More critical when skills infrequently used
Quality Improvement
○Paramedic care requires greater oversight
9
Future Considerations
Tiered approach (ALS and BLS), flexibility
Many changes in health care delivery that we
will need to respond to, including likelihood of
shrinking reimbursement
High-quality Emergency Medical Dispatch
(EMD) system supports more selective use
of resources
Goal – sustainable, safe, efficient and
effective delivery of EMS based on
available resources
10
Contra Costa Emergency Medical Services
Optimization of Pre-hospital Care in Contra Costa County
Joe Barger, MD, Contra Costa EMS Medical Director
July 29, 2014 Board of Supervisors Presentation
Background: As a core function, Contra Costa Emergency Medical Services (EMS) is tasked with assuring timely 911 ambulance availability throughout the county, coordinating the efforts of fire first-responder services in conjunction with ambulance responses, receiving hospitals and specialty care centers to establish the most optimal configuration of the system. The goal of that configuration is to provide safe, effective, and efficient medical care that meets the needs of patients with emergency conditions within the capabilities of the community. In Contra Costa’s EMS system, the level of care provided by EMS responders has evolved over the past three decades. Initially in the early 1980’s, the first-responder component consisted of fire agencies with EMT (emergency medical technician) or first aid levels of training. The ambulance system was configured primarily with EMT-level personnel, with a limited number of paramedic units. Over time, increasing paramedic ambulance units were added, and the ambulance system became all-paramedic 10 years ago. Fire departments began implementing first-responder paramedic programs in the late 1990’s and currently six of nine fire departments are providing first-responder paramedics (covering approximately 75% of responses) while three other agencies -remained at the EMT responder level. As the system evolved, EMS also developed modifications in response to come closer to providing the same relative access to paramedic care in those areas with EMT-level first responders through reduced response times (Richmond) and addition of Quick Response Vehicles (QRVs) in Crockett and east county areas.
The Science and Local Experience of EMS First Medical Response Over the past decade we have had an ample opportunity to observe the performance of our system to assess the utility of first-responder paramedics in both the QRV and first-responder fire setting. As well, we have seen the science of EMS develop world-wide with research that demonstrates which paramedic interventions improve patient outcomes. Well-done research out of Ottawa, Canada (known as the OPALS study) demonstrated that addition of paramedic (advanced life support) care improved outcome in patients with respiratory distress. Similar research from that area has shown that ALS care did not improve outcomes in cardiac arrest or traumatic injuries. In cardiac arrest, providing CPR early defibrillation (basic life support skills) are key interventions. In trauma, early transport along with hemorrhage control and basic airway management (again basic life support skills) appear to be the critical interventions. There are no other large-scale studies showing the benefit of advanced life support in other conditions, although there is growing evidence that early treatment and
Contra Costa Emergency Medical Services cessation of seizures improves patient outcomes. As well, it is known that delayed recognition and treatment of anaphylaxis (severe allergic reaction) worsens outcomes, so it is widely accepted that early treatment is appropriate. Management of hypoglycemia (low blood sugar) is also an accepted urgent treatment – delay in treatment within a few minutes of onset may not make a huge difference in outcome, but depending on the length of time the condition is present prior to EMS activation it is always prudent to treat in a rapid fashion. Clearly there are interventions that provide increased comfort to patients, but the number of time-sensitive treatments that paramedics provide that have been shown to improve outcome are small and the addition of those skills in a system-wide manner in the first-responder setting (both with QRVs and first-responder paramedic fire units) comes at a significant cost for the minimal additional impact to the system. The provision of many paramedic-level interventions in a slightly earlier time frame may lead to earlier relief of symptoms or earlier recognition of conditions, but this care does not lead to significant outcome improvements. The most efficient EMS system configuration is complementary – the pieces fit together in a way to provide the best system without large gaps in care and without significant duplication of services. Ambulances transport patients from the scenes of incidents to hospitals, and then are re-posted to areas of the county that have the best access to the next call. The deployment is -flexible and can take advantage of predictable hourly or daily utilization. First-responder fire units are statically deployed (when engine-based, posted at their stations) and advantageously have presence in some areas with lower volume of calls, geographically placed in locales where ambulances may not tend to be posted (frequently far from hospital facilities). An overlap or redundancy in paramedic care in the system exists in urban and suburban areas where there is a high likelihood of ambulance resources being promptly available. In those areas, first-responder fire units arrive at nearly the same time as ambulance resources, and the duplication of paramedic resources in those situations add minimal or no value to the system.
Fire First Medical Response Funding Recognizing the fiscal commitment fire agencies had to take on to support paramedic first medical response in 2004, the Contra Costa Board of Supervisors (BOS) created funding to support the expansion of paramedic first medical response. The Board was able to do this by redirecting Measure H funds used to subsidize emergency ambulance service.to fire first responders providing a paramedic level of service. In 2013 that funding model was broadened to support all fire first responder agencies service level enhancements the EMS System. The new funding model recognized the science, that all fire service providers enhance EMS Systems, by participating in a coordinated, data driven EMS system of care. The EMS Agency respects that the primary responsibility for fire first medical response rests with the fire district governing bodies. We understand that the board of directors of each fire agency, providing first-responder EMS service, has
Contra Costa Emergency Medical Services the option to choose a level of service that they feel best meets the needs of their communities.
Quick Response Vehicles (QRVs) Based on 2013 data, we have an ability to look at the impact of QRVs in Contra Costa. Outside the city of Brentwood, time-sensitive interventions provided by QRVs in East County and in Crockett are rarely administered – if one looks at the treatments for cardiac arrest, altered level of consciousness requiring glucose, anaphylaxis requiring epinephrine, and active seizures, those interventions amount to an average of less than 2 episodes per month. Treatment of shortness of breath with albuterol similarly is administered less than twice a month in those outlying areas. Approximately 90% of all QRV calls are responses in Brentwood, and while there are a larger number of calls, the frequency of time-sensitive interventions is even less frequent than in outlying areas, which speaks to the duplication of services that QRVs provide in that setting. Given the minimal clinical impact of QRVs (associated with an extremely low volume of calls in outlying areas and the duplication of efforts in Brentwood), EMS no longer supports the QRV concept in those areas. We believe patients will be better served by the ambulance provider in the future by enhancing ambulance availability rather than to provide QRV services. Among first-responder fire agencies providing paramedic care (excluding the transporting departments of Moraga-Orinda Fire and San Ramon Valley Fire Protection District who generally do not document first-responder interventions separately), critical interventions are also seen in low numbers (again by 2013 data). Time-sensitive interventions are provided in those four agencies (Contra Costa County Fire, Pinole Fire, Rodeo-Hercules Fire and El Cerrito Fire) the order of approximately five times per day in these first-responder fire agencies. While data is not easily available for Moraga-Orinda or San Ramon Valley Fire, it would not be surprising to see a similar pattern in those agencies. Approximately one-half of time-sensitive interventions are related to cardiac arrest. Treatment of shortness of breath with albuterol averages around 1.2 times per day in the four agencies. Treatment of active seizures occurs approximately twice per month. Treatment of hypoglycemia with ALS medications occurs around two to three times per week and treatment of anaphylaxis occurs around once per month. Overall, important time-sensitive treatments are provided by first-responder fire providers in 2-4% of all calls in which they arrive on scene.
The Value of Fire First Responder Paramedic Care It should not be inferred that there is no value in paramedic care or in first-responder paramedic care – certainly this care provides important medical assessments, comfort for patients and begins the continuum of care with rare events where earlier critical treatments can be given. While provision of first-responder paramedic care in low-volume (rural) areas and fractional increase in ambulance
Contra Costa Emergency Medical Services response times in urban areas does not appear cost-effective, there are limited suburban areas in which first-responder paramedics more can predictably provide paramedic interventions in an earlier time frame (at times several minutes prior to ambulance arrival). These are generally areas where ambulance responses may be slightly longer on average (typically in areas distant from hospitals). Examples of these areas include but are not limited to the El Cerrito, Rodeo, and the Rossmoor, Clayton, and Bay Point areas of CCCFPD districts-. However, many first-responder units based at fire stations have response areas typically well-covered in a timely fashion by ambulance responses, and first-responder paramedics represent duplication in resources in areas already reasonably well covered by ambulances. While the “squad” concept may more effectively provide first-responder paramedic services in our county is yet unknown – the program recently developed by CCCFPD is small and the patient care impact data sample is also small. It is again recognized that the level of response provided by first-responder personnel is a decision each first responder agency’s governing body must make. But in consideration of optimally structuring the EMS system however, the expenditure of Contra Costa EMS financial resources on first-responder paramedic care does not appear to be cost-effective. The continuation of prior efforts to modify the system to marginally increase paramedic arrival time (with shorter response times in Richmond and QRV placement in other areas) also does not appear to be warranted. We have established previously that fire first-responder services at the BLS (basic life support) level are indispensable in an EMS system to provide critical aid such as early defibrillation. We believe support for those services are vital. Beyond the direct provision of care, there are also necessary costs for infrastructure to support high-quality paramedic-level care for first-responder fire agencies. These costs include training, quality improvement and system oversight. Paramedic-level interventions are not without risk and when skills used are done infrequently, there needs to be additional emphasis on training. In Contra Costa, the EMS training and quality improvement infrastructure in many of the fire agencies is minimal at best, and in our opinion is not currently robust enough to support sustained high-quality training and oversight in those agencies. Fire agencies desiring to provide ALS level care need to be willing and able to support those costs necessary to assure appropriate patient care and safety. Some of the same concerns are certainly applicable to the level of care provided by our 911 ambulance providers. Less than half of the EMS transports require advanced life support skills and less than 10 percent require critical interventions. In many situations, rapid transport is the most important “treatment” provided.
Contra Costa Emergency Medical Services
Optimal System Design: Tiered EMS Service Delivery Going forward, Contra Costa EMS wants to consider a tiered 911 ambulance service with provision of both basic life support (EMT) and advanced life support (paramedic) units. Given the abundance of calls for transport of patients with mental health issues, other transport modalities (neither a BLS nor ALS ambulance) may be appropriate. This is an EMS system re-design that leverages partnerships to provide a comprehensive EMS System of care as part of a broader health care delivery system. In such a EMS System the EMS Agency within its medical control can partner with EMS System stakeholders to create an environment that supports enhancements in patient safety, flexibility and cost savings for service providers using strategic deployment of coordinated EMS System resources. This approach is intended to benefit communities by providing informed choices within their fiscal capabilities. Lastly, to accomplish optimal system function, an essential feature is a high-quality emergency medical dispatch system that can help determine the appropriate level of resources to send to an incident (as well as the appropriate urgency of response). This is fundamental in order to effectively utilize a tiered system and assure that the appropriate level of response is matched to the needs of the patient.