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Home My WebLink AboutMINUTES - 12071999 - SD6 TO: BOARD OF SUPERVISORS - Contra FROM: William B.Walker,M.D.,Health Services Director Costa DA'rE: December 7,1999 County - ST'4 SUBJECT: Impact Evaluation Policy for Hospital Emergency Services Closure Downsizing :tPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION RECOMMENDATION: 1. Designate the Contra Costa Emergency Medical Services Agency to perform required impact evaluations for hospitl emergency service closure or downgrading pursuant to California Health and Safety Code Section 1300. 2. Approve the attached Impact Evaluation Policy proposed by the EMS Agency based upon the Impact Evaluation Policy Guidelines issued by the State EMS Authority. FISCAL IMPACT: This recommendation has no fiscal impact beyond the expenditure existing staff time and office resources to conduct required impact evaluations. BACKGROUND: Recently enacted California Health and Safety Code Section 1300 (AB 2103/Gallegos)requires that hospitals planning on reducing or eliminating emergency services provide notice at least 90 days notice to the local health agency and requires that the county or its Emergency Medical Services agency conduct an impact evaluation within 60 days of receiving such notification. The impact evaluation must include at least one public hearing and must include consultation with all hospital and prehospital providers in the impacted area and must include notification to all planning or zoning authorities within the area. A copy of the impact evaluation report must be forwarded to the State Department of Health Services within three days of completion. As required under Section 1300,the State EMS Authority has issued guidelines for use by counties in developing their impact evaluations policies. On November 16, 1999,Contra Costa Health Services received notification from Doctors Medical Center of intent to close the emergency department at the Pinole Campus in March 2000. This was announced as part of a realignment of hospital services between the Pinole and San Pablo facilities,which would result in the relocation of intensive care,acute medical services and emergency care to San Pablo. The Pinole campus would retain outpatient surgery services,transitional care, long term care,substance abuse,sleep lab and cardiac rehabilitation. An urgent care center at the Pinole campus would replace the existing emergency department. In order to comply with the provisions of Section 1300,the County will need to adopt an impact evaluation policy and complete an .impact evaluation report by January 15,2000. CONTINUED ON ATTACHMENT:NO SIGNATURE RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER SIGNATURE(S): ACTION OF BOARD ON December 7, 1999 OTHER SEE ADDENDUM FOR BOARD ACTION VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE X _ UNANIMOUS (ABSENT a aZ e.,) 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. Contact:Emergency Medical Services 646-4690 CC: County Administrator ATTESTED County Counsel PHIL BATCHELOR,CLERK O THE BOARD OF Auditor-Controller SUPERVISORS AND COUNTY ADMINISTRATOR Emergency Medical Services BJYAjne DEPUTY t ADDENDUM TO ITEM SD.6 December 7, 1999 On this date, the Board of Supervisors considered two recommendations from the Health Services Department: 1. Designating the Contra Costa Emergency Medical Services Agency (EMS)to perform required impact evaluations for hospital emergency service closure or downgrading, pursuant to California Health and Safety Code Section 1300; and 2. Approval of the Impact Evaluation Policy proposed by the Contra Costa EMS Agency, which was based upon the Impact Evaluation Policy Guidelines issued by the State EMS Authority. At this time, Supervisor Gerber provided a copy of the policy utilized by the San Francisco Emergency Medical Services and a list of items for the Board to consider adding to the criterion proposed by staff for the evaluation. The Board discussed the matter of the Impact Evaluation Policy Guidelines and the specifics of what data the analysis would include. Chair Canciamilla invited public comment. The following persons presented testimony: Maria Alegria, Pinole City Council; Ralph Cornejo, SEIU Local 250, 560 201" Street, Oakland; Nancy Casazza, California Nurses Association, 2690 Sonoma Way, Pinole; Nancy McCoy, California Nurses Association, 232 Dryden Drive, Vallejo; Carol Harped, 3509 Morningside Drive, Richmond; Kevin Reilly, California Nurses Association, 2000 Franklin Street, Oakland; Deborah Campbell, California Nurses Association, Hercules; Joan Weber, 569 Rock Oak Road, Walnut Creek; Judy Materne, 400 Lake Ave, Rodeo. After further discussion, the Board took the following actions: DESIGNATED the Contra Costa Emergency Medical Services Agency (EMS)to perform the required impact evaluations for hospital emergency service closure or downgrading, pursuant to California Health and Safety Code Section 1300; APPROVED the Impact Evaluation Policy with the following additions and amendments: Section III. Policy: Paragraph A, subsection 1 is amended to reflect two (2)public hearings to be held; [In the instance of the proposed closure of emergency services at Doctors Hospital in Pinole,the meetings were scheduled for December 16, 1999, and January 6, 2000, in the Pinole Council Chambers.] Paragraph A, subsection 3 is amended to read: "The EMS Section shall submit the completed EMS Section Community Impact Evaluation to the State Department of Health Services,the State EMS Authority,the Contra Costa County Board of Supervisors, and the hospital proposing the closure and/or reduction of emergency services within three days of its completion." Paragraph A, add item: The EMS Section shall make the Community Impact Evaluation available for public review upon request. Paragraph B, subsection 1, Geography ( ...travel time and distance to next nearest facility,...) criterion will specifically address the issue of the impact of traffic congestion and major construction and retrofit projects in the relative area regarding their impact on travel time. Paragraph B, Subsection 1, Geography , add "the number of physicians available at the nearest facility" Additional criteria to be added: ♦County Counsel shall assist EMS to identify any potential liability resulting from ER closure and identify probable defendant(s). ♦Data on ambulance diversions, number, frequency, duration. Collect same data for other hospitals in the same geographic area(this could include other counties). ♦Average ER wait times from input to through put in closing facility and potential receiving facilities (data may not be available) ♦Average ER census, number of patients treated per shift ♦Communicable Disease Treatment. Assess availability of negative flow isolation rooms in hospitals remaining in the geographic area. Volume of patients with communicable diseases (HIV/AIDS, TB) presenting in the ER. ♦Absorption capacity at surrounding hospitals. ♦Patient mix (uninsured, medi-cal, medicare, private) ♦Ambulance travel times to surrounding hospitals during peak traffic. ♦Demographics of area population (age, socio-economic) and projections of population and demographics 10 years forward. ♦Require 2 public hearings. ♦ Effect during a Worst Case Scenario involving seismic or hazardous material events, utilizing available data ♦ Ambulance Diversion(number, frequency, duration) impact on hospitals in affected area ♦The availability of ICU beds ♦Standards for hospital emergency services for county and impacted area(e.g., the American College of Emergency Physicians standard of one emergency treatment station per 2,000 annual emergency department visits) The Impact Evaluation data collection will encompass a specific time frame, determined by the EMS Agency. Data for the Impact Evaluation will be provided by the facility closing or reducing emergency services, other impacted hospitals, and prehospital emergency services. Contra Costa Health Services Emergency Medical Services Agency December 7, 1999 Impact Evaluation Policy I. Purpose To establish the process and criteria to be used to evaluate the impact of the closure or downgrading of hospital emergency services. II. Authority California Health and Safety Code Section 1300. III. Policy A. Following receipt of written notification from a licensed acute care hospital located within Contra Costa County that it intends to close or downgrade its emergency service, the Contra Costa EMS Agency will: 1. Complete an evaluation report, including at least one public hearing, on the proposed closure or downgrade within sixty (60) days. 2. Ensure that hospitals and prehospital emergency care providers in the geographic area impacted by the service change are consulted with and that local emergency service agencies and planning or zoning authorities are notified prior to completing the impact evaluation. 3. Notify the State of the results of the impact evaluation within three (3) days of completion of the evaluation report. B. The following criteria will be used to evaluate the impact of the proposed closure or downgrade of hospital emergency services: 1. Geography (facility isolation; service area population density; travel time and distance to next nearest facility; number and type of other available emergency services; and availability of prehospital care resources, including ambulance and fire first responder service; impact on other hospital emergency services). 2. Base hospital designation (number of calls; impact on patient, prehospital personnel, and other base hospitals). 3. Trauma care (number of trauma patients; impact on other hospitals, trauma centers, and trauma patients). 4. Specialty services provided(neurosurgery, obstetrics, burn center, pediatric critical care etc., and their next nearest availability). 5. Patient volume (number of patients annually, including 9-1-1 transports and other patients seeking emergency services). 6. Notification to the public (public hearing, advertising, etc.) 7. Communication with health plans and health plan members. 8. Steps taken by hospital and community providers to accommodate members of the public who may be affected by the proposed closure or downsizing. add to criteria: 9. Identify any potential liability resulting from ER closure and r y� (r�''t identify probable defendant. 10. Data on ambulance diversions, number, frequency, duration. Collect same data for other hospitals in the same geographic. (this could include other counties) 11. Average ER wait times from input to through put in closing facility and potential receiving facilities. 14 IV 12. Average ER census, number of patients treated per shift. 16/� 13. Communicable Disease Treatment. Assess availability of negative flow isolation rooms in hospitals remaining in the geographic area. Volume of patients with communicable diseases (HIV/AIDS, TB) presenting in the ER. / 14. Absorption capacity at surrounding hospitals. 15. Patient mix (uninsured, medi-cal, medicare,private). / 16. Ambulance travel times to surrounding hospitals during peak !/ traffic. / 17. Demographics of area population (age, socio-economic) and !/ projections of population and demographics 10 years forward. 18. Require 2 public hearings. 08:34 SUPERVISOR GERBER 510 620 6E'-:'7 P.02 APPMTI ]all SAN FRANCISCO EMERGENCY MEDICAL SERVICES SECTION Fahey Rderem Na:W1 Iffectlyl Dam 06r3tIt999 Septt des: WA EMERGENCY DEPARTMENT DOWNGRADE OR CLOSURE IMPACT EVALUATION POLICY I. PURPOSE A. To establish EMS Section policy and procedures Used for eval the co=munhy --dr -I of a Enwrgaacy Department down;rtde or closure. B. To establish San Francisco Receiving Hospital procedum for cation to the EMS Section and the load community of a plaund Esnea ency Department downgrade of closm. C. To idea*ImpW Evaluation data collection respombilities for ft hospital proposing the seMet change.,the EMS Section,and other hospitals in the defined service area. IL AUT HORffY A. HeWth& Sahty Code,Division 2.5,Section 1255.1 -1255.3, 1300(b), 1300(c)and 1364.1. B. The City&County of San Fmucisco Charter Appendix Q.Sutton 11. X. DEFINITIONS A. Dofinad Service Area- The City&County of San Francisco. B. Emcrj=7 Department Downgrade— A reduction in the Emergency Dqwt=nt's service level provided under dicir Department of Hodth Senices licem. For example,if a Basic Emersawy Department changes their service offering to a Stand-By Emergency Depwunent or an Urgent Cam Center. C. Special Need Pop3hdon—Padent pupation that requires additional44PYAn LLV 1011AIn LL V 9Q1ffv1C-" in the pmvision of ffigir medial em. For example,wn-Euglish qmking patients nquk*the Foirwon of trSOSlatidn sgrv�=- D. Specialty services—Limited to the special cut wrvices defined in the EMS Sadon Ambulw=Destinsdon Policy#8000 to inchkies Dmuftaft AW*%-od for Pediatrics(EDAP),Obstetrics,Reimplantation,Traxmz,Buns,and Psychiatry. Wo 'Mull CIPT A. Hospitals shall provide public notice of least 90 days prior to closing,elinginsfin&or downgrading the level of senrices provided by their£mGrgancy D9P8rWWW. This Owe Post 1 of 4 MC-06-1999 17:36 5106631625 94%, P.02 06:35 SUPERVISOR GERBER 510 620 6627 P.OJ Polity Rdtr mtx N94 ROt11 ]C fecbv*Deft 0613OM Saptrwdess: NIA wtim sbn include one public bearing'with the Sia F'mci=o Health in cordplietmC With all the requirements of Sala Frcmiwo Cba Ser Appel&Q Section II. The hoVjW is requited to notify the Sectary of the Health Missim in writing at bag 90 days prior to the dowztsm&or clot of&e Fin crg y DepytmM. The public hmme"be hcld within 60 days of nodficaboa fim the howtal. 8. Hospitals sly notffy the,EMS Sion of the D""W of Public Hcalth in writing ax Inst"days before the ft coded date of closing,efi-winslins,orfew the lerct of services provided by their E:aerMcy Dqmmakt C. Upon removing written notice of a proposed Emergency Depext uw closure Jaz reduet w in kva of aetvice„the EMS Section sban aamplete a C0-ma t ity Evaluation of the dwwAgm&or closurc upon the community with 60 d*-& This EMS Seccdon Cc�rmuority Imp=Evatnation eW be coutptPad in consultation with the bospital props ixtg the seavicc change,,other San Fracisco hospitals,the Hospi W Council.and prel titaI =Mency care providers and ftU meet the is outlined in Swdm V.of this policy. D, The bosgitst pro+pK'ysiog the clorwe or reducdon o savlees,amd other Mals in tie dcrined servioe area, proYa Tufo =for the ko=uoity Impact Evahnion when requaL d by the EMS Section. Mw requested inforea l 21 —dwi most the requiremmts as outlined in outlined in Section V.afthis policy. 1� E. The EMS Sccdon stall submit the CEMS section Coity Ingw, Evahiati(m to the Stews DVw mmcat of Health Services,the State EMS Authority,the Sen ssiON and the hospatsl pro►posiug the closwe or mductiion of cm�ergency cervices withsn three days of its cotntphetioss. F. The EMS Section ahat3 make the Commwdty b V t En u don svtiuluble for publics ov iew upon rcqucst Cir. Ex+cepdm to this policy mud'be by*c Stage Depwftneat of Health nmder the Hca th&Safety Code,Div.2.5.Section 1255.1(c)if it detem&L"M hM that rn MnWvdng the k=gency D'e meat thr aum the ftbWrf of the hospital as a whole or the waio iaary nater is cited for unsafe sudrmg. V. PROUR A. 7b&Conum>nity Impact Evalus m sluff include doscxtiptioias of owcmrnt+coaamumirt�► se�:csssto pr+eb�itai and bospitai emetg+rrzcy care In be defined service am of the hoerp ai pro�pcaiug tbe chsage sod bow for Etna--ewy D9wtzwfls dude or clasure wdl&&ct thane services. 4 7- Pec 2 of 4 Le -Ct b DEC-06-1999 17=37 51066316n 94% P.03 ITEC-07-1999 06:36 SUPERVISOR GERBER 510 820 6627 P.04 Polley Retentsm Nw 8001 Mogtia Date. 0600/" Sup-my seder N/A B. Mw*w prod for the Coacuauuity IMPMA Evaluation data collec6an"I i wwc 6e �t most remt full caleodar year plus year to dare Warmalim beg' with the date of Donee for the see ice cbamge. C6 The Hospital pr+vposthe agc p� e�arovitk to the Section the folkm*id wmadam 1. Defined service arm populadm density. 2. T*W aumbcr of Emageacy Depwftent trafaot spaces. I Total amabct of aantW E=crgmcy Dcpartmemt pabmt visits{both 911 transp�arts and wak-ims}. 4. Des4ription of the general pop adon and any special need P*itation nerved by the . hospital. 5. Type of EMS spwialty mvices olferod OWdW to the EMS SectionArr Wla»aa Des ination,policy 08000). 6. Ptocedures for hsadiing patina who self-direct to the downgraded Emergency Dcpwtmew and require aar+,tgea v apical cam 7. 'cation Flaw murding the mvicx dbov to the adty at hmp and to applicable hWth plans,and health plan membors. S. If the Howta is a desigmttad Base Hospital„thea the impact Sb&RUO i=lwt: f a. Total=mbtr of calls by call type aid vcd=e. Ib. Irrkpact on padmu and field pasmad p. If the Ho*td is s draiq ^A Tnums C eller,than the impost Man also include: a. Total n=bw of U ma pad=. b. Impwt as other hospitals'tem=cevtm and a patios /D. b&' is else dcfiwd service fta the EMS S+dcon,provide the fou ovriag iafcaunaticrn: 1. T�t1 air of E �Dkpsr��tramz�cat . 2. Total u mba of ammol Etaetrrggency Iklaarmsaat patient Aft beth gi 1 tratsspvrts and walfc-1m), I Steps tmda to aca__mW__ to the ptopasad +ergeac y Ik.'ParImt-W do closure ind-naing descxiwed N s of clmtges m anergtncy deper+tmr nt Mvaces sad EMS specialty"Mees as&&wd in i6e EMS Secdm AmbLhpm Desffi=*n Fancy Page 3 of 4 6A IEC-e&-1999 17--37 510663162'S 95:; P.04 ------------------------------------ -------------------- 510 620 EE,---"'7 P.05 DE'=—C� 1999 061:36 SUPERVISOR GERBER Potlry Rt*rtnee No.:BOOT ItfbdWe Dow 06M" Svpnwdes: NIA 4. M*EMS Section sball coUect and r*M the following Wonugou: A. Locsti=of facillit'y In sing the EmeReaty DVaartment service Cb&Ugc. PIWAUJ ity to Dd=E=Seacy DePartcneats itt the defaad sctvice area,, incIW4 travel time,distance,And a map With atea bospitals and public t=sit routes noted. b. Aspegatt nmbcr of Ea=gaacy DepaAmcnt tmAmeat qWW in the 4e5aed senice arm C. Net cla nge m tU aggregatc number of EmmacSenry Department beds inthe defined service area as a result of the Emergency Department closure or downgrade. d- A VeWe mmiber of smug dewy Depattzma patial visits nth 911 ftnsports and walk-ins). - e. F-st mated net change in the number of ptieau tram by ambuls" to the defined service xu Emergeucy Departments as a result of the Emergency . utment closure or downgrade. f. Type of specialty ser%im currently offered by the hMital pr+c►positzg the service change as defined and the Want vevest available altautive providers. g. Steps bospitals and Mumunity pmvidcrs have undertaken to accontmodate the Emergency Department dovmgmdelclosure and affected sp=Wty services. . I Current and estimated net change on arnbuianbce and fire response Wait thne on task in the dcfiwd sezvice area. r1�t�rvew�or+dlr�rtearet�a�+in lwpoerpeiwyr�wit�d��toc v Page 4 of 4 6.(1 Z TOTAL P.05 "Nov-15-99 16:13 From-ADMINISTRATION +5109705726 T-274: P.02/06 F-005 �D• XL Doctors Medical Center Tenet HealthSysrem RECEIVED San N1310 Cuupas 2000 Vak Rood II San Pablo,CA 94806 DEC 0 7 1999 Tdl 5 10 970 5000 hRp//wNw rene�hcohh.com CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. November 15, 1999 Ms.Maria Alegria Mayor,City of Prole 2131 Pear Street Pinole, Ca 94564 Dear Mayor Alegria: Today,Doctors Medical Center of San Pablo and Pinole has announced the realignment of hospital services effective March 2000. 1 am writing to inform you about our decision and help you and your staff answer any questions you may receive from your constituents. For your information,I have attached a press release that is being distributed today. It is our intent to relocate intensive care,acute medical services and emergency care to Sari Pablo. The Pinole campus will retain Outpatient Surgery services, Transitional Care, Long Term Care, Substance Abuse,Sleep Lab and Cardiac Rehabilitation. Emergency care services at Pinole will be converted to an urgent care center,and all ambulance trafhe will be directed to Sari.Pablo in March. The Governing Board,Medical Staff leadership and hospital numgement made this decision after an evaluation of the needs of the community and the ability of the hospital to meet those needs. During this transition,we will maintain all medical services required for our patients'medical care. This realignment effort will consolidate expertise at the two respective campuses to improve patient care outcomes and achieve operational efficiency. Litre many hospitals in the region,Doctor's Medical Center is seeking to respond to reimbursement reductions by federal progrnrns and insurance companies. in addition,both hospitals are faced with lower bed usage as a result of Kaiser redirecting patients to facilities outside of San Pablo and Pinole_ This realignment of services will focus complex tertiary level services at DMC San Pablo and enable improved outpatient surgical services and inpatient long-term care services at DMC Pinole. Since 70%of the patients treated in Pinole's emergency room require only urgent care services, establishing an urgent care center at Pinole will respond to the community's needs while accomplishing the goals of the realignutent. In.addition,the hospital has expanded emergency services in San Pablo from I 1 to 24 emergency bays,increased m.onitared care capacity and upgraded facility and equipment to accommodate the consolidation of acute care services- TENET. r� ,� a , t• Nov-15-99 16:14 From-ADMINISTRATION +5109705728 T-274 P.03/06 F-005 Page 2 of 2 DMC Service Realignment November 15, 1999 Long term plans have been initiated to build an additional 14-beck intensive care unit(ICU)at DMC San Pablo to meet the expected needs for beds after the realignment. While the process of gaining approval from the California Office of Statewide Health Planning and Development (OSHPD)can tape as long as 24 months,the hospital will be working with the agency to expedite the process in this case. In the meantime,Pinole's ICU beds will be available in tate event of a surge in did for acute services. Our main priorities are to continue to meet the immediate medical needs of our patients. During this transition,we will maintain all medical services required fbr our patients'mmUual care and conduct a community education campaign to raise awareness of the realigned services within our community. The hospital has sought to uiinun'ze the disruption of this service realignrn►ent plan on our employees. We anticipate that this service realignment will result in the elimi lion of fewer than 20 positions out of a total of 465 Pinole employees. Every effort will be made to assist our personnel in acquidug alternative employment opportunities within the facility,at other Tenet hospitals in.Northern California or other area hospitals. Change is never easy.However,we are comx>3ined to responding to challenging environmental changes to secure health care in West Contra Costa County. It is our intent to wok with our elected officials to ensure a smooth transition for our patients,physicians and employees_ Please call me directly at(5 10)970-51.02 if you have any questions. Sincerely, Gary oan Chief Executive Officer n0�m` �o�o�o�8m|Pr�tTh�A�� hup mu�munn— amr�amev2 . ^ PRINT THIS ARTICLE BACK TO STORY I HEL�P i Press the PRINT button or select File Print on your browser to print this document Page Address: Published Tuesday, December 7, 1999 ��~��U ��U�~��=�� °��D�K�� uu"��~�" ~°��"n��~~�� ^ ~ ^~�~ ~~'-' The head of P'no|e/s Doctors Medical Center passes on fC3n'C3ht/s meeting on the controversial closure By Carolyn &4oK8iUan TIMES STAFF WRITER The top official at Doctors Medical Center has decided to skip any public forums on the pending closure of the Pinole emergency roonn, other than a single hearing required by state law. Gary 8|oon, chief executive ofDcer, was slated to attend the Pinole City Council meeting tonight to discuss the controversial plan. Sloan decided to pass after learning that a crowd of opponents, including members of the nurses union, were expected. "(t'sclear to us this isn'ta forum for educating the public," Sloan said, "When you get an emotional forum like the City Council is planning, | don't think there is an opportunity for effective communication." Although Sloan has met with some oornrnunUx groups and will continue to do so, the only public hearing he plans to attend is a forum in January that is required under a new state |avv, he said. "I had hoped Mr. Sloan would be a little more forthriQht." said Pinole Councilwoman WqarieA|egria. ''| think he owes it to our community. People are really upset." Hospital officials announced the changes in mid-November. They say they have expanded the number of emergency stations at the San Pablo campus, so there will be no net loss in services when the reo|iQnrnamt goes through in March 2000 The intensive care unit at Pinole will also be closed. Within 18 months or so, Doctors Medical Center expects to have replaced those beds through an expansion at the San Pablo campus. Sloan insists that the realignment will improve patient core by allowing resources to go into developing areas of expertise at each hosp|ta|, instead of duplicating sen/ices. But in Pinole, Rodeo and Hercu|ea, many residents worry that critical minutes will be lost going the extra few miles to San Pablo during g life-threatening emergency. "This has been a safety net for us." said Pinole resident Ann Snyder, who belongs to an interfaith coalition that has asked to meet with Sloan. "It's so important to our communities that we have |rnrned|abe help." Her daughter has suffered from asthma attacks on severe that she loses consciousness and is barely breathing. Snyder said. "The last time, the nurse in the ICU said another minute or two and it would have been too late," she said. "When there is a 911. they bring her to Doctors(|n Pinole) because it's the closest." With much of West County growingpid|y, the region needs to expand emergency services rather than consolidate them, several city officials said. They also worry that heavy traffic on Interstate 80 could make itdifficult to reach the San Pablo hospital during e crisis. "if you think about the 1-80 oorridor, many times it's totally stopped up," City Manager Marc Grisham said. "People will have to trust the traffic on the 1-80 corridor in a |ih*and death situation." 12/07/1999 10:33 AM �' A W lrotcoco.cbm I Print This Article http://www.hotcoco.com/cgi-bin/emailfri...contracosta/westcc/stories/ije02510.htm Those are the kinds of concerns that Contra Costa County must evaluate in an impact assessment to the state Department of Health Services due Jan. 15. The evaluation is required under a law that took effect earlier this year. The county Board of Supervisors will be asked today to approve criteria for assessing how the changes at Doctors Medical Center could affect health care in West County. They will also be asked to authorize the county's Emergency Medical Services Agency to conduct the evaluation. The assessment will address such things as the availability and demand for intensive care unit beds; travel time and distance to other facilities; and how ambulance and paramedic services might be affected. "The two central questions are probably going to be what the impact will be in getting critical emergencies to timely care and what the impact will be during peak periods like flu season," said Art Lathrop, director of the county agency. Doctors Medical Center is owned by Tenet Healthcare Corp., one of the nation's largest for-profit hospital chains. It had revenues for the quarter ending Aug. 31 of$2.8 billion. Carolyn McMillan covers health issues. Reach her at 925-977-8506 or cmcmillan a@cctimes.com zf @1999 Contra Costa Newspapers, Inc. 2 of 12/07/1999 10:33 AM � e � M RECEIVED RE: Criteria for impact evaluation of emergency services DEC 0 7 1999 CLERK BOARD OF SUPERVISORS 1) Community demographics (population characteristics, including hge, MWAMMno. ranges/proportions, residential zip code, and insurance status; geographic density, and population and development/housing growth projections) 2) Impact on disaster preparedness, including proximity of services/resources to rail lines, earthquake faults, industrial plants (including oil refineries), and major freeways 3) The American College of Emergency Physicians recommends one emergency room treatment bed per 2,000 ER visits. By considering the "East Bay" region as a whole, determine if there are adequate ER beds currently per population before allowing another closure. Must aggregate all data from each hospital to get annual ER visit total and divide into total population for analysis. Population growth should also be considered in this analysis. 4) When considering the number of"monitored beds" available, how many of these are available all at the same time? (In other words,just because you have X number of monitored beds possible in one unit and Y number of monitored beds available in another unit of the same facility, you may not have X+Y number of monitored beds together if you do not have Y number of functioning monitors.) e� l� rev �� r, � f c �� f, .. .. r. 01 C u ID CLER►. 17CU. IMPACT ANALYSIS FOR THE INTENDED CLOSURE OF UCSF - MT ZION CAMPUS EMERGENCY DEPARTMENT NOVEMBER 16, 1999 San Francisco Department of Public Health Emergency Medical Service Section 1540 Market Street, Suite 220 San Francisco, CA 94102-6052 415-554-9960 x • 48 TABLE OF CONTENTS 4 I. BACKGROUND II. DEFINITIONS III. PROFILE: UCSF—MT ZION CAMPUS A. Defined Emergency Department Service Area Population Density B. Total Number of Mount Zion Emergency Department Treatment Spaces C. Total Number Of Annual Emergency Department Patient Visits D. Special Needs Population Served by Mt. Zion Hospital E. Type Of Emergency Medical Services Specialty Offered F. Mt Zion Hospital Procedures for Patients Who Present to the Emergency Department After Its Closure G. Communication Plans Regarding The Service Change To The Community At Large And To Applicable Health Plans And Health Plan Members IV. SAN FRANCISCO HOSPITALS RESPOND TO THE CLOSURE V. THE EMS SECTION RESPONDS TO THE CLOSURE A. Current Community Access to Prehospital and Hospital Emergency Care B. How The Mt Zion Emergency Department Closure Will Affect Community Access To Prehospital And Hospital Emergency Care 1. Travel Time—Ambulance& Private Vehicle 2. Aggregate&Net Changes in Emergency Department Treatment Spaces and Patient Visits C. Estimated Net Change in the Number of Patients Transported by Ambulance To Other Emergency Departments As A Result Of the Mt. Zion Emergency Department Closure D. Type Of Specialty Services Currently Offered By Mt Zion Hospital and the Next Nearest Available Alternative Providers 1, Diversion 2. Disaster Preparedness E. Current and Estimated Net Change on Ambulance&Fire Response Unit Time on Task in the Defined Service Area VI. SUMMARY FINDINGS, CONCLUSIONS AND RECOMMENDATIONS VII. FOOTNOTES VIII. APPENDICES LBACKGROUND On September 23, 1999, the San Francisco Health Commission Secretary received notice from the University of California— Stanford Health Care of its intention to eliminate and reduce various services at the Mt. Zion Campus (See Appendix 1). Among the intended services to be eliminated were the Emergency Department and all acute care medical-surgical beds including the Intensive Care Unit and the Cardiac Care Unit. Physician offices, outpatient clinics and the Cancer Center will remain open and will continue to offer outpatient care including cancer care, primary care, specialty physician services, imaging and diagnostics, and ambulatory surgery. The Health& Safety Code, Division 2.5, Section 1300 (b) requires that the local Emergency Medical Services (EMS) Agency submit an Impact Evaluation to the State Department of Health Services before that Department approves the downgrade or closure of hospital emergency services. This Impact Evaluation assesses the hospital emergency department closure or downgrade impact upon the community access to emergency care. This Impact Evaluation was developed following the guidelines delineated in the Department of Health's EMS Section, Policy#8001, The Emergency Department Downgrade or Closure Impact Evaluation Policy. The San Francisco Health Commission must also determine whether the elimination or curtailment of health services by the University of California—Mt. Zion Medical Center has a detrimental effect on the health and well-being of this community. This Impact Evaluation is intended to provide information in support of the Health Commission's duties in making that determination in the area of emergency medical services. U. DEFINITIONS Defined Service Area - The City& County of San Francisco. Emergency De Downgrade—A reduction in the Emergency Department's service level Department Dow�g� provided under their Department of Health Services license. For example, if a Basic Emergency Department changes their service offering to a Stand-By Emergency Department or an Urgent Care Center. Special Need Population—Patient population that requires additional supportive services in the provision of their medical care. For example, non-English speaking patients requiring the provision of translation service. Specialty Services—Limited to the specialty care services defined in the EMS Section Policy #8000, Ambulance Destination Policy, that includes Emergency Departments Approved for Pediatrics (EDAP), Obstetrics, Reimplantation, Trauma, Burns, and Psychiatry (See Appendix X11). M. PROFILE: UCSF—MT ZION CAMPUS Mt. Zion Hospital was founded at the turn of the century to serve the Jewish immigrant community in San Francisco. The hospital holds a license for a Basic level Emergency Department. It was the first local hospital in San Francisco to allow African-American physicians on its staff. It serves a population that includes a large number of low-income people in the Western Addition and other neighborhoods. Many of the patients are African-American, and a significant number are Russian-speaking. In 1990, Mt. Zion Hospital merged with the University of California at San Francisco (UCSF). In 1997, UCSF merged with Stanford to form UCSF-Stanford Health Care. Dissolution of the merger was recently announced on October 29, 1999. At the writing of this report, UCSF has made public its intentions to continue go forward with the closure of in-patient services and the Emergency Department at the Mt. Zion Campus. For the remainder of this report, the former UCSF-Stanford, Mt Zion Campus will simply be referred to as"Mt Zion Hospital." A. Defined Emergency Department Service Area Population Density Patients throughout San Francisco and the surrounding region use the Mount Zion Emergency Department. Appendix IX displays the origin of Mt. Zion Emergency Department visits by Zip Code from January 1, 1999 through September 30, 1999. Mount Zion Hospital is located in the 94115 Zip Code. The table also displays the zip code origin of Emergency Department hospital admissions and ambulance visits. Only 20% of the total Emergency Department visits and 18% of the ambulance visits were from the same 94115 Zip Code. R Total Number of Mount Zion Emergency Department Treatment Spaces There are 10 treatment spaces at the Mount Zion Emergency Department. For all San Francisco Emergency Departments, there are 145 Treatment Spaces in total.' The loss of the Mt. Zion Hospital Treatment Spaces will result in a 7% decrease in the overall number of Emergency Department treatment spaces for all of San Francisco. Information about utilization of Treatment Spaces either by Mt. Zion or the other hospitals was not obtained for this report since it was not considered in the original guidelines for the Impact Analysis promulgated by the State Emergency Medical Services (EMS) Authority. C Total Number Of Annual Emergency Department Patient Visits Mount Zion Emergency Department visits were 14,662 for calendar year 1998, and 10,251 from January I though September 30, 1999. Average ambulance transports by month to Mt. Zion were 210 for the 1998 full calendar year and 264 for January I through September 30, 1999. D. Special Needs Population Served by Mt. Zion Hospital The Mount Zion Emergency Department serves a population that includes a large number of low-income people in the Western Addition and other neighborhoods. A large percentage of its patients are covered by Medicare or Medi-Cal. It also serves a large Russian-speaking population. 3 E. Type Of Emergency Medical Services Specialty Offered EMS Specialty services are limited to those described in the EMS Section Policy#8000, Ambulance Destination Policy(See Appendix XII). Mt. Zion Hospital offers emergency pediatric and critical care services to the community in addition to adult medical-surgical services. A. Mt Zion Hospital Procedures for Patients Who Present to the Emergency Department After Its Closure As of the writing of this report, UCSF has not finalized its procedures for patients who present to the Mt. Zion Emergency Department after its closure. A preliminary list of procedures as reported by UCSF to the EMS Section includes the following: • Removal of existing Emergency Department signage. • Posting of signs that clearly state that the Emergency Department is closed. The signs shall direct persons requiring emergency services to call 911. • An Urgent Care Center located at 2380 Post, Second Floor, will be open to serve patients in the community with minor illness or injury. Urgent care staff will transport by ambulance to the UCSF- Parnassus Campus Emergency Department more acutely ill or injured patients who are clinically stable, but who require a higher level of care or possible admission. For unstable, acutely ill or injured patients, practice staff will call 911. Urgent Care Clinic hours of operation have not yet been determined, but will initially include 12 — 8 p.m. daily. • Training of on-site security, practice personnel, and other support personnel who may encounter patients seeking emergency care in other areas of the medical office buildings to respond appropriately (e.g., calling 911). G. Communication Plans Regarding The Service Change To The Community At Large And To Applicable Health Plans And Health Plan Members The following activities were undertaken or will be undertaken to communicate the changes at Mt. Zion Hospital to the community at large, health plans, and health plan members: • Posted closure notices at Mount Zion Hospital. • Written notification of the closure to all health plans contracting with UCSF-Mount Zion. • We have sent letters to patients explaining the changes at Mount Zion. • Held a series of community meetings before and after the decision. UCSF will continue to meet with members of the local community. • Participate in the San Francisco Health Commission's November 16, 1999 public hearing on the intended changes. • Post signs at the former location of the Emergency Department. • Distribute flyers to neighborhood residents around Mount Zion and also send letters to a mailing list of interested members of the community describing the changes. • Mt. Zion Hospital is also planning newspaper advertisements and letters to primary care physicians whose patients might use the Mount Zion ED. 4 CQ 5 Z IV. SAN FRANCISCO HOSPITALS RESPOND TO THE CLOSURE All San Francisco Hospitals with licensed Basic and Comprehensive Emergency Departments were requested to describe the steps their respective.facilities have undertaken to accommodate the closure of Mt. Zion Hospital. Listed below are their responses: California Pacific Medical Center- Pacific Campus • Evaluating the possibility of adding four beds to our Emergency Department increasing our bed capacity to 23. We anticipate that these beds could be operational by the end of 1999. • Reviewing our staffing and resources with a view to an increased patient volume and varying community health care needs. • Reviewing and changing internal Emergency Department and hospital policies and protocols in order to streamline care delivery systems and patient throughput(length of stay in the E.D.). California Pacific Medical Center- Davies Campus • Evaluating the possibility of adding three beds to our Emergency Department increasing our bed capacity to 11. We anticipate that these beds could be operational by the end of 1999. • Reviewing our staffing and resources with a view to an increased patient volume and varying community health care needs • Reviewing and changing internal Emergency Department and hospital policies and protocols in order to streamline care delivery systems and patient throughput (length of stay in the E.D.). St Francis Memorial Hospital • Annual Emergency Department visits increased in 1998 because of the Fire/EMS merger. At that time, we increased staffing (RN staff by 14% and Clerical staff by 83%). • Emergency Service shift physician coverage provides for occasional overlap during high volume shifts. • Psychiatric Assessment/Observation Unit next to the Emergency Department has moved. The Emergency Service anticipates expanding into this space in the next few months (number of treatment spaces undetermined at this time). This expansion was done in response to the increase in Emergency Department volume not the Mount Zion closure. • Our EMS Specialty Service has not changed, we maintain a 10 bed Intensive Care Burn Center • To date we have not felt an influx of Mount Zion patients. St Lukes Hospital • Emergency Department is expanding by four observation beds and two acute care beds. • It is believed that the impact of the closure on St. Lukes will be minimal since it located far from Mt. Zion Hospital. St Mary Hospital Our total number of Emergency Department beds is 12. We are underutilized with our current staffing levels. We believe that we can accommodate additional volume without altering our current bed or staffing configurations. 5 • We have added an Emergency Department Technician to our night staffing, and have a "float" nurse available to assist on the day and evening shifts as the need arises. UCSF—Parnassus Campus • We will be increasing the number of Emergency Department treatment stations by at least 10 (the same number as are now located at Mount Zion) immediately, and by more in the next two years. • We will also be increasing the capacity at UCSF Medical Center to treat patients who need more than normal acute care by adding more telemetry beds (acute care beds with EKG monitoring) and recovery room beds. This will allow UCSF Medical Center to move patients out of the existing ICU beds sooner, and in some cases (e.g., post-surgery patients) avoid the use of ICU beds entirely. We believe these increases, which are planned to occur by the end of December, will be sufficient to accommodate the patients who have typically occupied critical care beds at Mount Zion. UCSF Medical Center also has step-down or transitional beds, which provide staffing and elect.,)nic monitoring greater than acute beds though less than ICU beds. Along with the telemetry beds, they are used to treat patients who do not need to be in the ICU but need more than normal acute care beds. At Mount Zion, those patients have occupied ICU beds. Kaiser Permanente Medical Center • Added 1 FTE RN with potential to add another FTE. • Added 1.4 FTE Emergency Department Technicians with potential to another FTE. • Opened second medical-screening office. San Francisco General Hospital • No planned changes at this time. It is believed that the impact of the closure on SFGH will be minimal since it located far from Mt. Zion Hospital. V. THE EMS SECTION RESPONDS TO THE CLOSURE A. Current Community Access To Prehospital And Hospital Emergency Care Members of the public requiring emergency medical care may access it by dialing 911 to receive an ambulance, or by self-presenting or health provider referral to a local emergency department. Members of the public or health providers may also call private ambulance companies directly to arrange ambulance transport. In San Francisco, there are nine Receiving Hospitals for Code 3 (lights and sirens) and Code 2 (no lights and sirens) ambulance traffic. Eight of those hospitals are licensed as Basic Emergency Departments and one hospital (SFGH) is licensed as a Comprehensive Emergency Department. Chinese Hospital is the only licensed Stand-by Emergency Department in San Francisco. The Veterans Administration Medical Center does not hold a state license since it is a federal entity. Both the Chinese Hospital and Veterans Medical Center may receive their respective patients via emergency ambulance only if they are clinically stable. Since those two hospitals do not receive critical patients, they were excluded from much of the analysis in this report. Additional information regarding hospital ambulance destination for EMS in San Francisco can be found in Appendix XII. .M� 6 B. How Mt Zion Emergency Department Closure Will Affect Community Access To Prehospital And Hospital Emergency Care 1.Travel Time—Ambulance and Private Vehicle As noted previously, only 20% of Mt Zion's total Emergency Department visits and 18% of the ambulance visits were from the same 94115 Zip Code. Potential ambulance destinations within or adjacent to that zip code are as follows: • Kaiser Permanente Medical Center= 0.3 miles (1 minute driving time )3 • California Pacific Medical Center—Pacific Campus= 0.9 miles (3 minutes driving time) Other nearby Emergency Departments is as follows: • UCSF—Parnassus Campus= 2.5 miles (6 minutes driving time s • California Pacific Medical Center—Davies Campus= 1.1 miles (3 minutes driving time) • St. Mary's Hospital= 1.5 miles (4 minutes driving time) • St. Francis Hospital = 1.7 miles (4 minutes driving time) San Francisco is geographically small. Therefore, unlike other communities in California where the closure of an Emergency Department can greatly increases travel time to other, open Emergency Departments, the closure of the Mt. Zion Emergency Department will not have a significant impact on travel time either by private vehicle or by ambulance. A map of San Francisco hospitals can be found in Appendix II. Public transit routes are also noted. Mt. Zion serves a population that includes a large number of low-income people in the Western Addition and other neighborhoods. Some members of this population may not have ready access to private vehicles and may instead be reliant on public transportation or walking to the hospital. Closure of the local Emergency Department may present a hardship to this particular group; however, it is not possible to quantify the potential number of affected patients in this category. 2 Ak7grezate & Net Changes in Emergency Department Treatment Spaces and Patient Visits It was noted in Section III.B. that Mount Zion Emergency Department has 10 Treatment Spaces. Also mentioned in that Section was that there are 145 Treatment Spaces in total for all San Francisco Emergency Departments.' The loss of the Mt. Zion Hospital Treatment Spaces represents a 7% decrease in the overall number of Emergency Department treatment spaces for San Francisco. However, if all hospitals implement their stated increases in Emergency Department Treatment Spaces as described above, San Francisco may eventually experience a net gain in Emergency Department capacity. Total Number of Basic&Comprehensive ED Treatment Spaces in San Francisco* With Mt.Z Without Mt.Z Cal Pac—Pac Campus 19 19 Cal Pac—Davies 8 8 Kaiser 24 24 Mt.Zion 10 0 St.Francis 8 8 St.Lukes 13 13 St.Mary 12 12 San Francisco Gen 31 31 UCSF 20 20 Total 145 135 As reported to the EMS Section in Oct. 1999. lQ•�� It should be noted, though, that there may be no or little overall benefit to the EMS system as a result of this net gain in Emergency Department Treatment Spaces. In 1995, there were 230,606 Emergency Department visits for San Francisco. In 1998, the last full calendar year, that number increased to 241,861 for a 4.8% increase in Emergency Department volume in 3 years. Total Aggregate ED Visits for San Francisco: 1995—Sept 30, 1999* All ED Ambulance Walk-In Visits** 1995 230,606 40,336 190,270 1996 2322090 42,135 189,955 1997 237,345 NotAvailable** NotAvailable** 1998 241,861 46,529 195,332 1999 184,906 36,799 148,107 thru 9/30 Source:ED Visits Self-Reported by Hospitals. Ambulance Visits from San Francisco EMS Section Historical Data&San Francisco Fire Dept CAD Data. *Includes visits to licensed Comprehensive&Basic Emergency Depts.in San Francisco. Chinese Hospital&Veterans Med.Center are not included. **In 1997,the former Paramedic Division of the Dept of Public Health merged into the San Francisco Fire Dept. Computer data on EMS call volume during the transition is unavailable for the latter halfof 1997. During the same time period, San Francisco has lost Emergency Department capacity with the closure of Children's Hospital Emergency Department. Also, during the same time period, San Francisco's population has increased from 751,900 to 790,500 for a 5% gain in total population.' Today, there may exist a relative undercapacity of Emergency Department Treatment Spaces in San Francisco. Evidence for this lies with increase in the use of Total Diversion, the diversion of ambulance due to an Emergency Department reaching capacity, as well as the increasing frequency of the suspension of Total Diversion; when multiple hospitals are closed to ambulance traffic due to their reaching maximal capacity. Ambulance diversion data from 1995 to September 1999 can be found in Appendix X and XI. Questions about San Francisco's Emergency Department capacity and utilization deserve further in-depth study. Information about utilization of Treatment Spaces either by Mt. Zion or the other hospitals was not obtained for this report since it was not considered in the guidelines for the Impact Analysis developed by the State EMS Authority. It should be noted that while hospitals individually review Treatment Space utilization as an efficiency measure of their throughput, the comparability of such information for multiple hospitals in a given geographic area is not well defined since numerous factors influence utilization. Such factors include time of day, day of week, season of the year, individual hospital staffing patterns and type, availability of individual hospital ancillary services, patient presenting conditions, and patient demographics among others. Information about utilization of Treatment Spaces by particular patient populations also was not obtained for this report since it was not considered in the guidelines for the Impact Analysis developed by the State EMS Authority. Over the last two—three years, anecdotal reports from San Francisco Emergency Departments about the increasing use of Treatments Spaces by intoxicated patients have been growing. Such reports have led to calls for the creation of "Intermediate Care Facilities" where intoxicated patients can be offered sobriety services in lieu of an Emergency Department bed. Anecdotal information about the types of patients needing this type of service are chronic, homeless alcoholics. System-wide studies of this problem have not been done. Questions about the utilization San Francisco's Emergency Department capacity for this particular patient population deserve further in-depth study to quantify and qualify the magnitude of the problem. C Estimated Net Change in the Number of Patients Transported by Ambulance to Other Emergency Departments As A Result Of the Mt. Zion Emergency Department Closure UCSF was unable to provide estimates on the anticipated volume of former Mt. Zion Emergency Department patients it expects the UCSF- Parnasuss Campus to absorb. Mount Zion Emergency Department visits were 14,662 for calendar year 1998, and 10,251 from January I though September 30, 1999. Average ambulance transports by month to Mt. Zion were 210 for the 1998 full calendar year and 264 for January I through September 30, 1999. Census and demographic figures for Mt. Zion's Emergency Department can be found in Appendices V through IX. The EMS Section is unable to estimate the number of patients that may present to other Emergency Departments after the Mt. Zion Hospital closure. This is due to the lack of certain types of data submitted by the responding hospitals and due to some of the inherent exigencies in emergency field care. Ambulance destinations are based on(in descending order of importance) the patient's presenting clinical condition(i.e., critical, noncritical, specialty care need), patient's choice of facility and hospital availability (i.e., not on Total Diversion or Critical Care Diversion). When appropriate, EMS providers will offer patients desiring transport to the former Mt. Zion Hospital the alternative option of transport to the Emergency Department at UCSF- Parnassus Campus. However, some patients may choose to go elsewhere either based upon personal preference or if their physicians choose to join practices outside of UCSF. Patients previously seen at Mt. Zion Hospital) but who not affiliated with the UCSF Health Care system, are transported to their hospital of choice if appropriate. Patients who express no choice to EMS providers are taken to the closest hospital. It was previously noted, only 20% of Mt Zion's total Emergency Department visits and 18% of the ambulance visits were from the same 94115 Zip Code as Mt. Zion Hospital. Therefore, it is feasible that an influx of former Mt. Zion patients may be felt at hospitals across the City rather just restricted to the hospitals nearest to that facility. D. Type Of Specialty Services Currently Offered By Mt Zion Hospital and the Next Nearest Available Alternative Providers Mt. Zion Hospital offers pediatric emergency and critical care services to the community in addition to adult medical-surgical services. Adult medical-surgical and critical care services are offered nearby at Kaiser Permanente Medical Center, St. Mary's Hospital, California Pacific Medical Center- Pacific & Davies Campuses and the UCSF-Parnasuss Campus. Both St. Mary's Hospital and California Pacific Medical Center- Davies Campus do not offer pediatric emergency services. Some individuals who are accustomed to receiving their care at Mt. Zion Hospital may not be willing to go to other medically equivalent facilities for their health care needs. We recognize that the wholly unique character of this hospital will be changed by the closure of its Emergency Department and acute care capabilities, and for these members of the community the loss of this service will be detrimental. 9 It should be noted that the closure of Mt. Zion Hospital represents a loss of Critical Care beds for San Francisco. The impact of this loss is unknown. Critical Care Bed information was not requested for this report since it was not a part of the State EMS Authority guidelines used for developing the Impact Evaluation. Earlier this year, the EMS Section did independently attempt to look at the number of Critical Care beds in San Francisco when it focused on EMS System data analysis with the goal of improving the Diversion Policy. Our objective was to analyze data from our EMS system and local hospitals to quantify to some degree total system(hospitals and ambulances) capacity and utilization during periods of high patient demand for emergency services. Included in this analysis was an examination of Critical Care beds. All hospitals were requested to submit information on a set of data points to the EMS Section. Unfortunately, less than half of the San Francisco hospitals reported their data. Due to incomplete system-wide hospital data, an evaluation of total hospital system capacity and utilization for that data project was not possible. 1. Diversion ` The closure of the Mt. Zion Emergency Department along with its in-patient critical care services is likely to have a significant negative impact on ambulance diversion in the upcoming winter season where demand for EMS services is at its peak. It was previously noted in Section V.C. that an influx of former Mt. Zion patients may be felt at hospitals across the City that the facility attracts patients throughout San Francisco. In Section V.B.2., it was noted that San Francisco may have an undercapacity of Emergency Department Treatment Spaces. It was also noted that hospitals are taking steps to address Emergency Department capacity and in some cases, staffing, to address the potential increased patient volume related to the Mt. Zion Emergency Department closure. However, the closure of Mt. Zion Hospital means a net loss of Critical Care beds and medical-surgical beds for San Francisco. It remains to be seen whether the proposed additions to capacity at UCSF Medical Center noted in Section IV. will sufficiently address the loss of those beds. Critical patients that cannot be moved to Intensive Care Unit beds.must remain in a Emergency Department until either a bed becomes available or a transfer to another hospital's Intensive Care Unit can be done. Often times, patient transfers out of Intensive Care Units are dependent upon available Medical-Surgical beds. The inability to move patients through the various levels of care within a given hospital leads to gridlock and back up both within the hospital and within the Emergency Department. In the past, hospitals have relied on diversion as a means to manage this problem. However, when all hospitals are experiencing this problem and all are using diversion to manage it, the EMS system becomes gridlocked (multiple hospitals are on diversion). At this point, the EMS Section steps in and suspends diversion for the entire EMS system. Significant problems with hospital overcrowding, diversion and gridlock were seen in San Francisco and throughout the state during the 1997-1998 winter and to a lesser degree during the previous winter. In response to the 1997-1998 winter , a Statewide task force was convened to examine the problem. A report entitled, "The California Health Care System: Overview of the Hospital/EMS Crisis Winter 1997-98," was the product of the group's efforts.4 10 CQ .s� On the local level, the EMS Section implemented a new Interim Diversion policy in November 1998. The policy specifically addressed an increasing citywide trend in critical care diversion by reducing the numerical threshold for invoking a suspension of Critical Care Diversion from 5 hospitals to 3 hospitals on Critical Care diversion or 5 hospital on combination of Total and Critical Care diversion. Additionally, the new Interim Diversion Policy mandated a fixed time period for the any Critical Care diversion suspension. The Interim Diversion policy, as well as significant efforts on the part of hospitals to address critical care diversion avoidance significantly reduced critical care diversion during 1999. Unfortunately, the gains made in reducing Critical Care Diversion were eroded by a gradual increase in Total (Emergency Department) Diversion throughout the system. During the past year, Total Diversion rates for our system were higher than the comparable time period last year. With the exception of the month of May, Total Diversion suspension has been invoked on at least one occasion in every month of this year. It is anticipated that the loss of one Emergency Department and its inpatient services is likely to drive the trend of Total Diversion and Critical Care Diversion in a negative direction. The EMS Section will soon be issuing a new Diversion Policy that will reflect a new numerical threshold for Critical Care and Total Diversion suspension. However, the intent of Diversion Policy remains the same--to manage short-term day-to-day patient demand and hospital capacity mismatches for short periods at one or a few of the hospitals that participate in the EMS system. It still does not address the long-term question of adequacy of hospital resources for San Francisco residents and visitors. A more in-depth investigation of this issue should be undertaken. 2 Disaster Preparedness The loss of any healthcare resources always raises concerns about the ability of a community to respond to medical needs in the event of a major disaster. Such concerns were raised by the Statewide Task Force that authored"The California Health Care System: Overview of the Hospital/EMS Crisis Winter 1997-98 Report." As noted in that report, the State Task Force concluded that the "capacity [of California counties] to respond to events of even moderate impact is doubtful.774 If Mt. Zion Hospital maintains capacity to respond to disaster the situation will be partially mitigated. Nonetheless, it will take some time to make the hospital operational in an emergency (in its new proposed configuration) and this will slow our City's disaster res-)onse capability. E. Current and Estimated Net Change on Ambulance and Fire Response Unit Time on Task in the Defined Service Area `Time-On-Task" refers to the time interval that begins when an ambulance or fire response unit is assigned a call ("dispatched") and ends when patient disposition is completed and the ambulance or fire response unit is available to receive another 911 call assignment. Factors that influence Time-on-Task include travel time to the patient, presenting patient condition, extrication time, travel time to the hospital, time for transition of patient care to hospital staff and time for completion of patient documentation Factors that are relevant for this discussion are travel time to the hospital and time for transition of patient care to hospital staff. It was previously noted in Section V.B. that the closure of the Mt. Zion Emergency Department will not have a significant impact on ambulance travel time to another hospital since San Francisco is geographically small. It is also believed that the transition of patient care from EMS personnel to hospital staff will not be greatly affected.. VI. SUMMARY FINDINGS, CONCLUSIONS AND RECOMMENDATIONS 1. Patients throughout San Francisco and the surrounding region use the Mount Zion Emergency Department. Only 20% of the total Emergency Department visits and 18% of the ambulance visits were from the same 94115 Zip Code as Mt. Zion Hospital. UCSF was unable to provide estimates on the anticipated volume of former Mt. Zion Emergency Department patients it expects the UCSF- Parnasuss Campus to absorb. Therefore, the EMS Section is unable to estimate the number of patients that may present to other Emergency Departments after the Mt. Zion Hospital closure. Conclusion: Because of the wide geographic distribution of Mt. Zion patients, it is feasible that hospitals across the City rather just hospitals nearest to that facility will experience an influx of former Mt. Zion patients. The EMS Section is unable to quantify the numbers of patients that may present elsewhere. Recommendation: All San Francisco hospitals should be prepared to receive additional Emergency Department patients as a result of the closure of the Mt. Zion Emergency Department. 2. Mt. Zion Hospital offers emergency pediatric and critical care services to the community in addition to adult medical-surgical services. UCSF-Parnassus Campus and other nearby hospitals offer similar services. Conclusion: The closure of Mt. Zion does not represent a loss of a unique service-type for the community, although some patients who have traditionally received care at Mt. Zion Hospital may be reluctant to seek there care elsewhere. Recommendation: None. 3. Mt. Zion Hospital is located in area of San Francisco served by multiple ot':er hospitals. Travel time to these other hospitals is insignificant. Conclusion: Since San Francisco is geographically small, the closure of the Mt. Zion Emergency Department will not have a significant impact on ambulance transport times to other Emergency Departments. Recommendation: None 4. In response to the closure of Mt. Zion Hospital, the UCSF Medical Center is: • Increasing the number of Emergency Department treatment stations by at least 10 (the same number as are now located at Mount Zion) immediately, and by more in the next two years. • Adding more telemetry beds and recovery room beds. Conclusion: The closure of Mt. Zion Hospital means a net loss of Critical Care beds and medical-surgical beds for San Francisco. The closure of the Mt. Zion in-patient critical care services is likely to have a significant negative impact on ambulance diversion in the upcoming winter season where demand for EMS services is at its peak. Recommendation: Questions about San Francisco's Emergency Department and Critical Care Bed capacity and utilization deserve further in-depth study. 12 (0 .� d 5. The loss of the Mt. Zion Hospital Treatment Spaces will result in a 7% decrease in the overall number of Emergency Department treatment spaces for all of San Francisco. However, if all hospitals implement their stated increases in Emergency Department Treatment Spaces in response to the closure, San Francisco may eventually experience a net gain in Emergency Department capacity. Conclusion: San Francisco may eventually experience a net gain in Emergency Department capacity if all hospitals implement their stated increases in Emergency Department Treatment Spaces. Recommendation:None. 6. Even if all hospitals implement their stated increases in Emergency Department Treatment Spaces in response to the Mt. Zion closure, there may be no or little overall benefit to the EMS system as a result of this net gain in Emergency Department Treatment Spaces for the following reasons: • In 1995, there were 230,606 Emergency Department visits for San Francisco. In 1998, the last full calendar year, that number increased to 241,861 for a 4.8% increase in Emergency Department volume in 3 years. - • During the same time period, San Francisco has lost Emergency Department capacity with the closure of Children's Hospital Emergency Department. • During the same time period, San Francisco's population has increased from 751,900 to 790,500 for a 5% gain in total population. • There has been a gradual increase in Total (Emergency Department) Diversion throughout the system as well as an increasing frequency of the Total Diversion suspension. Conclusion: There may be no or little overall benefit to the EMS system as a result of this net gain in Emergency Department Treatment Spaces resulting since there may exist a relative undercapacity of Emergency Department Treatment Spaces in San Francisco. The closure of the Mt. Zion Emergency Department is likely to have a significant negative impact on ambulance diversion in the upcoming winter season where demand for EMS services is at its peak. Recommendation: Questions about San Francisco's Emergency Department capacity, utilization, and the benefits of diversion deserve further in-depth study. 7. Over the last two to three years, anecdotal reports from San Francisco Emergency Departments about the increasing use of Treatments Spaces by intoxicated patients have been growing. Conclusion: System-wide studies of this problem have not been done. Recommendation: Questions about the utilization San Francisco's Emergency Department capacity for this particular patient population deserve further in-depth study to quantify and qualify the magnitude of the problem. 13 .La � 8. Disaster responses should also be considered with the closure of any Bay Area hospital. Conclusion: The loss of Mt. Zion Hospital raises concerns about the ability of our community to respond to medical needs in the event of a major disaster. Recommendation: The EMS Section recommends that UCSF continue to maintain disaster capabilities at the former Mt. Zion Hospital. This includes medical personnel, equipment and supplies that may be used to medical needs in the event of a major disaster. 9. Emergency response times as measured by "time-on-task" should also be considered with the closure of any local hospital. Conclusion: Since San Francisco is geographically small, the closure of the Mt. Zion Emergency Department will not have a significant impact on ambulance and fire response unit time on task. Recommendation:None. 14 FOOTNOTES 1 San Francisco Emergency Department Treatment Spaces self reported to the EMS Section for this Impact Analysis. 2 State of California, Department of Finance,Historical City/County Population Estimates, 1991- 1999, with 1990 Census Counts. Sacramento, California, May 1999. 3 Source: http://www.yahoo.com/maps 4 The California Health Care System: Overview of the Hospital/EMS Crisis Winter 1997-98 Final Report can be downloaded from the State Emergency Medical Services Authority website: • www.emsa.cahnet.gov • click on"SMSA-What's New" • click on"Old News" and scroll down to the report 5 "Less to Rely On in Next Big Quake: New Medical Landscape Leaves Bay Area with Fewer Disaster Resources," Sabin Russsell— San Francisco Chronicle. Oct 14, 1999, page Al. i:Immlwinwordlrhlmtzionlhc report on mtzion ed closure impact analysis.doc 15 APPENDICES I. Notice: UCSF— Stanford Health Care Intention to Eliminate or Reduce Services at UCSF-Mt. Zion Medical Center II. San Francisco Receiving Hospitals Map & Public Transportation Information III. Total Aggregate Visits for All San Francisco Emergency Departments: 1995 — 1999 IV. 1998 — 1999 Transports to Hospitals by 911 Dispatch Ambulances—Bar Graph V. Mt. Zion Emergency Department Census: 1994 — 1999 VI. Average Ambulance Transports by Month to UCSF Mt. Zion Hospital: 1995 - 1990 VII. SFFD EMS Division Ambulance Transports to Mt Zion ED: Sept 1998— February 1999 VIII. Ten Most Frequent Dispatch Call Types for 1998 SFFD EMS Ambulance Transports to Mt. Zion Emergency Department IX. Mt Zion Emergency Department Demographics by Zip Code: Jan 1 through September 30, 1999 X. Critical Care Diversion & Total Diversion Reports: 1995 - 1999 XI. Monthly Average Diversion Hours by Hospital XII. Ambulance Destination Policy # 8000 XI-11. ED Closure Policy #8001 16 NOTICEJ V APPENDIX I Pursuant to Appendix Q to the San Francisco Charter, UCSF Stanford Health Care gives notice of its intention to eliminate or reduce the following services at UCSF/Mount Zion Medical Center: Estimated Number Estimated Number of Services to be Eliminated Qf Patients Affected* Employees Affected* Acute care medical/surgical beds, 515 per month 483 including ICU/CCU Acute Rehabilitation Unit 21 57 Skilled Nursing Facility 72 64 44 58 Emergency Department 1,239 50 Cardiac Catherization Laboratory 33 4 Estimated Number Estimated Number of Serviegs to be Reduced of Patients Affected* Empl9vees Affected* Operating Rooms (reduced to 230 per month 116 provide ambulatory surgery only) Ancillary services, such as laboratory, 609 44 44 72 pathology and radiology(reduced to support outpatient services only) Physicians' offices, outpatient clinics, and the Cancer Center will remain open, and will continue to offer outpatient care, including cancer care,primary care, specialty physician services, imaging and diagnostics, and ambulatory surgery. UCSF Stanford Health Care also plans to develop an Urgent Care Center at Mount Zion. The precise timetable for the,elimination and reduction of these services has not yet been determined. UCSF Stanford Health Care will inform its employees, the public, and the Health Commission of the timetable when it has been determined. Patients who are in the hospital now will continue to receive care at UCSFIMount Zion or, if clinically appropriate, will be transferred to UCSF Medical Center. *This notice is required by Appendix Q of the San Francisco Charter, which requires the specification of the number of patients and employees 'affected. Many of the employees identified in this notice as affected by these changes will be offered transfers to UCSF Medical Center or other UCSF Stanford facilities, and most patients identified as affected by these chancres will be able to obtain care at UCSF Medical Center. The estimates of affected patients are based on the number of patients seen over the last year. The estimate for Emergency Department patients is based on the number of Emergency Department visits over the last year, and includes 260 patients per month who are admitted as inpatients and also included in the estimate for the_jqpatient service. For more information call: Members of the public 885-3607 Patients and their families 885-7437 . Employees Contact your Supervisor Mn }-ranciSCU 1"uniclpdi haiway OownAown T od«Tr+nsJtsysierru NO 1 POtNt N' it ,[i,<: Wit EM Peck Hot.Qrtly � "®- AC Thns� Y BAY� �"' � A � #w �' FRANC{ AP P�ND I X ! HESTN s1� Gosscown handst�S�rtiicr Q'J- SaMTrans y C 0� SL �' t-arrroi f T II OM9AfEt0 Route : T- ' 1 �`• CHESTNUT, !�tt+a+rxa ;, --- Mori Metro �""'CG Tr nat r REt CH L ._.��.�:L: -----_... ° GR+rface) y,t ( '+0:101,}BAP0 rror�ST. } t } s Iir o- � ...... kiwi Metro ►--+ Ptede*fan "'" GREENWttH ST. 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'� ,3lOs.� ��(' :� ,/�+� ,.,� •�� :: 111!• ;�;�.��_; !!��,_, .• L` �� 'i f ,!��•� ,1� ..\��`'1�--�,,1i � � � _1 r 1 (,•• ".� .ail r ,l ,�'.� � �~I � ' '�' �rl `�� .1• •;_LLI• �_'-� �' �iUl�:`:1 �r�■ fly QUI r.\'�.!��atr O "� � 1�'�• ��, ,�,i.�r S', �ar+i air•ir roTl'_'S..t�� - • �_ duh ,�rrf>•r •�!Mrrrlr �. r � � ~ �� , r_..�..rw rr+_-•.+ "k r rrr r.y:s �. _.r� +.". Ill r[ee i:J�r rti: -• -�"r A'>!""�'� �• 1.t _ � �� sr r Al _L\. G:-Y/ii• • rl�l r r r nr'R~ ��<r.�l� �r �i:w•■ ,�r r aii�� .is.-}�a,r.w' � -i•.r:� I .r,► nr r,.:��,::'`;is fo ....�..�.r r itr r iiJ•"�rl�lrs �l/;L _, li •r "slll'Sa il.�S't�T+�r��l-!�'1� 1��+7s J "�,•.atilr,•`f r v11/ am r•ii�lr tiY r.!ai>A f>•a!OWN �ul J f�rrr� .i•11S�a� � nar!!��sf.f _.=�_•�� rf/�� r� ar•r Omm ,.Ir` �.il/'vi• r rr r .:i i is• ow.c... APPENDIX III cd E� 0 o c, o CT N c cl00 .� .� � U v � .� a i Ia� � A 1 Iwo o CIN too 1 l 1 i 0 0 o a o 0 o 0 0 0 0 0 o to o to o Vr, S�SiSi��IIaI�L'a AppE�IX. IV � N C C' t� COto 00 Cf) CD ' 1 � CD mom— Z c� a i U) 0 Sz 4 OKr O Z� � � �o ce) � CIO Go CL CD I. 00co COS) 'N.!I �- S a BMW O O O O N f.. --.-- O O r 1 O ,t O a C) M �` 0), r i � 1 t17 co ell sVodsu ' all CS O cC'C4-) � tJl O as ON � O � tU N \r 00 all , O o cfl o 0 o co O_ o \ O_ w SIAM" `o ��E�ZX vz A 0 �' Cn LO \` O N rn N to o Y o v � o o ,r to sew CU •�'' O CO r- 0o N \ -i,, ° N OOo © N s O ILO r y 0 tp M co 0) tL1 �PE�ZX Vii - N OIN POD M \ IPA 400 o IPA 0 PA .0 .01 ............................... .................................................. ce) luc) APPENDIX VIII O t/1 n .�,.� 2 o �iy UO 3 U E -%d O o A lima C •_ '� C un U 0 un Q chcn U 'v� Q a M ■ ❑ ❑ ■ M ■ ❑ ■ ■ .> o cl ' A � V � Cd 0 h+�I ,P c o O CON lid L o �w�Yo�rr .3 N M A Oo Ut- \p N No cz o • � O � � o0 w c -v a a� s U APPENDIX IX MT.ZION EMERGENCY DEPT. DEMOGRAPHICS BY ZIP CODE:Jan 1 -Sept.30, 1999 ALL AMB AMB %OF ALL %OF ALL % AMB%OF AMB%OF %OF AMB ZIP VISITS ADMITS VISITS ADMITS AMB VISITS VISITS DMITTED TOTAL VISITS ADMITS ADMITTED 94101 4 0 1 0 0% 0% 0% 25% 0% 31% 94102 704 100 191 52 8% 7% 14% 27% 52% 27% 94103 228 37 72 22 3% 2% 16% 32% 59% 38% 94104 11 1 2 0 0% 0% 9% 18% 0% 43% 94105 56 4 11 2 0% 1% 7% 20% 50% 26% 94106 4 2 2 1 0% 0% 50% 50% 50% 33% 94107 158 19 32 10 1% 2% 12% 20% 53% 58% 94108 57 8 18 4 1% 1% 14% 32% 50% 32% 94109 584 126 179 68 8% 6% 22% 31% 54% 42% 94110 327 50 59 25 2% 3% 15% 18% 50% 36% 94111 51 19 20 9 1% 0% 37% 39% 47% 31% 94112 425 121 156 90 7% 4% 28% 37% 74% 44% 94113 9 1 4 0 0% 0% 11% 44% 0% 37% 94114 206 35 43 16 2% 2% 17% 21% 46% 26% 94115 2013 255 429 135 18% 20% 13% 21% 53% 44% 94116 218 43 50 22 2% 2% 20% 23% 51% 12% 94117 550 76 127 33 5% 5% 14% 23% 43% 27% 94118 446 82 118 39 5% 4% 18% 26% 48% 31% 94119 9 0 2 0 0% 0% 0% 22% 0% 34% 94120 3 0 0 0 0% 0% 0% 0% 0% 40% 94121 567 119 141 60 6% 6% 21% 25% 50% 22% 94122 323 73 80 29 3% 3% 23% 25% 40% 18% 94123 199 35 38 10 2% 2% 18% 19% 29% 45% 94124 382 55 62 20 3% 4% 14% 16% 36% 43% 94125 1 0 0 0 0% 0% 0% 0% 0% 50% 94126 4 2 1 1 0% 0% 50% 25% 50% 11% 94127 89 21 15 6 1% 1% 24% 17% 29% 0% 94128 1 0 0 0 0% 0% 0% 0% 0% 0% 94129 20 3 4 2 0% 0% 15% 20% 67% 0% 94130 1 0 1 0 0% 0% 0% 100% 0% 0% 94131 176 27 15 4 1% 2% 15% 9% 15% 50% 94132 189 45 43 19 2% 2% 24% 23% 42% 0% 94133 130 20 29 10 1% I% 15% 22% 50% 0% 94134 180 21 26 3 1% 2% 12% 14% 14% 50% 94137 4 2 3 2 0% 0% 50% 75% 100% 100% 94142 26 4 7 3 0% 0% 15% 27% 75% 67% 94143 19 1 9 1 0% 0% 5% 47% 100% 0% 94147 5 2 2 1 0% 0% 40% 40% 50% 0% 94150 1 1 1 1 0% 0% 100% 100% 100% 0% 94159 3 0 1 0 0% 0% 0% 33% 0% 0% 94160 1 0 0 0 0% 0% 0% 0% 0% 0% 94164 10 0 0 0 0% 0% 0% 0% 0% 100% 94174 1 0 0 0 0% 0% 0% 0% 0% 0% 94188 5 0 1 0 0% 0% 0% 20% 0% 0% Total SF 8,400 1,410 1,995 700 Other 94*** 1,151 143 135 35 Other Zip 701 74 241 41 TOTAL 10,252 1,627 2,371 776 All Visits=total no.of visits. Admits=no.of pts admitted from the ED. Amb Visits=no.of ED patients arriving by ambulance. Amb Admits=No.of pts arriving by amb&admitted. %of all Amb Visits=%of all amb visits to the ED contributed by this ZIP code. %of All Visits=%of all visits to the ED contributed by this ZIP code %Admitted=%of ED patients from this ZIP code admitted to the hospital Amb%of Total Visits=%of all visits from this ZIP code who arrived by ambulance Amb%*of Admits-percentage of all ED admits from this ZIP code who arrived by ambulance %of Amb Admitted=%of ambulance arrivals from this ZIP code who were admitted source:UCSF APPENDIX X K" City and County of San Francisco Department of Public Health 0 coulyp). Population Health and Prevention Ir S 0 Emergency Medical Services Section Report Date: 11/1/99 Critical Care Diversion Report NOTE:July Data incomplete/inaccurate due to TRENDS System Failure September Data Self-Reported by each Hospital 1999 Critical Care Diversion Hours...Percent of Month on Divert Status-Hours Adjusted toCompensatefor Diversion Suspension Hospital Jan Feb Mar Apr May Jun Jul Aug Sep** Oct Nov Dec Averagefflobs A Chinese 0 0 1 0 01 0 0 0 0 0 CPMC(Pac) 8 8 5 9 2 2 1 8 3- 6 Davies 5 16 24 12 12 2 11 2 2 9 Kaiser 0 1 0 1 1 0 0 0 0 0 Mt.Zion 7 1 4 0 1 0 0 2 3 2 St. Francis 13 6 6 2 12 2 5 6 —5 6 St. Luke's 8 1 1 5 0 0 (++) 0 1 2 St. Mary's 12 5 4 0 4 1 0 0 0 3 SFGH 2. 11 4 2 1 4 4 3 10. 5 UCSF 4 7 3 7 1 0 1 0 3 3 Average/ Month 6 61 5 4 3 1 2 2 3 4 Note: A figure of 1 indicates that some diversion hours were reported but the total percent of the month is less than or equal to 1 percent. Suspend Hrs 101,92 67.48 0 33.63 32.70 33.53 0 0 132.42 Suspend% 14% 9% 0% 5% 5% 5% 0% 0% 18% (**)Hours Adjusted for Diversion Suspension NOTE: January data incomplete due to change from CHORAL to TRENDS System-data for the days of January 13-16 incomplete (++)St.Lukes Hospital offline for entire month of July 1998 Critical Care Diversion Hours...Percent of Month on Divert Status-Hours Adjusted to Compensate for Diversion Suspension Hospital Jan Feb Mar Apr May Jun Jul Aug Sep Oct - Nov Dec AveragelHos' A Chinese 7 0 0 0 0 0 0 0 0 0 0 1 1 CPMC(Pac) 20 45 31 23 15 17 36 26 13. 31 1 12 22 Davies 3 12 10 13 25 16 9 27 12 2 22 3 13 Kaiser 7 18 19 11 0 0 3 1 2 0 0 3 6 Mt.Zion 7 38 19 7 3 16 7 7 1 0 0 1 9 St. Francis 17 26 16 22 261 16 19 29 26 23 26 10 21 St. Luke's 4 21 7 1 5 8 3 4 41 2 0 0 6 St. Mary's 19 5 6 15 6 1 2 1 3 —1 0 2 6 FGH 31 13 13 20 25 19 2 10 19 12 6 11 15 UCSF 11 10 7 6 29 2 4. 24 1 21 1 8 Average/ Month 131 19 13 12 11 10 8 11 10 7 8 4- 10 Note: A figure of 1 indicates that some diversion hours were reported but the total percent of the month is less than or equal to 1 percent. Emergency Medical Services Section 1540 Market Street, Suite 220 (415)554-9960 San Francisco, CA 94102-6052 FAX(415)241-0519 City and County of San Francisco Department of Public Health C0ujvj o Population Health and Prevention Z O�Y3S 075, Emergency Medical Services Section Report Date: 11/1/99 Total Diversion Report NOTE: July Data incomplete/inaccurate due to TRENDS System Failure September Data Self-Reported by each Hospital 1999 Total Diversion Hours...Percent of Month on Divert Status A verage/Ho Hospital Jan "" Feb *" Mar Apr"* May Jun ** Jul** Aug ** Sep** Oct Nov Dec Sp, Chinese 7 6 2 8 5 1 1 1 2 4 CPMC(Pac) 18 13 6 6 6 3 5 8 6 8 Davies 9 4 3 3 3 1 1 2 4 3 Kaiser 11 1 2 1 21 1 1 1 1 1 Mt. Zion 2 1 2 2 71 2 3 1 1 2 St. Francis 20 24 18 24 22 23 24 23 22 22 St. Luke's 9 9 7 8 5 1 (++) 1 3 5 St. Mary's 1 0 1 1 1 1 1 1 1 1 SFGH 24 22 35 35 34 29 29 15 20 27 UCSF 5 1 1 1 1 1 1 1 0 1 Overage/ i Jlonth 10 8 8 9 9 6 7 5 6 8 Note: A figure of 1 indicates that some diversion hours were reported but the total percent of the month is less than or equal to 1 percent. Suspend Hrs 25.88 2.5 0 12.98 0 2.42 1.98 3.75 12.98 Suspend% 4% <1% 0% 2% 0% <1% <1% <1% 2% (**)Hours Adjusted for Diversion Suspension NOTE: January data incomplete due to change from CHORAL to TRENDS System-data for the days of January 13-16 inc. (++)St. Lukes Hospital offline for entire month of July 1998 Total Diversion Hours...Percent of Month on Divert Status verage o Hospital Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec** SP. Chinese 6 0 1 1 0 0 0 0 0 1 0 1 1 CPMC(Pac) 11 2 5 6 4 3 2 3 3 2 1 8 4 Davies 2 2 1 1 01 2 2 2 2 21 1 1 2 Kaiser 30 20 3 2 11 1 1 1 2 1 0 2 5 Mt. Zion 4 1 1 2 2 0 1 3 1 1 1 5 2 St. Francis 11 14 5 11 9 5 7 9 101 9 6 15 9 St. Luke's 7 5 2 4 5 2 3 8 4 4 0 5 4 St. Mary's 2 4 1 1 2 1 1 1 1 2 2 1 2 SFGH 12 10 6 12 41 6 10 8 16 8 5 8 9 UCSF 14 6 7 3 3 1 4 1 3 3 2 2 4 Average/ Month 10 61 3 4 3 2 3 4 4 3 2 5 4 .ote: A figure of 1 indicates that some diversion hours were reported but the total percent of the month is less than or equal to 1 percent. Emergency Medical Services Section 1540 Market Street, Suite 220 (415)554-9960 San Francisco, CA 94102-6052 FAX (415)241-0519^I w L3 w Department of Public Health EMS Section Diversion Suspension Worksheet Month: September 1999 1 9/17/99 cc 14:25 23:59 9.57 9/18/99 cc 0:00 23:59 23.98 9/19/99 cc 0:00 8:00 8.00 2 9/19/99 cc 8:55 23:59 15.07 9/20/99 cc 0:00 8:00 8.00 3 9/21/99 cc 3:30 23:59 20.48 9/22/99 cc 0:00 8:00 8.00 4 9/23/99 cc 21:30 23:59 2.48 9/24/99 cc 0:00 23:59 23.98 9/25/99 cc 0:00 8:00 8.00 5 9/27/99 Total 17:00 23:59 6.98 9/28/99 Total 0:00 6:00 6.00 6 9/30/99 cc 19:08 23:59 4.85 Total Hours Diversion Suspended 132.42 12.98 Percent of Month Diversion Suspended 18.39% 1.80% NOTE: suspension data entered as two or more separate days if the period crosses midnight. Trauma Override Invoked 1 9/24/99 16:45 23:59 7.23 9/25/99 0:00 8:00 8.00 0.00 Total Hours of Trauma Override 15.23 Average hours trauma override f:\data\diversn\suspension: Sep 99 11/1/99 rn 01 r c 0 .cn CL cn = L- v - to U) = ti AW — L.0 LC,'O n� �. N � N 0 CSO N Cl) U) 000 C'n m a 0 c L co Z c°o ti c p O QD W M O -C CTI C I '� S v O O NCV) N U Q, CD 0 (D M c 'a N M�> .�>E CU m 00 co N CL � foo � p N (D .r ._ > W 0 i i o 4co 00 o Uj •� CIS / v O O W �n J pow ++ M O co N N EO M LOO I U') N co Crl IV- co N O :000 r, f o 0 0 0 0 0 0 > N O 00 Co IT N uoIsaania;o sinoH G City and County of San Francisco Department of Public Health C°UNT, Population Health and Prevention rrOlYas 0�5�� Emergency Medical Services Section Report Date: 11/1/99 Critical Care Diversion Report 1998 Critical Care Diversion Hours...Percent of Month on Divert Status-Hours Adjusted to Compensate for Diversion Suspension veraget Hospital Jan ** Feb *"' Mar** Apr** May** Jun *' Jul** Aug** Sep'* Oct Nov Dec** HOW. Chinese 7 0 0 0 0 0 0 0 0 0 0 1 1 CPMC(Pac) 20 45 31 23 15 17 36 26 13 31 1 12 22 Davies 3 12 10 13 25 16 9 27 12 2 22 3 13 Kaiser 7 18 19 11 0 0 3 1 2 0 0 3 5 Mt.Zion 7 38 19 7 3 16 7 7 1 0 0 1 9 St. Francis 17 26 16 22 26 16 19 29 26 23 26 10 21 St. Luke's 4 21 7 1 5 8 3 4 4 2 0 0 5 St. Mary's 19 5 6 15 6 1 2 1 3 1 0 2 5 SFGH 31 13 13 20 25 19 2 10 19 12 6 11 15 UCSF 11 10 7 6 2 9 2 4 24 1 21 1 8 Average/ 11 Month 13 19 13 12 11 10 8 11 10 7 8 4 10 Note: A figure of 1 indicates that some diversion hours were reported but the total percent of the month is less than or equal to 1 percent. Suspend Hrs 347 55.27 58.43 6.38 11.58 15.9 11.98 26.13 9.48 0 0 90.68 Suspend% 47% 8% 8% 1% 2% 2% 2% 4% 1% 0% 0% 13% (**)Hours Adjusted for Diversion Suspension 1997 Critical Care Divertion Hours...Percent of Month on Divert Status-Hours Adjusted to Compensate for Diversion Suspension Averagel Hospital Jan ** Feb Mar** Apr May Jun Jul** Aug Sep** Oct** Nov Dec** Hosp. Chinese 0 0 0 0 0 0 0 0 0 0 0 14 1 CPMC(Pac) 17 16 3 5 1 1 3 4 8 23 12 22 9 Davies 6 17 7 8 4 18 12 7 4 1 9 13 9 Kaiser 3 18 23 13 5 4 11 7 15 20 19 13 13 Mt.Zion 21 11 6 3 7 5 7 71 10 17 12 11 10 St. Francis 32 13 12 14 5 4 3 13 4 3 6 21 11 St. Luke's 19 16 7 20 9 4 4 1 11 11 5 10 10 St. Mary's 6 1 17 7 10 6 6 2 0 2 6 14 6 SFGH 4 1 6 11 0 1 2 10 21 13 5 47 10 UCSF 16 10 12 *3 4 1 1 4 6 26 6 1 8 Average/ Month 12 10 9 9 5 4 5 6 8 12 8 17 9 Note: A figure of 1 indicates that some diversion hours were reported but the total percent of the month is less than or equal to 1 percent. Emergency Medical Services Section 1540 Market Street, Suite 220 (415)554-9960 San Francisco, CA 94102-6052 FAX(415)241-0519 t '1n City and County of San Francisco Department of Public Health '000UIV.J.. Population Health and Prevention A S 0 Emergency Medical Services Section Report Date: 11/1/99 Total Diversion Report 1998 Total Diversion Hours...Percent of Month on Divert Status AveragelH Hospital Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec OSP. Chinese 6 0 1 1 0 0 0 0 0 1 0 1 1 CPMC(Pac) 11 2 51 6 4 3 21 3 3 2 1 8 4 Davies 2 2 1 1 0 2 2 2 2 2 1 1 2 Kaiser 30 20 3 2 1 1 1 1 2 1 0 2 6 Mt. Zion 4 1 1 2 2 0 1 3 1 1 1 5 2 St. Francis 11 14 5 11 9 5 7 9 10 9 6 15 9 St. Luke's 7 5 2 4 5 2 3 8 4 4 0 5 4 St. Mary's 2 4 1 1 2 1 1 1 1 2 2 1 2 SFGH 12 10 6 12 4 6 10 8 161 8 5 8 9 UCSF 14 6- 7 3 3 1 4 1 3 3 2 2 4 Average/ Month 10 61 3 4 31 21- -- 3 4 4 3 2 5 4 '-)te: A figure of I indicates that some diversion hours were reported but the total percent of the month is less than or equal to I percent. ,.)UCSF CHORAL computer was off line for the period of April 2-7,actual TOTAL Diversion for that period unknown (**)Hours Adjusted for Diversion Suspension 1997 Total Diversion Hours...Percent of Month on Divert Status Average/H Hospital Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec** osp. Chinese 6 3 2 0 0 0 0 0 3 2 1 8 2 CPMC(Pac) 7 1 1 1 21 1 1 1 2 1 1 5 2 Davies 0 0 1 0 01 1 2 1 2 2 1 3 1 Kaiser 7 7 4 10 1 3 15 3 3 4 12 4 6 Mt. Zion 2 1 1 1 1 1 1 1 2 1 1 11 2 St. Francis 3 4 1 1 1 2 3 5 7 6 7 8 4 St. Luke's 9 6 6 4 3 2 4 5 10 10 4 5 6 St. Mary's 2 1 1 1 1 1 1 1 1 2 1 1 1 SFGH 6 4 2 2 1 2 3 4 10 7 6 4 4 UCSF 4 7 1 *1 1 1 1 4 3 3 1 7 3 Average/ Month 4- 3 2- 2 1 1 3 3 4 4 3 61 3 Note: A figure of 1 indicates that some diversion hours were reported but the total percent of the month is less than or equal to 1 percent. Emergency Medical Services Section 1540 Market Street, Suite 220 (415)554-9960 San Francisco, CA 94102-6052 FAX(415)241-0519 (- C:�, t7 Data tiofSa bCity and County of San FranciSCO:ity and Coun Francisco Department of Public Health Department of Public Health %;0tJNJ'.4. Emergency Medical services Emergency Medical Service Agency Report Date: 1/23/97 Diversion Report 1996 Critical Care Diversion Hours...Percent of Month on Divert Status (December 1996 Hours Adjusted for Diversion Sus erasion) A verage Hospital Jan Feb I Mar Apr May Jun Ju/ Aug Sep '6c' t Nov Dec per Chinese 6 0 0 0 0 1 0 0 0 0 0 0 0.08 CPMC(Pac) 10 0 1 12 7 2 4 6 3 7 17 13 6.83 Davies 3 1 10 4 4 2 1 4 2 4 1 31 3.25 Kaiser 8 Ol 11 2 3 0 3 2 0 1 4 6 3.33 Mt. Zion 2 1 10 0 1 1 0 1 12 11 7 32 5.67 St. Francis- 4 1 2 8 3 21 3 1 5 5 2 22 4.83 St. Luke's 17 6 1 5 6 4 1 5 6 13 321 30 10.50 St. Mary's 0 21 6 0 3 1 0 0 0 2 1 14 2.42 SFGH 10 61 16 20 1 23 19 18 2 5 13 20 12.75 UCSF 3 26 27 0 0 0 0 0 0 1 4 7 5.67 ,17erage� Month 5.70 4.30 8.40 5.10 2.80 3.60 3.10 3.70 3.00 3.90, 8.10 14.7.0 5.53 1996 Total Diversion Hours...Percent of Month on Divert Status A verag Hospital Jan Feb Mar. Apr MaJun Jul Aug Sao' 'Oct Nov Dec per Chinese 1 0 1 5 0 2 0 0 1 0 3 2 1.25 CPMC(Pac) 3 11 2 2 4 21 4 1 4 2 2 8 2.92 Davies 3 0 0 1 1 0 1 0 1 1 1 1 0.83 Kaiser 3 1 2 5 2 1 2 1 4 5 3 6 2.92 Mt. Zion 1 1 1 1 1 1 1 1 1 1 1 1 41 1.25 St. Francis- 1 1 2 2 2 1 1 3 2 1 1 -3 1.67 St. Luke's 8 71 3 7 5 3 3 3 3 1 3 6 4.33 St. Mary's 1 2 0 01 1 1 1 0 11 0 1 2 0.83 SFGH 2 1 1 3 1 0 1 1 1 3 1 2 1.42 UCSF 0 1 1 1 0 0 0 0 1 -0 1 2 0.58 ,IAverage / Month 2.30, 1.50, 1.30 2.70, 1.70 1.10 1.40 1.00 1.90 1.40 1.70 3.60 . 1.80 Note: A figure of I indicates that some diversion hours were reported but the total percent of the month is less then or equal to I percent. Emergency Medical Services Agency 1540 Market Street, Suite 220 (415)554-9960 San Francisco, CA 94102 FAX(415)241-0519 ta vided by City and County of San FrancisceiyandCo tiof Sans Francisco Department of Public Health Department of Public Health ,,t,c�n�n,T} Emergency Medical Services w osa Emergency Medical Service Agency Report Date: 1/23/97 Diversion Report 1995 Critical Care Diversion Hours...Percent of Month on Divert Status Hospital Jan Feb Mar I A r May Jun Jul A Ug Sep Oct Nov Dec Avera e Chinese 0 0 0 0 0 0 0 0 0 0 0 1 0.08 CPMC(Cal) 0 01 0 0 01 0 0 0 0 0 0 0 0.00 CPMC(Pac) 1 0 6 17 1 1 1 3 4 12 0 2 4.00 Davies 3 10 2 1 0 1 4 3 1 0 1 13 3.25 Kaiser 0 2 4 1 0 0 0 2 0 3 0 1 1.08 Mt. Zion 0 1 0 5 11 2 1 1 0 01 0 3 1.17 St. Francis 3 1 2 1 1 1 5 1 2 0 25 15 4.75 St. Luke's 6 6 8 4 2 1 3 6 0 1 4 23 5.33 St. Mary's 0 0 -0 1 0 0 0 0 0 1 1 0 0.25 SFGH 10 4 10 13 81 5 16 4 0 9 15 14 9.00 t 0 0 3 14 5 7 5 5 5 8 4 12 5.67 ge /h 2.30 2.40 3.50 5.18 1.64 1.64 3.18 2.27 1.09 3.09 4.55 7.64 3.21 1995 Total Diversion Hours...Percent of Month on Divert Status If yos ital Jan Feb Mar -A r May Jun Jul w 'Aug ..SepOct Nov:: .:.:Dec Avera e t;hinese 0 1 1 0 1 0 0 1 1 1 0 1 0.58 CPMC(Cal) 0 0 0 0 01 0 0 0 0 01 0 0 0.00 CPMC(Pac) 1 1 1 1 1 2 1 1 0 2 2 5 1.50 Davies 1 1 2 0 0 1 1 1 1 0 1 1 0.83 Kaiser 7 4 2 4 1 1 1 1 5 1 1 4 2.67 Mt. Zion 0 1 0 1 01 0 0 1 1 1 1 0 2 0.58 St. Francis 2 1 1 3 2 3 1 1 2 1 3 2 1.83 St. Luke's 6 3 2 4 4 3 3 1 1 5 4 5 3.42 St. Mary's 1 0 1 0 0 0 1 0 1 1 0 0 0.42 SFGH 1 4 1 1 1 1 3 1 1 1 3 1 1.58 UCSF 0 0 0 00 1 0 1 0 0 0 1 0.25 Average / Month 1.90 1.50 1.00 1.27 0.91 1.09 1.00 0.82 1.18 1.18 1.27. 2.00 1.26 Note: A figure of 1 indicates that some diversion hours were reported but the total percent of the month is less than or equal to I percent. NA=not available/not collected Emergency Medical Services Agency 1540 Market Street, Suite 220 (415)554-9960 San Francisco, CA 94102 FAX(415)241-0519 r ��• f' �T APPENDIX XILL - Y tDu V IV co .J �^•'tYo s: s .i i$ {}h•�'a .}{}�t�Y xr � vc t�a•�`^�✓i? T v/ N cu co co ._ M Ooj (n CO O N Y ` • ;<,::xe':•}}E:{3<:.:?. ?:its: ti LO ii CO N v, Yi::• �/� � i:•:}C}::{::: %ti}iii.ti<M1p > G') cu O Co T T cu = O U f C T T U a� L U LO Cl V) o LO o � 0rn cz a� rn c� ch N N T T � O- T T ■ UOISJOAia 10 sjnOH 06BJOAV APPENDIX 'XII SAN FRANCISCO EMERGENCY MEDICAL SERVICES AGENCY Policy Reference No.: 8000 Effective Date: 3/16/87 Supercedes: 1/83 AIMBULANCE DESTINATION POLICY I. BASIC CONCEPTS A. This Policy determines the hospital destination of all emergency patients served by paramedics certified by the City and County of San Francisco wd transported by Advanced Life Support(ALS) ambulance,both public and private. It is operative at all times during the usual operations of the Emergency Medical Services (EMS) system. In the event of a multi-casualty incident(MCI) situation.,it may be suspended. B. The objective of this policy is to assure that critically ill or injured emergency patients will be taken to the hospital most appropriate to their immediate needs,regardless of ability to pay and supporting established physician/patient relationships to the extent possible. C. All patients shall be taken to the Receiving Hospital of choice, or the closest designated Receiving Hospital if no choice was expressed,unless a prescribed clinical condition prevails.* (see Section III. Clinical Field Triage Criteria). Exception: Requests for transport to Chinese Hospital may be honored providing the patient demonstrates stable vital signs and Base Hospital contact is not required by policy. D. Hospitals may be designated as Receiving Hospitals based upon established categorization criteria(see Attachment A). E. The primary responsibility for implementation to this policy lies with the paramedic providers and the Base Hospital. However, it also defines the responsibilities of the EMS Agency and the Receiving Hospitals for its establishment,revision, monitoring and evaluation and for public and'provider education regarding its provisionz. F. Paramedics are responsible for: 1. obtaining pertinent patient clinical assessment data 2. eliciting individual patient hospital preference 3. determining closest Receiving Hospital. G. The Base Hospital is responsible for confirming/clarifying patient assessment data to determine the most appropriate hospital destination. In the event of unusual circumstances or uncertainty about patient assessment,transport code assignment,or destination., the paramedics will call the Base Hospital. Destination and transport code will then be determined by the Base Hospital. H. The EMS Agency is responsible to designate Receiving Hospitals and Special Care Facilities and to notify participants of any revisions. I. The provider agencies,the Base Hospital and all other hospitals are responsible for the education and training of their staffs in compliance with this policy and its revisions.- J. The EMS Agency is responsible to periodically monitor and annually evaluate the implementation and effectiveness of this policy. On a routine and periodic basis,the EMS Agency shall provide statistical reports regarding hospital destinations of all patients, and to conduct pertinent quality assurance(QA)outcome studies. Page I of 4 l0 . 00q Policy Reference No.: 8000 Effective Date: 3/16/87 Supercedes: 1/83 IL DEFINITIONS The following terms which are unique to the Ambulance Destination Policy are defined below. All other terms are defined in the the EMS Agency Policy Manual. A. Designated Receiving Hospital: A general acute care hospital with an Emergency Department which meets or exceeds the local established Receiving Hospital criteria. (See Attachment A) B. Closest Designated Receiving Hospital: The closest Receiving Hospital in travel time (not necessarily distance)to the pick-up location. C. Special Care FacilitL A designated Receiving Hospital certified by the Department of Public Health as meeting the additional criteria needed to care for specific clinical conditions. III. CLINICAL FIELD TRIAGE CRITERIA A. Burns Excepting those associated with major trauma,all burn victims meeting the following crite is shall be transported to the closest designated burn specialty care facility: 1. Burns that involve more than 25%of the body surface (20%in children under ten and adults over 40). 2. Full thickness or third degree burns involving more than 10%of the body surface. 3. Partial thickness or second degree bums involving more than 20% of the body surface. 4. All burns involving the face, eyes,ears,hands,feet or perineum. 5.. High voltage electrical burns. 6. Inhalation injury (this would apply to burns sustained in a closed space,for field triage purposes, or for facial burns). B. Amputation and Devascularization Injuries Excepting those injuries associated with major trauma which shall be transported to the Trauma Center,patients with amputation and/or devascularization injuries shall be transported to the reimplantation special care facility of their choice or the closest facility when no choice is expressed. Amputations are defined as body parts severed from below elbow or below knee. Devascularization injuries are defined as partial amputation without perfusion. NOTE: Simple avulsion lacerations of the distal phalanx shall not be included in this field triage criteria. C. Acute Medical Adult Patients should be transported to the closest designated Receiving Hospital. Acute medical patients are those with one more or more of the following conditions: 1. cardiopulmonary arrest ` 2. airway obstruction or respiratory insufficiency with inadequate ventilation 3. hypotension with shock 4. status epilepticus 5. acute deteriorating level of consciousness .r Page 2 of 4 �.$5- Policy Reference No.: 8000 Effective Date: 3/16/87 Supercedes: 1/83 D. Acute Medical Pediatric Patients should be transported to the closest designated pediatric special care facility. - Acute medical pediatric patients are patients,,age fourteen and under,with one or more of the following conditions: 1. cardiopulmonary arrest 2. airway obstruction or respiratory insufficiency with inadequate ventilation 3. hypotension with shock 4. status epilepticus, 5. acute deteriorating level of consciousness E. Acute Obstetrics Patients should be transported to the closest designated obstetric special care facility. Acute obstetrics patients are those with one or more of the following conditions: 1. hemorrhage with shock 2. nuchal cord 3. cord prolapse 4. breech presentation partially delivered F. Psychiatric 1. Voluntary: Adults and minors voluntarily seeking psychiatric care may go to the designated Receiving Hospital of their choice; if they have no hospital preference they shall go to the closet designated psychiatric specialty care facility. 2. Involuntary: a. Adult psychiatric patients who qualify for or are on a 5150 or 5170 hold are transported to Psychiatric Emergency Services(PES) at San Francisco General Hospital(SFGH)or Community Crisis Services at Mt. Zion Hospital. Destination shall be the facility closest to the patient's resident address or the pick-up location. b. All patients on a 5150 or 5170 hold AM in police custody shall be transported to PES at SFGH. c. All minors on a 5150 hold shall be transported to PES at SFGH. G. Major Trauma Patients should be transported to the Trauma Center. Major trauma patients are those with one or more of the following: 1. Anatomic Criteria: a. all gunshot wounds b. all penetrating stab wounds proximal to the elbow or knee 1. Patients with superficial lacerations, stable vital signs and an appropriate mental status may be taken to their hospital of choice. c. all blunt trauma with suspected significant chest, abdomen,pelvis injuries 1. Suspected significaiit injuries include but are not limited to patients with abrasions, lacerations or bruises associated with complaints of pain or tenderness on palpation of the involved area. d. head injury with level of consciousness (LOC)or neck trauma with significant facial, scalp lacerations or hematoma 1. Patients with diff-use neck pain,no localizing neurological findings and an appropriate mental status may go to their hospital of choice. Page 3 of 4 Policy Reference No.: 8000 _ Effective Date: 3/16/87 Supercedes: 1/83 2. Mechanism of Injury Criteria a. high energy dissipation or rapid deceleration injuries b. motor vehicle accidents: 1. striking a relatively fixed object at greater than 25 miles per hour(MPH) unbelted or 35 MPH belted 2. extrication time greater than 20 minutes 3. passenger compartment invaded by twelve inches or more 4. passenger ejection c. motorcycle accidents where rider has been thrown off bike or has struck a relatively fixed object 1. Riders in low velocity accidents and without significant injuries may be taken to theiAospital of choice. d. motor vehicle/pedestrian accidents where the pedestrian has been thrown to the ground 1. Pedestrians brushed in accidents or with low velocity accidents and isolated extremity injuries may go to their hospital of choice. e. falls from heights greater than 15 feet 3. Physiologic Criteria If none of the above conditions are present but the patient is a trauma victim with one of the following criteria,they should be transported to the Trauma Center. a. blood pressure less than 90 systolic b. respirations less than ten or greater than 24 c. heart rate of less than 50 or over 120 d. cutaneous evidence of shock(skin pale,cool,moist) e. altered level of consciousness or any localized weakness or sensorychanges EApol icym nlambdest.pol Page 4 of 4 n yid Policy Reference No.:8000 Attachment A revised 01/30198 Ambulance Destination Schematic Does patient meet criteria for NOTES specialty care facility? *Chinese&Veterans-May only I receive self identified patients who are stable, Code 2 transports.Advanced notification Hospital Preference? .4 —No required. Seton-May receive Code 3 or Yes Na-- Code 2 patients. Advanced notification required. CPMC-Calif_-Receives only Transport to Facility of Transport to Closest OB Patients. Yes Choice Receiving Facility X ,PMC-PC St. Francis CPMC-PC St. Francis Davies St.Lukes Davies St.Lukes Kaiser St. Mary's Kaiser St. Marys Mt.Zion UCSF Mt.Zion UCSF SFGH SFGH Chinese* Veterans* TRANSPORT TO CLOSEST APPROPRIATE ICPMC-CC*** SPECIALTY CARE FACILITY Emergency Dept. Adult Critical 1 0r Approved Acute Routine Replan-lan - j rauma Burns Psych for Medical 0B Cation Pediatrics CPMC_PC Closest CPMC_CC Davies SFGH SFGH See Psych Kaiser Open Kaiser CPMC_PC St.Francis Destination Mt.Zion Critical SFGH SFGH Schematic& SFGH Care St.Luke's UCSF Policy St.Luke's Receiving UCSF UCSF Facility fV"mivisiblambdest98-1.vsd I C)t. APPENDIX XIII SAN FRANCISCO EMERGENCY MEDICAL SERVICES SECTION Policy Reference No.:8001 Effective Date: 06/30/99 Supersedes: N/A EMERGENCY DEPARTMENT DOWNGRADE OR CLOSURE IMPACT EVALUATION POLICY I. PURPOSE A. To establish EMS Section policy and procedures used for evaluating the community impact of an Emergency Department downgrade or closure. B. To establish San Francisco Receiving Hospital procedures for communication to the EMS Section and the local community of a planned Emergency Department downgrade or closure. C. To identify Impact Evaluation data collection responsibilities for the hospital proposing the service change,the EMS Section, and other hospitals in the defined service area. II. AUTHORITY A. Health& Safety Code, Division 2.5, Section 1255.1 — 1255.3, 1300 (b), 1300 (c) and 1364.1. B. The City & County of San Francisco Charter Appendix Q, Section II. III. DEFINITIONS A. Defined Service Area- The City& County of San Francisco. B. Emergency Department Downgrade— A reduction in the Emergency Department's service level provided under their Department of Health Services license. For example, if a Basic Emergency Department changes their service offering to a Stand-By Emergency Department or an Urgent Care Center. C. Special Need Population—Patient population that requires additional supportive services in the provision of their medical care. For example, non-English speaking patients requiring the provision of translation services. D. Specialty services—Limited to the special care services defined in the EMS Section Ambulance Destination Policy#8000 that includes Emergency Departments Approved for Pediatrics (EDAP), Obstetrics, Reimplantation, Trauma,Burns, and Psychiatry. IV. POLICY A. Hospitals shall provide public notice at least 90 days prior to closing, eliminating, or downgrading the level of services provided by their Emergency Department. This public Page 1 of 4 („ 4;9 Policy Reference No.:8001 Effective Date: 06/30/99 Supersedes: N/A notice shall include one public hearing with the San Francisco Health Commission in compliance with all the requirements of San Francisco Charter Appendix Q Section II. The hospital is required to notify the Secretary of the Health Commission in writing at least 90 days prior to the downgrade or closure of the Emergency Department. The public hearing shall be held within 60 days of receiving notification from the hospital. B. Hospitals shall notify the EMS Section of the Department of Public Health in writing at least 90 days before the intended date of closing, eliminating, or reducing the level of services provided by their Emergency Department. C. Upon receiving written notice of a proposed Emergency Department closure or reduction in level of service, the EMS Section shall complete a Community Impact Evaluation of the downgrade or closure upon the community within 60 days. This EMS Section Community Impact Evaluation shall be completed in consultation with the hospital proposing the service change, other San Francisco hospitals,the Hospital Council, and prehospital emergency care providers and shall meet the requirement as outlined in Section V. of this policy. D. The hospital proposing the closure or reduction in services, and other hospitals in the defined service area, shall provide information for the Community Impact Evaluation when requested by the EMS Section. The requested information shall meet the requirements as outlined in outlined in Section V. of this policy. E. The EMS Section shall submit the completed EMS Section Community Impact Evaluation to the State Department of Health Services, the State EMS Authority, the San Francisco Health Commission, and the hospital proposing the closure or reduction of emergency services within three days of its completion. F. The EMS Section shall make the Community Impact Evaluation available for public review upon request. G. Exceptions to this policy may be made by the State Department of Health under the Health& Safety Code, Div. 2.5, Section 1255.1(c) if it determines that maintaining the Emergency Department threatens the stability of the hospital as a whole or the emergency center is cited for unsafe staffing. V. PROCEDURE A. The Community Impact Evaluation shall include descriptions of current community access to prehospital and hospital emergency care in the defined service area of the hospital proposing the change and how the Emergency Department downgrade or closure will affect those services. Page 2 of 4 ( „ gr, Policy Reference No.: 8001 J Effective Date: 06/30/99 Supersedes: N/A B. The time period for the Community Impact Evaluation data collection shall include the most recent full calendar year plus year to date information beginning with the date of notice for the proposed service change. C. The Hospital proposing the service change shall provide to the EMS Section the following information: 1. Defined service area population density. 2. Total number of Emergency Department treatment spaces. 3. Total number of annual Emergency Department patient visits (both 911 transports and walk-ins). 4. Description of the general population and any special need population served by the hospital. 5. Type of EMS specialty services offered(limited to the EMS Section Ambulance Destination Policy#8000). 6. Procedures for handling patients who self-direct to the downgraded Emergency Department and require emergency medical care. 7. Communication Plans regarding the service change to the community at large and to applicable health plans, and health plan members. 8. If the Hospital is a designated Base Hospital,then the impact shall also include: a. Total number of calls by call type and volume. b. Impact on patients and field personnel. 9. If the Hospital is a designated Trauma Center,then the impact shall also include: a. Total number of trauma patients. b. Impact on other hospitals' trauma centers and trauma patients D. Other individual Hospitals in the defined service area shall, upon request from the EMS Section, provide the following information: 1. Total number of Emergency Department treatment spaces. 2. Total number of annual Emergency Department patient visits (both 911 transports and walk-ins). 3. Steps undertaken to accommodate the proposed Emergency Department downgrade/closure including descriptions of changes in emergency department services and EMS specialty services as defined in the EMS Section Ambulance Destination Policy #8000. Page 3 of 4 Policy Reference No.:8001 Effective Date: 06/30/99 Supersedes: N/A 4. The EMS Section shall collect and report the following information: a. Location of facility proposing the Emergency Department service change. Proximity to other Emergency Departments in the defined service area, including travel time, distance, and a map with area hospitals and public transit routes noted. b. Aggregate number of Emergency Department treatment spaces in the defined service area. C. Net change in the aggregate number of Emergency Department beds in the defined service area as a result of the Emergency Department closure or downgrade. d. Aggregate number of annual Emergency Department patient visits (both 911 transports and walk-ins). - e. Estimated net change in the number of patients transported by ambulance to the defined service area Emergency Departments as a result of the Emergency Department closure or downgrade. f. Type of specialty services currently offered by the hospital proposing the service change as defined and the next nearest available alternative providers. g. Steps hospitals and community providers have undertaken to accommodate the Emergency Department downgrade/closure and affected specialty services. h. Current and estimated net change on ambulance and fire response unit time on task in the defined service area. is Immlivimvordlrhled closure impact policy-limited comment.doc Page 4 of 4