EMS Committee

August 2022
Elizabeth Basnett, Acting Director, thanked everyone, especially the Commissioners, for their resilience and dedication through ongoing issues such as COVID response, drought, infant formula shortage, wildfire season, and many others. She emphasized her intention for the Emergency Medical Services Authority (EMSA) and the California Emergency Medical Services (EMS) System to stay patient-centered in all their efforts and decisions.
Acting Director Basnett reviewed EMSA’s three focus areas: data and technology, strategic planning, and partnerships and service orientation. She provided an overview, with a slide presentation, of the background, makeup, four working groups, goals, and timeline of the California EMS Strategic Planning Subcommittee (Advisory Committee).
Approval of Community Paramedicine and Transport to Alternate Destination Proposed Regulations
Mr. Meyer stated, based in part on the success and outcomes of the pilot project, the proposed regulations are being promulgated as required by AB 1544, which was approved by the Governor on September 25, 2020. The Community Paramedicine or Triage to Alternate Destination Act of 2020 authorizes a local EMS agency to develop community paramedicine or triage to alternate destinations programs, and requires the EMSA to develop and adopt regulations and to establish minimum standards for the development of these programs.
Mr. Meyer stated the proposal provides for approving and renewing LEMSA programs, approving training programs, community paramedicine providers, triage to alternate destination providers and facilities, training requirements for paramedics to become accredited to participate in these programs, and procedures for obtaining, renewing, and reinstating official accreditation as well as procedures for actions taken against the various approvals and accreditations.

Ambulance Patient Offload Time (APOT) Report
Tom McGinnis, Chief of the EMS Systems Division, provided an overview of the APOT Report, which was included in the meeting materials. He stated AB 2961 required that LEMSAs submit APOT reports quarterly to the EMS Authority effective July 1, 2019. The bill also required the EMS Authority to calculate APOT times provided by the LEMSAs and provide biannual reports to EMS Commission. This report is the first report for the 2022 calendar year.
Ambulance Patient Offload Time Committee Update
Acting Director Basnett stated the Ambulance Patient Offload Time Committee was created seven months ago with the purpose of developing recommendations to reduce ambulance patient offload delays. The Committee continues to move toward the goal of developing two sets of recommendations: one set for the Emergency Medical Services System and one set for the Hospital System. This committee will conclude by June 30, 2022, and will bring recommendations for Commission approval at a future meeting.
C. After-Action Reporting Presentation: Ambulance Patient Offload Times Teams
Acting Medical Director Garzon reported on APOT during the Omicron Surge and the response to support hospitals, emergency departments, and the EMS. He reviewed the background, purpose, methodology, conclusion, and next steps of the APOT Deployment Survey, as provided in the staff memo for this agenda item in the meeting materials. He stated the feedback received from the survey confirmed that a sizable difference was seen in decreasing wall times, releasing ambulances back to service, and supporting emergency departments in their operations, especially during COVID surges.
Discussion
Commissioner Dunford asked about services provided to expedite a reduction in APOT times.
Acting Medical Director Garzon stated 52 percent served as nurse extenders. The original concept of the APOT team was doctors, mid-level providers, nurses, and paramedics to help support and staff the emergency department. Having more hands to do the work has an indirect benefit on emergency department throughput. Getting to the work quicker theoretically decreases wall times. Later, assigning paramedics specifically to take transfer of care meant that the transporting medics can return to the field.
Commissioner Dunford suggested looking at the reduction in APOT times for those teams.
Acting Medical Director Garzon agreed that that would be beneficial. It is a potential strategy in managing APOT going forward.
Commissioner Snyder asked about the cost of these teams.
Acting Medical Director Garzon stated he will follow up with Commissioner Snyder on that figure.

August 2022

Reports:
1. Pre-meeting update, The meeting was held on August 1st, and attendance was low. Future pre-meeting will be assessed for need, and reminders will go out prior to the meeting.
2. EMS Commission/ DAG Carole Snyder provided an update on both the DAG meeting and the June commissioner’s meeting
3. Emergency Medical Services Advisory Council no update provided. EMSAC is meeting today as well.

Task Forces:
1. State Trauma Regulation Revisions Workgroup-This advisory committee will meet in November. The virtual State Trauma Summit will be held on October 6th. Flyers will be sent out for members interested in attending.
2. STEMI/Stroke Technical Advisory Committee-The State Summit was well attended on June 27, 28th, and feedback from the attendees was very positive.
3. EMSC Technical Advisory Committee-The ENA will now have a seat on this advisory committee. The next meeting and summit will be in November more information to come.

EMSAAC/EMDAC-The next meeting will be held in San Diego on September 20-21st. Both virtual and live
options will be available.

Community Paramedicine Regulations-EMSA will be forming a workgroup to build an implementation toolkit to assist the LEMSAs. ENA may want to have a representative join this committee.

APOT- Interim Director Bassinett has released formal Recommendations, these will be voted on in September. The ENA is currently drafting a letter to the Commission to express concerns with several of these recommendations.

Legislation
• AB2117-Mobile Stroke Unit: Status: In Senate
• AB2130-EMS: Training Status: In Senate

Roundtable Discussion-ENA will be meeting regularly with CHA to discuss current Legislation. Discussion of the importance of our relationship with EMS among the tension of APOT and initiatives not aligning between hospitals/Fire/Ambulance agencies. What can we do personally to promote or continue a strong relationship with our EMS partners?

May 2022

Chair: Loreen Gutierrez & Leslie Duke
EMS Commissioner: Carole Snyder
AGENDA and update May 20, 2022
A. Welcome/Introductions
B. Reports
1. Pre-meeting update -no meeting was held prior to the State meeting
2. EMS Commission/ DAG (Carole Snyder)-Next meeting scheduled for June 15, 2022; DAG hasn’t met.
3. Emergency Medical Services Advisory Council (Matt Powers)-New Director for the Office of EMS, Gamunu Wijetunge. Working on current advisories to set direction to Federal Interagency Committee on EMS (FICEMS). One advisory, Profession Safety working on is recognizing EMS practitioners as healthcare workers when it comes to healthcare guidance during national emergency healthcare crises. 4. Task Forces:
a. State Trauma Regulation Revisions Workgroup-The workgroup is now meeting every 6 weeks and reviewing the current California State Regulations section by section.
b. STEMI/Stroke Technical Advisory Committee-STEMI/Stroke Summit June 27 &28. Free, virtual, and CE’s provided. https://www.eventbrite.com/e/california-state-stroke-summit-2022-tickets-288659808257?aff=ebdssbonlinesearch https://www.eventbrite.com/e/california-state-stemi-summit-2022-tickets-288681914377?aff=ebdssbonlinesearch
c. EMSC Technical Advisory Committee-Conference on June 3rd in San Diego C. EMSAAC/EMDAC- Meeting on 5/31/2022 and Conference June 1 & 2 in San Diego
D. Community Paramedicine Regulations- Second public comment period ended. Last meeting on 3/17/2022, looking at changing the structure and possibly needing a complete re-write, moving toward making the language a statute more than a regulation. There may be a longer public comment period in the future. Discussions about the addition of a public substance as an alternate destination option.
E. APOT- (Stephanie Jensen)-AB1770: on 4/29/2022 the bill failed the deadline and is not moving forward.
F. Legislation- AB 2117 Mobile Stroke Units: All financial and re-imbursement verbiage was removed and now the bill just reflects that the mobile stroke unit would be defined to mean a multijurisdictional mobile facility that serves as an emergency response critical care ambulance under the direction and approval of the local emergency medical services (EMS) agency. AB2130 Emergency Medical Services: Training: On 5/19 it was placed on assembly consent calendar, read, passed, and moving onto Senate. AB2729 EMS: Workplace Violence Prevention: On 5/4 referred to the assembly appropriations suspense file and held by the author. SB1022 EMS: Certifying examination: 5/6/2022 Failed deadline and died in the Com. On Health.
G. Roundtable- Discussion on Narcan leave behind in SB and Riverside County. There are some hospitals that are starting Substance Abuse activations and follow up by a case managers or social workers to connect patients with support after discharge from the ED or hospitalization. Some Fire Departments are starting Narcan kit education to school districts.

March 2022

Introduction to a LEMSA-presentation
EMS pre-state meeting held 3/14/2022
Legislative bills on the watch list include:
SB1022- EMS Certifying exam>watch
AB 2130- EMS Training human trafficking>watch
AB 2729- Emergency Ambulance Services>watch
EMS Commission update by Carol Snyder
EMS Advisory Council update by Matt Powers
STEMI/Stroke Technical Advisory Committee-State Summit June 27 & 28 APOT update by Stephanie Jensen
Community Paramedicine Regulations in another 15-day public comment period
EMSAAC Conference June 1 & 2 EMSC Conference June 3.

January 2022

12.21 EMSA meeting Elizabeth Basnett, Acting Director, provided an overview of her background, her role at Agency, and the EMS Authority vision for 2022. She reviewed the three goals for 2022: data and technology; partnerships and service orientation, and strategic planning. Hernando Garzon, M.D., Medical Director, provided an overview of the status of health care in California and what the EMS Authority has been doing to support and assist during the COVID-19 surge. EMS RESPONSE TO BEHAVIORAL HEALTH PATIENTS Chair Uner reviewed the background and details on the recommendations made by the Subcommittee on Behavioral Health, which were included in the meeting materials.

The Subcommittee recommendations were as follows: 1. The topic of behavioral health in EMS becomes a standing agenda item for discussion at Quarterly Commission on EMS Meetings. This is not to be part of the Consent Calendar. 2. The Commission on EMS recommends the joint position paper Clinical Care and Restraint of Agitated or Combative Patients by Emergency Medical Services Practitioners as a guiding principle for local emergency medical services agencies (LEMSAs), from which to create (or modify) policies and procedures. 3. The Commission requests EMSA to survey the LEMSAs regarding their current protocols and procedures for behavioral health responses. Ambulance Patient Off-Load Time (APOT) Report Tom McGinnis, Chief of the EMS Systems Division, reviewed the background, process to date, and the second report to the Commission for this year regarding the APOT tracking.

Future reports will come out in June and December. Staff is considering display options for the tracking data. The APOT Committee has been established with 20 members, including EMSA staff and stakeholders, and is chaired by Sean Trask, former Chief of the EMS Personnel Division. The Committee is discussing avenues, processes, and toolkits to help decrease APOT and to make the data more useable and accessible. Discussion Chair Uner stated the third APOT Committee meeting will be held on January 5th. Minutes Dec. EMSA meeting.

Dr. David Duncan was appointed as the new EMSA Director. Paramedic regulations: Alternate destination has been removed from current version of regs. In the latest public comment draft, EMSA removed the proposed alternate destination language found under subsection (a) of from Section 100170 under Article 7 of Chapter 4, Title 22 of the California Code of Regulations (CCR). Throughout the regulatory process, it has become clear to EMSA that further discussion about these details will take more time than initially expected. The changes noticed on September 13 are necessary to allow a new EMS Authority Director the opportunity to work with stakeholders and collaborate on a path forward for both alternate destination and community paramedicine policy. Presently, EMSA’s immediate priority is to proceed with the remaining proposed revisions to Chapter 4 of Title 22 of the CCR, including, but not limited to, modifying paramedic licensure fees and paramedic training program requirements. In order to meet the one-year (1) rulemaking process timeline pursuant to Section 11346.4 of the Government Code, and the Rulemaking Calendar schedule approved during the December 2018 Commission meeting, the EMS Authority is requesting the Commission on Emergency Medical Services to consider the proposed regulatory action for approval at the meeting scheduled for December 4, 2019. Community Paramedicine projects have been extended through November 2020.

This is copied from the minutes “DEPUTY DIRECTOR OF LEGISLATIVE, REGULATORY & EXTERNAL AFFAIRS LIM: The next bill is the AB 1544 and that is Community Paramedicine or Triage to Alternate Destination Act. This bill would authorize the local EMS agency to adopt a community paramedicine or triage to alternate destinations program and provide community paramedicine services, in which we have had pilot programs since 2014. This bill would require EMSA to develop regulations to establish minimum standards. It also would augment the Commission as it stands now in its compilation, among other features of the bill. Again, this bill has had a similar look in last session and that bill was 3115, I believe. I can’t remember but before that it was SB 944. We understand there is a lot of discussion around this bill. Is there any discussion that anyone would like to have? CHAIR DUNFORD: Commissioner Barrow. COMMISSIONER BARROW: This bill is a pretty contentious bill at the Capitol and there are alternative legislators exploring alternatives because they are unhappy with different provisions in this. One of the biggest concerns is the local political and monetary costs associated with this bill in changing EMS system unnecessarily when there is already a collaborative setting at LEMSA to handle CP. I think there is going to be more legislation coming out soon. The administration has made it really clear that they are not really happy that this is the only discussion happening at the Capitol so it will be interesting to see what happens by our September meeting, what the landscape looks like on this. DEPUTY DIRECTOR OF LEGISLATIVE, REGULATORY & EXTERNAL AFFAIRS LIM: Thank you. CHAIR DUNFORD: And Commissioner Snyder. COMMISSIONER SNYDER: Carole Snyder, Emergency Nursing Association. Just to reiterate, this is a sneaky bill that changes the makeup of this commission. It removes the Emergency Nursing Association and it removes the California Paramedic Association, which are not representing anything but the right type of care. And I just want to reiterate that if it was a clean bill ENA may be in support of it; but we are definitely in opposition right now and I would like you guys to take that into consideration. CHAIR DUNFORD: Thank you. Other comments? Commissioner Uner. COMMISSIONER UNER: I would like to second what Carole just said. I think removing emergency nurses and paramedics from this commission is not a good move. CHAIR DUNFORD: Thank you. Others? Commissioner Hinsdale. COMMISSIONER HINSDALE: Echo that, also agree with Carole. Thank you.

June 2019

The Trauma regulations are starting to be revised. EMSA will align with the American College of Surgeon guidelines, their verification process and their quality improvement process as the regs are reviewed and revised. They will concentrate on tracking patients and secondary transfers which may flow over to other specialty transport regulations. Other issues for trauma are how to look at regional issues. Do the current RTCCs accomplish the desired goals? Do we need to re-look at that concept and how can we integrate the concept of some regional evaluation or care into regulations? There are EDs around our state, who are beginning to initiate medically-assisted therapy. In other words, start patients on SUBOXONE, as opioid replacement, through something called the ED-BRIDGE Program. Recently the Scope of Practice Committee has recommended and Dr. Backer approved several additions to Local Optional Scope of Practice. These were either recommended through trial studies that were approved by this Commission such as TXA, or approved through evidence-based literature reviews and these include IV acetaminophen, ketorolac or Toradol which can be given through multiple routes, ketamine. Also approval for paramedics to monitor IV medications during transport to a higher level of care, medications that are initiated at the sending facilities, such as blood, pressors, anticoagulants and antibiotics. Per Dr. Backer-These expansions to Local Optional Scope of Practice provide better patient care, especially for our rural areas and our regional systems of specialty care when it is preferable to transport by paramedic ground ambulance because CCT is not readily available and air ambulance might be too much and too expensive. Dr. Backer announced his retirement from EMSA.

November 2018

Minutes to EMSA commission meeting can be found on the EMSA site: https://emsa.ca.gov/ems_commission_meetings/ Stroke and STEMI regulations were adopted, the full text of the proposed final regulations is posted on the website. Ambulance Patient Offload Time Update Mr. McGinnis stated staff continues to collect and work with data from the Ambulance Patient Offload Time project. 17 LEMSAs have provided information this year compared to 18 last year. Staff is learning more about ways to display this data. In working with the LEMSAs, staff learned that forms and ways data is collected can be difficult at times and is working to improve the process. Mr. McGinnis stated his hope that more submissions and more information will continue to come in and that, as staff learns better ways to visually display the information, it will present a good picture of what is happening in the state. Questions and Discussion Commissioner Dunford asked if there is any trend in favor of showing improvement based on the limited capacity of the current data. Mr. McGinnis stated there is no definitive trend. Dr. Backer noted that the data is only for the first year, 2017. There is variation year by year. Commissioner Dunford stated there are some significant outliers and asked if there is evidence of people trying to fix major problems. Mr. McGinnis stated it is early to say concretely. Action: Commissioner Stone moved to accept the ambulance patient offload time update as presented. Commissioner Burch seconded. . EMS Quality Core Measures Guidelines were approved. Alternate Destination The EMSA received a letter from EMS administrators and medical directors advocating implementing alternate destination by policy rather than seeking it legislatively. Staff will work with EMS administrators and medical directors on best strategies to achieve this. Disaster Medical Medical care support in times of disaster is one of EMSA’s key responsibilities. Medical and mental health care issues in shelters during large-scale evacuations are often underestimated. Individuals who end up in shelters often require a higher level of care because their usual home health care resources are unavailable in general population shelters. There is a need to explore alternative resources and concepts to medical shelters.

March 2018

Minutes to EMSA commission meeting can be found on the EMSA site: https://emsa.ca.gov/ems_commission_meetings/

Core Measures: EMSA has revised the Core Measures program to accommodate the transition to the NEMSIS Version 3.4 standards. EMSA initiated an ad-hoc work group comprised of EMS stakeholders to enhance the existing Core Measure set. This group, which met on November 2nd, 2017, reviewed each of the California Core Measures as well as those developed through the EMS Compass Initiative. The recommendations from the ad-hoc group were discussed and reviewed by the Core Measures Task Force on November 28, 2017. The EMSA commission deferred approval until the June meeting.

Disaster: There will be a 4% cut to HPP funding for the state.

Drug Shortages: EMSA is reporting pain medication shortages and is considering adding Ketamine, IV Tylenol and Nirtous Oxide to the optional scope of practice for paramedics.

Regulations: The following information is an update to the regulation rulemaking calendar approved by the Commission on EMS on December 6, 2017. In accordance with Health and Safety Code Section 1797.107, the Emergency Medical Services Authority is promulgating the following regulations: EMSC Open for public comment until April 30th. STEMI and Stoke regulations passed through finance department.

APOT: Ambulance patient offload times: Ambulance patient offload times (APOT) continue to be submitted quarterly to EMSA. To date, 15 of the 33 LEMSAs have provided at least one Quarter’s worth of APOT information, represented 238 (non-unique) hospitals for 2017 Data. Of those reporting LEMSAs, only 8 LEMSAs provided the full years’ worth of 2017 data. Currently, EMSA is working to develop a repository for this information to enhance the ability for review and analysis. Doing so will help to streamline future submissions of APOT information. Additionally, EMSA revised the APOT reporting spreadsheet to include clearer instructions, formatting enhancements, additional aggregate information, and cost per unit hour. EMSA continues the review of APOT submissions and is working to determine the best ways to visualize the information in a meaningful way. LEMSAs are encouraged to complete and submit APOT information to EMSA each quarter and continue to monitor and analyze APOT data to help identify and implement quality improvement strategies where needed.

The DHV Program has over 23,500 volunteers registered. Over 20,900 of these registered volunteers are in healthcare occupations. All 58 counties have trained DHV System Administrators in their MHOAC Programs. EMSA provides routine training and system drill opportunities for all DHV System Administrators. Over 9,300 of the 23,500 plus DHV registered responders are Medical Reserve Corps (MRC) members. EMSA publishes the “DHV Journal” newsletter for all volunteers on a tri-annual basis. The most recent issue was released on January 29, 2018. The “DHV Journal” is available on the DHV webpage of the EMSA webpage: http://www.emsa.ca.gov/disaster_healthcare_volunteers_journal_page. The DHV website is: https://www.healthcarevolunteers.ca.gov.

Ongoing technical support and clarification is provided to public safety agencies, LEMSA’s and the general public regarding all AED statutes and regulations. EMSA is working on a webpage to provide information regarding AED statutes for clarification. Review and approval of public safety AED programs according to Chapter 1.5 Section 100021 continues.

December 2017

California EMSA met September 13 in San Diego:

Jennifer Lim, EMSA Deputy Director of Policy, Legislative, and External Affairs, spoke about two bills that are inactive at this point but were significant and continue to be on the serious watch list for the two-year session. • AB 263 (Rodriguez) is entitled Emergency Medical Services Workers Rights and Working Conditions. It would require private employers that provide ground emergency medical services to authorize and permit its employees engaged in pre-hospital emergency services a prescribed rest and meal period. It would also require EMSA to publish an annual report containing specified information regarding violent incidents involving EMS providers. • AB 1116 (Grayson) is entitled Peer Support and Crisis Referral Services Act. It would create a Peer Support and Crisis Referral Services Program under the California Office of Emergency Services (Cal OES) with three separate tracks: o Fire service o Correctional officers o Rescue or emergency responders The Commission had some concern about the communication between the peer support member and the employee being confidential and not subject to civil or administrative disclosure.

Data: The Core Measures Report for the 2016 information will be posted soon, as will the report from UC Davis on how the Core Measures program is going. Dr. Backer felt that it is time to take a new look at the Core Measures – especially since all the providers in the state have moved over to the National EMS Information System (NEMSIS) 3.4 which gives more uniform and consistent data across the board. Data problems are now coming from the field entry level; we need to work with providers to not shortcut data entry. As they become facile in working with their ePCRs, they need to know the most important fields and the most important data to enter consistently.

APOT This Commission has shown an interest in ambulance patient offload times and delays (APOT). Because of the statute and our efforts to make standardized reporting, we need to see a statewide picture of APOT. Therefore, we are going to make the argument that we need all of the local EMSAs (LEMSAs) to report this data. An EMS fellow is going to work with us to write a report on the process. The next EMS Commission meeting will be held on December 6. Regards, Carole Snyder, RN.

Statewide Trauma Planning:

• The Trauma Plan was revised and renamed. This does not require the same levels of approvals a state-approved plan, which had unforeseen challenges.
• The American College of Surgeons’ Report on the California state-level trauma system review has now been posted on the EMSA website.

APOT

The first data on the ambulance patient offload times has started to arrive. The data confirms that the problem is localized, but it also confirms that the problem can be managed, since some health care systems with similar volumes have resolved the problem. Further data will point out examples of best practices and will also point out which medical centers the local EMS agencies and the California Hospital Association (CHA) need to work with to help improve this problem.

Community Paramedic Pilot Program Update:

The majority of the projects are moving forward with no difficulties.
The Alternate Destination Urgent Care Project has relatively few patients enrolled to date.
The UCLA Project in Santa Monica terminated on June 1st at the request of the fire chief due to the lack of patient enrollment.
The Carlsbad and Orange County urgent care projects are still active but do not have enough enrollees to support meaningful data analysis.
The San Francisco City and County Alternate Destination Sobering Center project is growing and is enrolling over one hundred patients per month.