HomeMy WebLinkAbout09/13/1988, 2 - EVALUATE ALTERNATIVE DIRECTIONS FOR CITY INVOLVEMENT IN EMERGENCY MEDICAL SERVICES MEETI GATE:
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FROM: Michael Dolder, Fire Chief By: Robert Neumann, Battalion Chief
Michael Ho eer
SUBJECT:
Evaluate Alternative Directions for ity Involvement in Emergency Medical Services
CAO RECOMMENDATION:
Review the history of Emergency Medical Services in San Luis Obispo and provide direction to staff
in preparing an action resolution for the September 20th Council meeting.
REPORT SUMMARY
In April, 1988 the County Board of Supervisors voted to allow paramedic services to be provided by
agencies throughout the county. Conversion from EMT-II to Paramedic level of service will save
additional lives and provide better medical care to 28% of the patients the Fire Department serves.
The Emergency Medical Services Agency (EMSA), responsible for regulating emergency medical
service in the county, has established a conversion program for EMT-II's currently operating in the
county. The usual training gap between Paramedic and EMT-II (134 hours) has been greatly reduced
and all EMT-II's with two years of experience can convert to Paramedic by taking a 48 hour class and
passing a certification test The SMSA will only offer three conversion classes during the next year
with a limited number of student spaces for each agency. The cost of the one time EMT-II to EMT-P
conversion for nine Fire Department EMT-II's is $8,964. A yearly cost increase of $10,800 will also be
required to provide funding for the Fire MOU salary differential, and $4,320 for insurance and
benefits for the differential. Equipment costs will not increase with the Paramedic program.
The last time a similar issue was before the City Council was June of 1982. At that time the Council
by resolution approved a policy that the City provide EMT-II Advanced Life Support to its citizens
through trained Fire Department personnel. Prior to that time, the Fire Department responded to
medical requests on an as needed basis. The Fire Department estimated that it could provide for the
training of nine EMT-II's and purchase the needed new equipment over a two year period (1982-83,
1983-84) for $67,372 (see Attachment I) which was done. Maintenance costs for the ongoing program
were estimated at $30,000 a year, which included an estimated salary differential. The negotiated
salary differential for the EMT-II's was $5,000 above the estimate. The actual maintenance cost for
the EMT-II program was $35,000. Last year the program cost was $46,240, including $6,000 of
administrative cost assigned to the program.
Currently, Advanced Life Support at the EMT-II level is provided by the Fire Departments of
Atascadero, Morro Bay, San Luis Obispo and the South Bay Fire District. All fire agencies provide
Advanced Life Support in conjunction with private ambulance companies. All remaining county Fire
Departments including those listed above also provide Basic Life Support (EMT-I) or basic first aid.
SIGNIFICANT IMPACT
The main effect of Council's decision will be felt by citizens in need of emergency medical care in
day-to-day settings and disaster situations. Financial impact for converting nine EMT-II's to
Paramedics will be $8,964 for conversion plus a yearly cost of $10,800 for salary differentials, and
$4,320 for benefits. Total first year Paramedic costs are $70,164 therefore, an additional general fund
appropriation of $23,924 would be required over the current EMT-II program costs of $46,240.
CONSEQUENCES OF NOT TAKING RECOMMENDED ACTION
Delaying the Paramedic conversion now will forfeit the cost saving advantages of the one time
conversion period. Postponing the conversion to Paramedics will cost approximately $80,000 for the
training of nine Paramedics. If no upgrade is recommended and we continue with EMT-II service,
future training costs will equal those of a Paramedic Program, but service provide will be EMT-II.
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COUNCIL_ AGENDA DEPORT
BACKGROUND ON FIRE DEPARTMENT EMS PROGRAM
In 1975, the Fire Department started responding a rescue squad with Basic Life Support, (BLS)
Emergency Medical Technician I (EMT-I) personnel to automobile accidents and emergency calls
based on citizens requests without clear policy direction. At the same time, State legislation was
passed which required all Firefighters to be medically trained at the basic first aid level. By 1982,
the Fire Department was responding to approximately 1,200 medical calls and completed training of
all personnel to a EMT-I, Basic Life Support level.
Various agencies throughout the county expressed the need for expanding emergency medical
response to the Advanced Life Support (ALS) level. However, these same agencies expressed concern
about the inability of the tax base and call load to support the costs of an ALS program at the
Paramedic level. The lower costs of an ALS program at the EMT-II level was the main reason for a
consensus recommendation to pursue the EMT-II offering. The San Luis Obispo County Board of
Supervisors in December, 1981 approved the development of the San Luis Obispo County Emergency
Medical Services Agency (EMSA) to provide training and administer an ALS program at the EMT-II
leveL
The EMSA was set up as a private non-profit corporation, and is funded mainly by the County of San
Luis Obispo. It is operated by a Board of Directors and has several committees that over see both
ALS and BLS programs. The Board of Directors is made of a physician appointed by the County
Health Officer, a hospital administrator, a Emergency Room Physician appointed by the County
Medical Society, an emergency room nurse, an EMT-II, three private citizens appointed by the Board
of Supervisors, and one representative from of the following agencies: County Fire Chiefs, County
Sheriff and ambulance service. The EMSA is responsible for providing both initial and on going
training and developing and implementing the required polices and procedures under State guidelines
for the County's ALS program.
On June 29, 1982, the City Council issued a policy statement (Exhibit 1) committing the City to
provide EMT-II service through trained City Firefighters. The Fire Department was directed not to
transport patients except in life or death situations where no ambulances were available. In the
original policy statement a consideration of user fees for medical services was also made.
In February of 1983 City Firefighter/EMT-II's began responding to emergency calls. Over the next
five years critical life saves in the field increased from almost none under the EMT-I system to
approximately 10 per year. EMT-II Advanced Life Support call loads increased over a four .year
period from 167 in 1984 to 303 in 1987. An average of 300 ALS calls per year was experienced during
this period. Over the same period, approximately 25% of all medical calls responded to by the Fire
Department involved EMT-II Advanced Life Support. The 1,400 BLS and ALS medical calls per year
currently account for approximately 60% of all fire department emergency responses.
Since 1983, the State has expanded the scope of EMT-II practice, including the use of four more drugs
and several medical procedures. The hours of continuing education (yearly training required to stay
certified) and initial training increased as the EWA adopted the new state standards. The increase
in EMT-II training has brought the County's EMT-II program closer, in terms of procedures and
training hours, to a Paramedic level of service; the usual 134 hour difference between Paramedic and
EMT-II has now been narrowed to 48 hours.
Fee For Service
In 1982 when Council approved the EMT-II policy statement and program, staff was directed to bring
back cost recovery alternatives. In September, 1984, (Attachment #2) four alternatives were
considered for recovering EMT-II operating costs. The four alternatives were as follows:
1. Fee for Services BLS ($50), ALS ($75)
2. Voluntary Subscription Service
3. Ballot Measure to assess a fee of $1.00 per occupancy per month.
4. Do nothing and continue providing emergency medical services from the general
f und.
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COUNCIL AGENDA REPORT
Considering the effects of each of the alternatives, Council chose to support the EMT-II Program
through the General Fund. The policy statement and budget statements were changed to reflect the
general fund support.
Once again, as we consider paramedics today, the issue of user fees could be considered to offset City
costs for EMS services. Numerous fee recovery alternatives could be considered. However, it is
staff's recommendation that user fees be considered separately after a determination is made
regarding the level of city EMS service, but it should be emphasized that cost recovery could be
implemented to recover all of this program's cost or at least offset the costs.
Several new options deserve consideration if the Council chose to again consider cost recovery. They
are the following considerations: First, charge the ambulance company a fee for assisting them in
providing medical care. Morro Bay currently charges San Luis Ambulance $25 when they provide
Firefighters to help transport a patient. Second, the City could provide its own ambulance transport
service, and charge for that service.
EMT-II To Paramedic Conversion
In April, 1988, the County Board of Supervisors, after reviewing the EMSA's Feasibility Study for the
Optional County Wide Conversion to Paramedic Advanced Life Support Ambulance and Fire
Department Personnel (Attachment #3), approved the optional upgrade of all County EMT-II's to the
Paramedic or EMT-P level of service. Following the Board's action, all major ambulance providers in
the county have made informal commitments of upgrading to Paramedic (EMT-P) service level. The
City Council of Atascadero has already approved the Paramedic conversion for their Fire Department
personnel.
Now, Council is again asked to make a policy decision as to whether City Firefighters will upgrade to
Paramedics. The Paramedic Program offers many advantages to the public, City, County and
ambulance companies. In the EMSA Feasibility Study (Attachment #3) it was estimated that the
survival of two patients per month at Twin Cities Hospital may have resulted if Paramedic vs. EMT-
II field intervention occurred. In a more extensive study done by the Sierra-Sacramento Valley
Emergency Medical Services (Attachment #4), elaborating on the advantages of Paramedic over EMT-
II treatment, the statistics are even more dramatic. The Paramedic conversion will offer substantially
more life-saving procedures than those allowed under an EMT-II Program. Examples of some of the
additional procedures are as follows:
Nasotrachaeal Intubation (Airway tube through the nose to the lungs)
Infant and Child Oral Endotracheal Intubation (Airway tube through the
mouth to the lungs)
Caraotid Massage and Valsalva Maneuvers (Message the neck to slow a too fast
heart)
Cardioversion on the Conscious Patient (Shock a chaotic heart to restore heart
beat)
Needle Thoracostomy (Insert a needle in the chest to reinflate a collapsed lung)
Needle Cricothyrotomy (Insert a needle in the throat-trachea; allows a person with
closed upper airway to breathe)
The specific list of procedures are found in Attachment #5.
The paramedic feasibility study also indicates that in the cities of San Luis Obispo and Morro Bay
along with the unincorporated area of Los Osos 28% of the patients would have benefitted from the
EMT-P service level over the EMT-II service level. A study done by the Fire Department (Attachment
#6) shows that during the first six months of 1987, 35% of all Advanced Life Support patients treated
at the EMT-II level would have benefitted from EMT-P service.
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city of san Luis osIspo
wi;% COUNCIL AGENDA REPORT
City Medical Responses Projected • to 1989 Are As Follows:
All Medical Calls 1,415
Advanced Life Support Calls 354
Advanced Life Support Calls 124
(Benefitting from Paramedic Skills)
"Based on 1987 Statistics without Population
increase adjustments
The above estimates show that 124 people a year could receive potential benefit from paramedic
intervention. Speculation on the number of lives saved or decreased in hospital stays is difficult and
mainly guesswork at best; however, due to advanced airway intervention the paramedic program will
save more lives than the existing-EMT-Il Program.
If the City decides not to convert to the Paramedic Program, then all current EW-11's will maintain
their current status and salary. But as these EMT-II's drop out of the EMT-II program all newly
trained ALS Firefighters will be trained under the Paramedic program, because it will be the only
ALS class taught in San Luis Obispo County. However, when these Firefighters complete the class
he/she will only be able to provide EMT-II service because our Department service level will be
EMT-II. Possible life saving skills could not be used even if needed.
Current Medical Response
The history of ALS coverage and response times in the City have been excellent. The program's
effectiveness has been a combined effort of the Fire Department and ambulance company with both
providing EMT-II's. The Fire Department has easily met the stated policy goal of providing
Advanced Life Support within six minutes of notification of a medical emergency. A high
percentage of days (80-85%), the Fire Department provides a back-up ALS unit for simultaneous calls
and multiple patient situations, in the form of EMT-11's with the Squad and an engine company. The
Fire Department and private non-dedicated (not required to stay within the city limits of San Luis
Obispo) ALS ambulance have delivered ALS coverage to the citizens of San Luis Obispo in six
minutes very nearly 100% of the time since 1984.
A six minute private ALS ambulance response has not been consistently delivered in the past due to
San Luis Ambulance's response into a large area of the county. In fact, for a majority of 1987, San
Luis Ambulance were short EMT-II's and opted to assign ALS units to out of city locations where they
were often the sole ALS providers.
Conversion Cost
The City's cost for a paramedic program can be estimated through June 1990 with a high degree of
confidence due to the accuracy of training costs and salary differentials, (see Attachment #3, Page 10
and Fiscal Impact section). The cost to convert nine EMT-II's to Paramedics during the one time
conversion period will be $8,964. The pay differential for Paramedic has already been established in
the Fire MOU at $300 per month. The current pay differential for EMT-I1 is $200 per month. The
salary differential increase equates to an annual cost increase of $10,800 in salary plus $4,320 for
benefits at the Paramedic level of service. Equipment costs, other than replacing aging equipment,
should not increase as no additional equipment is required for a Paramedic Program. After a medical
call, instruments, disposable supplies, medications and specialized items are returned to the Fire
Department and charged to the patient by the hospital. By increasing the number of medical
procedures that Firefighters can perform the City's liability for the procedures may increase.
However, other paramedic programs have not experienced a greater number of claims than have
EMT-11 programs, and to date our City has not experienced any claim under the EMT-II program.
Staff does not feel that the City will significantly increase its liability by converting to this program.
It is important to note that converting to the paramedic program at a later date (after the three
conversion classes are over) will cost $80,118 for the start up cost since we will have to send our nine
EMT-II's through the complete Paramedic course at a cost of $8,902 each.
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MOGe COUNCIL AGENDA REPORT
The opportunity now exists for the Fire Department to convert the nine existing EMT-II's to
Paramedics at a relatively inexpensive rate. A timely decision on whether or not to upgrade to a
Paramedic service level is vital if we are to benefit from the cost savings of the one time conversion
period. Currently, three Paramedic conversion classes will be offered in September, October, and
November, 1988. The total training costs during this period will be approximately $8,902. A decision
to convert to Paramedics at a later date will increase the training costs to approximately $80,118 for
nine Paramedics.
If a decision is made not to upgrade the Fire Department EMT-II Program to a Paramedic Program
then considerations should be given for provisions for providing private Paramedic Ambulance
service. This could be accomplished by entering into an agreement with the local ambulance provider
to maintain an ALS ambulance inside the City of San Luis Obispo. To provide this "dedicated"
ambulance, San Luis Ambulance would require a stand-by fee or subsidy. San Luis Ambulance has
estimated this fee to be $120,000 per year. Without this dedicated Paramedic response, citizens will
receive Paramedic treatment on a delayed basis estimated to be between six and twenty minutes
depending on the location of the private ambulance. Without a dedicated unit, the closest ambulance
could be as far away as Avila Beach, Cuesta College or at the top of Cuesta Grade.
Providing only a dedicated private Paramedic ambulance in the City and not providing City Fire
Department Paramedics will also substantially lessen Paramedic resources for multiple calls, mass
casualty or disaster situations and critical patient calls where three or four Paramedics are needed for
optimal care of one patient.
The option of staying at the EMT-II level presents additional program impacts. Except for the one
time paramedic conversion cost (approximately $9,000) and salary differentials (approximately
$15,000), the ongoing EMT-II program costs will remain much the same as a paramedic program while
providing a lesser service. Operational difficulties will also result when Fire Department EMT-II's
with a lower level of skills work in an essentially "Paramedic World". Confusion will result in the
field as well as at the base station hospital. Also, the City, operating under the existing ambulance
agreement, will have little quality control over Paramedic services.
Future Considerations
Converting to Paramedic Service raises several philosophical questions, such as:
1. Should our City residents receive a lower ambulance rate or a guarantee of a lesser rate increase
in the future as a result of our department being the first responder and providing the majority
of treatment?
2. Given that the Paramedic level of service is selected, should we:
a. Look at the possibility of adding a transportation component to the City's existing
response capability, in other words, providing a City ambulance service (realizing that thi
could not occur until 1992 because of an existing City/County agreement)?
b. Conversely, should we hold the ambulance company to a higher standard of service, one
that would effectively allow us to get out of the emergency medical response business and
make it a purely private enterprise concern, similar to the other components of the
emergency medical care business?
3. Should we work with the County, under the existing agreement, to take steps to gain further
direction over the private ambulance service in relation to service standards and rate increases?
4. Should we consider establishing a charge for service to either the patient or the ambulance
company or could we work to have the ambulance company charge a lesser fee when the City
provides the first response and Advanced Life Support treatment?
The seven alternatives listed below attempt to provide answers and options for most of the issues
raised in the philosophical questions above. c
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A01IMN COUNCIL AGENDA REPORT
ALTERNATIVES
1. Upgrade the Fire Department's ALS service from EMT-II to a Paramedic level and provide City
operated ambulance service (City operated ambulance can only be considered after 1992).
2. Upgrade the Fire Department's ALS service from EMT-II to a Paramedic level in combination
with a non-dedicated private Paramedic ambulance.
3. Upgrade the Fire Department's ALS Service from EMT-II to a Paramedic level with a dedicated
BLS private ambulance service.
4. Continue the Fire Department's EMT-II service with a non-dedicated Private Paramedic
Ambulance.
5. Reduce the Fire Department's service level from EMT-II to EMT-ID (Upgrade of EMT-I skills to
allow defibrillation) with a Dedicated Private Paramedic Ambulance.
6. Reduce the Fire Department's service level from EMT-11 to EMT-I with a Dedicated Private
Paramedic Ambulance
7. Reduce the Fire Department's service level from EMT-II to EMT-I with a Non-Dedicated Private
Paramedic Ambulance
Alternative 1: Upgrade the Fire Department's ALS service to a Paramedic level and provide City
operated ambulance service.
Under this alternative, the Fire Department would provide ambulance service and Paramedic services.
This alternative is not available to the City until May, 1992 as past Council action has transferred
ambulance regulatory authority to the County of San Luis Obispo via a Joint Powers Agreement
(Attachment #7). Future Fire Department ambulance service, would be subject to receiving
agreement on amendments in 1992, which would allow the "first call" ambulance to be a Fire
Department vehicle for medical emergencies within the City. Paramedics would respond the
ambulance along with an EMT-I engine company. Ambulance service for subsequent calls or multiple
patient calls would include private ambulance services. Fire Department ambulance personnel would
also respond to fires during which time the private ambulance would respond to medical calls.
An optional user fee could be implemented to offset some or all of the estimated $107,364 cost for the
City to operate an ambulance service. As an example, an ALS transport charge of $320 would yield
$96,000 for 300 calls per year. If BLS transport was also provided for 1,000 BLS patients an
additional $155,000 would be generated at a charge rate of $125 per patient. (This is based on a 100%
collection rate, which is highly unlikely)
1. Pro - All alternatives that involve Fire Department Paramedic Service have the
advantage of upgrading existing EMT-11's during the conversion period, which is a
relatively inexpensive means of training to the Paramedic leveL All alternatives
that involve Fire Department Paramedics also take advantage of a large statewide
hiring pool of Paramedics, which increases the possibility of reducing training
costs through new hires. An increase to a Paramedic service level will also mean
an increase in lives saved. Fire Department involvement in Paramedic service also
results in a greater number of Paramedics or EMT-P's available in the City during
multiple patient or disaster situations (i.e. plane, bus, and multiple car accidents,
and hazardous materials releases, etc.).
The advantages of operating a City Fire Department ambulance are many.
Revenues can be generated through user fees, that can offset the EMT-P program
costs. A City ambulance would be available at police and fire incidents for
standby at no charge to the City. On emergency scenes, Fire Department personnel
manning an ambulance would be under direct control of the Incident Commander
with better radio communications, resulting in safer operations and alleviating
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MaZe g COUNCIL AGENDA REPORT
patient and scene control misunderstandings.
Con - By providing a Fire Department operated ambulance, the City would be intruding
into private sector business opportunities. Any fee structure would require billing
and collections procedures and may have staffing impacts. The ambulance
company currently experiences a 50% collection rate. As the private ambulance
lost financial interest in the city area, ambulance units available for a timely
response during simultaneous calls, fires and multiple casualty situations would
decrease or be eliminated. Providing ambulance service with existing Fire
Department personnel would, at times, decrease or delay the manpower available
for fire suppression. Operating an ambulance would require the City to meet and
confer with the Firemen's Association. There would be initial and ongoing
equipment costs incurred with operating an ambulance. When the Fire Department
was transporting a Basic Life Support call, there would be a loss of dedicated back-
up ALS service as Paramedics would be committed during the transport, a decrease
of two personnel would result when the private ambulance personnel are
eliminated from emergency scenes. ALS calls are best managed by at least five
personnel. Currently, four persons are responded by the Fire Department and two
by the ambulance company. The proposed Fire Department ambulance and engine
company response would only provide four rescuers on emergency scenes.
Alternative 2: Upgrade the Fire Department's ALS service to a Paramedic level in combination
with a non-dedicated private Paramedic ambulance.
This alternative would be equivalent to the current medical response service except that both agencies
would provide Paramedic service. Fire Department Paramedics with a typically quicker response time
than the ambulance, initiates ALS care supported by a BLS engine company. The additional help of
ambulance personnel (sometimes non-Paramedic) arrives to deal with the logistics of getting the
patient to the hospital, allowing Fire Department EMT-P's to concentrate on patient care. In
situations where the ambulance is first on scgne, the ambulance EMT-P initiates patient care and Fire
Department personnel assist with patient care and transport logistics, again assuring patient care
continuity. One Fire Department Paramedic rides with the ambulance, while the other Fire
Department Paramedic is available to cover subsequent calls. Upon arrival at the hospital, the Fire
Department EMT-P's are almost immediately available for another response, however, ambulance
personnel are still committed to deliver the patient, recover their gurney and restock their ambulance.
This ambulance recovery time is usually 15-20 minutes.
2. Pro - This alternative allows for the quickest delivery of the most EMT-P's, including
multiple calls, and provides the best ALS service of all alternatives listed (more
lives saved) with the least impact on other Fire Department service responsibilities.
Patient care and scene control continuity are optimized with this system. Though
not dedicated, the private Paramedic ambulance has a financial interest in all
transports in the City and in the past has provided a timely transport. This service
level keeps the most Paramedics available for mass casualty (disaster) incidents.
By not having Fire Department personnel:committed to an ambulance, flexibility
of geographic reassignment is allowed (i.e. during Madonna Rd. construction Fire
Department EMT-II's were assigned to Station 4 to provide continual six minute
ALS coverage). All general advantages of Paramedic service level exist as stated in
Alternative 1.
Con - The disadvantages of this alternative are purely economic. The cost increase of
converting the existing nine Fire Department EMT-II's to Paramedic is $8,964 and
a salary differential increase of about $15,000 per year equates to a first year
increase of $24,000 (See Financial Impact Section for more detailed program costs.)
At times a duplication of Paramedic service exists between the Fire Department
EMT-P's and the ambulance EMT-P's. This duplication, however is eliminated as
soon as anything but an ordinary emergency response occurs; when treating one
critical patient or responding to multiple call situations, there is no longer
duplicated or idle Paramedic personnel in the City.
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COUNCIL AGENDA REPORT
Alternative 3: Upgrade the Fire Department's ALS service to a Paramedic level with a dedicated
BLS private ambulance service.
This alternative would have first call ALS provided by the Fire Department with BLS (EMT-I)
support coming from an engine company and a dedicated private BLS ambulance. Fire Department
Paramedics would provide patient care with patient transport logistics provided by the private EMT-I
ambulance. Second call ALS response would come from remaining Fire Department capabilities and
from a non-dedicated private ambulance service. Periodic delays for first call ambulance would be
eliminated under this alternative.
3. Pro - All pros associated with Fire Department Paramedics apply, (see Alternative 1 and
2's Pros). Ambulance response time is decreased and could increase patient care
and life saves. EMT-I (BLS) dedicated response keeps non-dedicated private ALS
ambulance available for additional calls after Fire Department Paramedics are
committed, resulting in better utilization of Paramedic resources for City and
county response.
Con - Cons of Paramedic conversion apply (see Alternative 2's Cons). The cost of
dedicating a BLS private ambulance ($100,000/year) may not be worth the service
that is received. The delivery of ALS Paramedic service in six minutes is crucial
and a slight delay in transport will not significantly alter patient outcome,
therefore paying for a dedicated BLS ambulance may not be the most effective use
of funds.
Alternative 4: Continue the Fire Department's EMT-II service with a non-dedicated Private
Paramedic Ambulance.
This alternative would allow the Fire Department to provide an EMT-II service level with a non-
dedicated private Paramedic ambulance providing transport and Paramedic service. Training at the
EMT-II level will no longer be offered in San Luis Obispo County. As a result, EMT-II's will have to
train at the more costly Paramedic level in this county. However, personnel will only be allowed to
practice at the EMT-II level. Given the facts that no additional costs are required to train at the
Paramedic level and that the only training cost difference is the one time EMT-II to Paramedic
conversion ($8,964) it would not seem prudent to stay at the EMI-II service level.
4. Pro - This alternative does not require a budget increase for the first year as no
additional training would be required and no salary differential increase would be
paid. Citizens would still receive a dedicated Fire Department EMT-II ALS service
with current Fire Department response times. However, after the first year,
continuing EMT-II costs and the cost of training new EMT-II's will increase to
equal those of Paramedic level training.
Con - While EMT-II's will be required to attend more costly Paramedic training and will
possess the same skills as Paramedic level personnel, they will only be allowed to
practice at the lower EMT-II level. Working in a two-tiered system will be
cumbersome at best and will not provide the best patient care available. When the
Fire Department EMI-II's are first on scene, the patients will have to wait until
the ambulance arrives to receive important, sometimes life saving Paramedic care.
Also, all patient information and prior treatment provided will have to be passed
on to the ambulance paramedics before they can start patient care. Hospital base
stations that give medical orders to EMT-II's and Paramedics in the field will be
burdened with trying to determine if they are giving orders to EMT-II's or
Paramedics. In short, this system will be unwieldy and be a source of many
conflicts and much confusion. In the long term, substantial cost savings would not
be realized and the City would not have control of paramedic service delivery time
or back-up capabilities for multiple casualty incidents.
city of San LUIS OBISp0
B COUNCIL_ AGENDA REPORT
Alternative 5: Reduce the Fire Department's service level to EMT-ID with a Dedicated Private
Paramedic Ambulance
This alternative would incorporate early Fire Department delivery of defibrillation (electrical shock
of a heart that is not beating). (EMT-II's and Paramedics can also defibrillate) with a private
Paramedic ambulance providing the remaining ALS procedures. The EMT-ID program uses EMT-I's
using automatic or semi-automatic defibrillators along with abbreviated training (four hours for
automatic system, ten hours for semi-automatic) to provide EMT-I's with the ability to defibrillate
ventricular fibrillation (V-Fib, one form of cardiac arrest). On a cost/benefit basis, when coupled
with early, back-up Paramedic support; this system is the optimal arrangement for saving ventricular
fibrillation, cardiac arrest patients that respond to defibrillation. However, the EMT-ID system does
not address other life-threatening areas, such as trauma, airway or breathing problems, allergic
reaction, diabetic complications, hemorrhage, etc. A dedicated Paramedic ambulance would assure
first call delivery of ALS procedures within 6 to 9 minutes.
5. Pro - Arrival of EMT-ID and defibrillation within 4 - 6 minutes of cardiac arrest and
the arrival of EMT-II's or Paramedics within 10 minutes can save 20% more lives
than the arrival of EMT-I's that can not defibrillate and ALS within 10 minutes.
Con - Eliminating the Fire Department's current EMT-II program and reducing the Fire
Department's medical service level to EMT-ID level will require providing a
dedicated ALS ambulance for the city. This dedicated private Paramedic
ambulance will cost $120,000 per year, and the total first year cost will be
$163,398. The net ongoing cost for this alternative is $93,084 per year vs. a Fire
Department Paramedic Program, which costs approximately $49,000 per year.
Additionally, defibrillation many times is ineffective without the administration
of cardiac drugs. Paramedic services for all other medical emergencies would be
provided only at the time the ambulance arrives, which is 6-9 minutes; back-up
capabilities would be contingent on additional ambulance and out of city
ambulance response. Certifying all Fire Department employees as EMT-ID would
be a change in working conditions and would require the City to•meet and consult
with the Firemen's Association prior to implementation.
Alternative 6: Reduce the Fire Department's service level to EMT-I with a Dedicated Private
Paramedic Ambulance
Fire Department EMT-I's could provide BLS support procedures and assist the ambulance after they
arrive. This alternative, even more so than Alternative #5,,would allow Fire Department personnel to
concentrate on fire suppression training and fire prevention assignments. However, Fire Department
manning could not be reduced as other emergency needs, i.e. fire and hazardous materials response are
already at a minimum.
6. Pro - This alternative would eliminate all Fire Department EMT-II costs, saving $37,600
annually. However, dedicating a private paramedic ambulance will cost
approximately $120,000 year. More time would be available for Firefighters to
concentrate on fire suppression, fire prevention and disaster preparedness
activities.
Con - Life saves would decrease due to inability of one dedicated ambulance to cover
subsequent calls in a timely manner. This alternative would have a net cost
increase of $71,600 per year. The city could choose to absorb these costs out of the
General Fund, or charge each user a set fee of approximately $400. It should be
noted that the majority of ALS users of the system tend to be senior citizens.
Alternative 7: Reduce the Fire Department's service level to EMT-I with a Non-Dedicated Private
Paramedic Ambulance
Fire Department EMT-I's could provide BLS support procedures and assist the ambulance after they
arrive. This alternative, even more so than Alternative #5, would allow Fire Department personnel to
��hillll�Pii�u��JJJl city OF sat t LUIS OBISPO
1NOGN COUNCIL AGENDA REPORT
concentrate on fire suppression training and fire prevention assignments. However, Fire Department
manning could not be reduced as other emergency needs, i.e. fire and hazardous materials response are
already at a minimum.
7. Pro - This alternative would eliminate all Fire Department EMT-II costs, saving $30,498
annually. More time would be available for Firefighters to concentrate on fire
suppression, fire prevention and disaster preparedness activities.
Con - Life saves would decrease (it is difficult to impossible to estimate the decrease)
due to the possibility of advanced life support not being available in a timely
period, and the inability of one non-dedicated ambulance to cover subsequent calls
in a timely manner.
CITIZEN PARTICIPATION
The Fire Department has not made an organized effort to gather public comment on the subject of
paramedic conversion. However, on August 24, 1988, the Citizen Advisory Committee reviewed the
proposal to upgrade the Fire Department emergency medical service level from the current EMT-II
level to the EMT-P (Paramedic) level. The committee unanimously felt that the cost of converting,
$23,924, was worthwhile (Attachment #10).
Additionally, based upon citizen letters received by the Fire Department, the general public already
perceives that they are receiving Paramedic services.
Bob Grayson, Emergency Medical Services Agency, Executive Director has stated that, "the Fire
Department and ambulance companies efforts are both integral parts of and highly responsible for
the excellent level of advanced life support care made available in the City of San Luis Obispo".
Frank Kelton owner of San Luis Ambulance stated that he would like to see a dedicated ambulance in
the City, but he is not opposed to the Fire Department upgrading to the Paramedic level of service.
However, he does not agree that the Fire Department should provide a transport service.
FISCAL IMPACT
In an attempt to avoid budget surprises after implementing any changes, the Fiscal Impact section has
been prepared using the highest estimates. As an example, all training costs are based on average
Firefighter overtime rates even though a portion of the training will be accomplished on-duty. All
cost estimates also include an annual $4,000 contribution to the SMSA.
The seven alternatives presented can be separated into two general categories. The first category of
alternatives is for the Fire Department to provide ALS services either at the current EMT-II level or
at the Paramedic level. The second category of alternatives reduces Fire Department services to some
form of Basic Life Support in conjunction with a dedicated private Paramedic ambulance service. (see
Table I for a break down of these cost)
Advanced Life Su000rt Cateeory
Converting Fire Department EMT-II's to Paramedics will cost an additional $23,924 the first year and
$14,960 each year thereafter. The first year's costs are based on a one time conversion cost of $8,964
for nine EMT-II's and a yearly salary differential cost increase of $10,800 and an increase in benefits
of $4,320. The ongoing costs are for the salary differential increase which totals $15,120. Operating
a City Paramedic ambulance with existing staff will cost an additional $50,000 per year. Table I lists
the costs of the Advanced Life Support alternatives (Alternative 1, Alternative 2, Alternative 3 and
Alternative 4).
Basic Life Su000rt Category
Evaluating the cost of reducing Fire Department services from ALS to BLS is more complex. The
first year cost for reducing Fire Department service levels to an EMT-ID program including training
33 Firefighters, purchasing automatic defibrillators and contracting for a dedicated private
Paramedic ambulance would be approximately $163,398. In contrast, converting Fire Department
personnel at EMT-II level to Paramedics and providing the service for one year will cost $70,164. The
cost of operating at the reduced EMT-ID level and dedicating a private Paramedic ambulance costs
� �uIhIIIbIlpn��II81U city of sari AS OBIspO
ONGe COUNCIL_ AGENDA REPORT
$93,234 more the first year than providing Fire Department Paramedic service and a non-dedicated
private ambulance (Alternative 2).
On-going costs for providing Fire Department EMT-ID and a dedicated private Paramedic ambulance
costs is $141,484. The on-going costs of operating Fire Department Paramedics is $61,200. The
continuing costs of providing Fire Department EMT-ID's and a dedicated private ambulance is
$80,284 higher than providing Fire Department Paramedic services.
Reducing Fire Department services to the EMT-I level and contracting for private Paramedic
ambulance service exceeds the cost of converting Fire Department EMT-II's to Paramedics by $65,578.
Table I lists the costs of the Basic Life Support alternates (Alternative 5, Alternative 6).
The only Basic Life Support alternative that provides the City a lower cost than converting to
Paramedics is Alternative 7 which saves $45,458 per year. But this alternative risks losing lives in the
City needlessly.
CONCURRENCES
The Finance Director has reviewed this report and concurs that sufficient General Fund balances are
available to support the program efforts during fiscal year 1988/89.
San Luis Obispo Firemen's Association has reviewed this report and vigorously supports the
conversion to the Paramedic Program, Attachment #8.
RECOMMENDATION
Review the history of Emergency Medical Services in San Luis Obispo and provide direction to staff
in preparing an action resolution for the September 20th Council meeting. A draft Paramedic policy
resolution is included for discussion purposes.
Attachments
Table 1 Cost Comparison of Seven Alternatives
Memorandum Memorandum from John Dunn concerning Paramedic Service
Resolution Proposed Resolution
Exhibit 1 EMT-II Policy Statement
Exhibit 2 EMT-Paramedic Policy Draft
Attachment #1 1983 Cost Summary Report
Attachment #2 Council Agenda Report of September, 1984
Attachment #3 EMSA Feasibility Study for County-Wide Paramedic Conversion
Attachment #4 Sierra-Sacramento EMT-Il to Paramedic Study
Attachment #5 Scope of Practice Comparison for Paramedic vs. EMT-II
Attachment #6 San Luis Obispo Fire Department ALS Analysis
Attachment #7 County/City Ambulance Agreement
Attachment #8 San Luis Obispo Firemen's Association Letter
Attachment 09 CAD's Comments Regarding Paramedic Services Feasibility Study
Attachment 010 Citizen Advisory Committee Letter
Attachment #11 San Luis Ambulance Rate Sheet
..... city of sAnr lu. is a3ispo
990 Palm Street/Post Office Box 8100 • San Luis Obispo, CA 93403-8100
August 8, 1988
MEMORANDUM
To: Mike Dolder
From: John Du
Subject: Some s on upgrading the City's emergency medical
response to paramedic level service
In the comments that follow, I will be speaking more generally and
philosophically, taking neither a pro or con position towards paramedic
service as such, more expressing concern about the background of the
situation, the "how did we get here?" and "do we want to extend the
present system, without taking a fundamental re-look at it?"
Background Comments:
Though we still call it the Fire Department, the modern reality is that a
majority of our emergency calls are for response to emergency medical
situations. Though emergency medical services is a legitimate municipal
service, I would contend that fire departments, by and large have slipped
into providing this service, by small incremental steps, rather than
assuming this service as a result of a deliberate and conscious policy
choice. In the case of San Luis Obispo we slid into providing basic life
support service. A policy decision was made when the City moved into
advanced life support (EMT-II) service in 1982.
One of the results of this incremental decision making, on the part of
both governmental agencies and private service providers, is that we today
have a dual system of emergency medical response, a redundant system
whereby, when the emergency medical call is received, both the San Luis
Obispo Fire Department and San Luis Ambulance Service, Inc. respond. Due
to having four fire stations within San Luis Obispo, the City simply has
the majority of personnel and equipment available, and is almost always
the first responder to emergency medical situations. The Fire Department
commences necessary medical procedures, including advanced life support.
When the ambulance arrives the ambulance attendants support medical
treatment & transport the patient to the hospital .
My first point would be that we probably would not allow this overlap and
duplication of service in any other area of municipal service. In other
areas we would recognize that it is not rational , effective, efficient or
economical to have, let' s say, a sewer line crew arriving to take care of
an emergency within the street, only to have a private contractor show up
and take over the job from us.
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One of the results of this redundant system is that our Fire Department
personnel (at least some of them) have to be just as highly trained as the
ambulance driver and attendant.
With this system the City delivers a dedicated advanced life support
program, without reimbursement except for an occasional thank you note.
There is no means built into the system to compensate the City either for
providing the service or for providing the additional specialized
training.
In the case of San Luis Obispo, compared to other areas served by San Luis
Ambulance Service, Inc. , we are a major population center, a major medical
center, and provide urban-type services. The implications of these are:
1 . Our Fire Department usually arrives at the scene within four
minutes, whereas San Luis Ambulance Service, Inc. usually
arrives within ten to fifteen minutes . In other parts of the
county there is no fire department to respond, and it takes the
ambulance company up to 45 minutes to respond.
2. Our citizens can be transported to a hospital within a matter
of two to five minutes if advanced life support procedures are
not required when an ambulance arrives; in other parts of the
county transport could take a half hour or better.
3. The base rate ambulance charges are such (subject to
verification) that our City residents pay the same for
ambulance service as do those in more remote areas, except for
transport miles; patients in more remote areas do not receive
the benefit of trained fire department personnel responding
prior to the arrival of the ambulance.
The end result of this "system" is that our City taxpayers subsidize a
privately-owned ambulance company, since the City most often is the first
responder and provides services until the ambulance arrives, for which we
do not receive reimbursement. The ambulance most often arrives secondly
and charges the patient fully for their services. Our City taxpayers may
be subsidizing ambulance users in other parts of the county in that our
citizens pay a relatively greater charge for the services received,
considering both the assistance they receive from our Fire Department and
the shorter distances to medical facilities.
In conclusion. I am not against the upgrading of our Fire Department
personnel to paramedic, above the current Emergency Medical Technician II
level. I am raising the concern that this is yet another incremental
change to the system which has grown without being fully examined, that it
provides nothing for the public agency itself, it probably intensifies the
degree of subsidy which we are providing to a privately-owned ambulance
company and, most importantly, there is no full documentation of how it
will improve service to the public or what the long-term impact on the
charges for the service will be.
t
What are the alternatives to the City taking the action of adding
paramedic service at this time?
The obvious alternative is not to take action at this time, until we have
further explored questions such as these (others could certainly be
added) :
1. Are there improved operating arrangements which could be worked out
between the City Eire Department and San Luis Ambulance Service, Inc. ,
some "decision guides" as to who arrives in certain situations and how
they respond when they get there. This is said with the realization
that much work has been done in this area over time.
2. Should our City residents receive a lesser rate, or a guarantee of
lesser rate increases in the future, as a result of our department
being the first responder and the majority of treatment being provided
by City resources?
3. Given that we're proposing to provide paramedic-level service, should
we:
(a) look at the possibility of adding the transportation
component to the City's existing response capability, in other
words, providing ambulance service (realizing that this could
not occur until 1992 because of existing agreements with the
County) .
(b) Conversely, should we hold the ambulance company to a
higher standard of service, one that would effectively allow us
to get out of the emergency medical response business and make
it a pure private enterprise concern, similar to the other
components of the emergency medical care business.
4. Should we work with the county under the existing agreement and take
steps to gain further direction over the private ambulance service in
relation to service standards and rate increases.
5. The City could consider establishing a charge for the service we
provide to either the patient served or the ambulance company or could
work to have the ambulance company charge a lesser fee to our citizens
when the City provides the first response and initial assistance.
JD:mp
c: Toby Ross
file
—x-
DRAFT
RESOLUTION NO. (1988 Series)
A RESOLUTION OF THE COUNCIL OF THE CITY OF SAN LUIS OBISPO ESTABLISHING
A NEW FIRE DEPARTMENT PARAMEDIC SERVICE POLICY AND APPROPRIATING
$23,924.00 FROM THE GENERAL FUND.
WHEREAS, the City Fire Department has been providing advanced life support service at the
EMT-II level since 1982; and
WHEREAS, the advanced life support service level has been increased to allow a paramedic
level by the Board of Supervisors; and
WHEREAS, a dedicated city paramedic service level can be provided by the fire department
at a reasonable cost; and
WHEREAS, there are sufficient general funds available to appropriate the $23,924.00 cost
increase;
NOW, THEREFORE, the City Council resolves that it rescinds the Fire Department EMT-II
program policy (Exhibit 1) and establishes a new Fire Department EMT-Paramedic policy (Exhibit
2) and appropriates $23,924.00 from the general fund.
On motion of seconded by
the following roll call vote:
AYES:
NOES:
ABSENT:
the foregoing Resolution was passed and adopted this day of
1988.
MAYOR RON DUNIN
ATTEST:
CITY CLERK PAM VOGES
EXHIBIT 1
tea= crty council policies handWok
SECTION 2.13 SUBJECT FIRE DEPARTMENT EMT-II PROGRAM -
ADOPTED 6/29/82
FIRE DEPARTMENT EDIT-II PROGRAM
Background
In 1975, the Fire Department started responding a rescue squad
with Emergency Medical Technician I (EMT-I ) personnel to auto
accidents and emergency medical calls. In 1982 the department
responded to approximately 1,200 medical calls and completed training
of all personnel to an EMT-I level. The San Luis Obispo County Board
of Supervisors in December of 1981 approved a private nonprofit
corporation to administer an Advanced Life Support Program (EMT-II) .
The local medical community has estimated this program, if
implemented, can save twenty lives a year in the City of San Luis
Obispo.
Policy Statement
The City of San Luis Obispo will provide EMT-II service through
the city's Fire Department. A maximum of nine fire fighters shall be
trained to a level of EMT-II during the next two years. These
personnel, in conjunction with ambulance-trained personnel will
provide advance life support to the citizens of the city within six
minutes of a request.
The Fire Department shall not transport any patients except in a
life or death situation when no ambulance is available and shall
consider appropriate user fees for medical services provided. The
city has the expectation that the County of San Luis Obispo will
participate as a lead agency in the EMT-II program.
Action
The cost for this increased level of service during fiscal year
1982-83 will be approximately $26,900. The Fire Department costs are
to be provided from the general fund and will cover class tuition and
overtime for the additional required training. Expendable medical
supplies, in-service training, and program administrative costs are to
be borne by the base station hospitals.
02 -i7
Paae 1 of 1
EXHIBIT 2
POLICY STATEMENT
FIRE DEPARTMENT EMT-PARAMEDIC PROGRAM
Background
In 1975, the Fire Department started responding a rescue squad with Emergency Medical Technician I
(EMT-I) personnel to auto accidents and emergency medical calls. In 1982, the department responded
to approximately 1,200 medical calls and completed training of all personnel to an EMT-I level. The
San Luis Obispo County Board of Supervisors in December of 1981 approved a private non-profit
corporation to administer an Advanced Life Support Program (EMT-II).
In 1983, Fire Department EMT-II's began responding to emergency medical calls. During the years of
1984 through 1988 the department responded to an average of 300 Advanced Life Support (EMT-II)
calls per year and an average of 1,400 ALS and BLS emergency medical calls per year.
In April, 1988 the San Luis Obispo County Board of Supervisors approved a resolution to upgrade
county emergency services to Paramedic level.
Fire Department studies estimate that an additional 120 people per year in the City could benefit
from Paramedic service over EMT-II service.
Policy Statement
The City of San Luis Obispo will provide Paramedic service through the City's Fire Department. Fire
Department personnel, in conjunction with ambulance-trained personnel will provide Advanced Life
Support to the citizens of the City within six minutes of a request.
The Fire Department shall not transport any patients except in.a life or death situation when no
ambulance is available and shall consider appropriate user fees for medical services provided. The
City has the expectation that the County of San Luis Obispo will participate as a lead agency in the
Paramedic program.
Action
The cost for this increased level of service during fiscal year 1988-90 will be approximately $61,200.
The Fire Department costs are to be provided from the general fund and will cover class tuition and
Overtime for the additional required training. Expendable medical supplies, in-service training, and
program administrative costs are to be borne by the base station hospitals.
MEM®RANDUATTACHMENT #1
MEMORANDUM ��ty Of SAn UOBISPO
MEMORANDUM
FIRE DEPARTMENT
MEMORANDUM 748 Pismo Street . San Luis Obispo, California 93401 . 805/543-6046
TO: City Council
VIA: Paul Lanspery, City Administrative Officer
FROM: Michael P. Dolder, Fire Chief
DATE: July 12, 1983
SUBJECT: EMT-II Cost Summary Report and Projections
The following EMT-11 report is intended to provide the City Council with an
overview of past, present and future EMT-II program costs. The cost summary
information should also aid Council in considering the two EMT-I1 funding
requests which are included as July 19th agenda items. .
The FY 82-83 City budget included an EMT-II policy statement, Attachment I ,
which appropriated approximately $26,900 for the program. The funding
allocation was to provide equipment, training, overtime and a contribution to
the Emergency Medical Services Agency (EMSA) . During the public safety budget
study sessions, EMT-II cost projections were presented which included the
following:
I . On-going EMT-11 certification would require an annual expenditure of
approximately $2, 150.
2. The EMSA had not requested additional funding, but staff suggested
setting aside $5,000.
3. The EMT-1 pay differential (2.63%) would most likely be transferred
to EMT-11 personnel and at some high percentage. This increase
differential for EMT-II personnel was estimated to be at least 5%,
however, actual costs would be subject to negotiations.
4. To reach the authorized level of nine EMT-Ills, additional personnel
would require training at a cost of $3,000 to $4,000 each.
FY 82-83 Training and Program Implementation
One EMT-11 training course was conducted by the EMSA during FY 82-83. The
course consisted of 250 hours of classroom work plus a field internship phase
which required each student to complete a minimum of ten supervised Advanced
Life Support calls. Three San Luis Obispo Firefighters were certified in the
class and are currently practicing EMT-Ills. A fourth Firefighter failed a
field internship proficiency module and will be repeating the course at his own
expense. The actual cost of implementing the EMT-11 program during FY 82-83
was $28,312. An itemization of the EMT-II costs is provided in Table I .
-2-
1983-84 Program Costs
The 1983-84 Fire Department emergency response program, budget page D-98
includes an approved EMT-II appropriation of $26,620. This budget allocation
was for equipment, tuition and overtime costs. The EMSA funding request and the
EMT-11 negotiated pay differential were not available at the time the budget was
prepared and were not included in the Fire Department's original budget
request.
At the July 19th Council meeting, the City Council will consider two EMT-II
funding requests:
I . An EMSA Funding Request of $7,370
2. EMT-II Differential of $200/month per certified EMT-11
If both requests are approved, the 1983-84 EMT program costs will be as
follows:
A total of $26,620 has already
been funded. These EMT-II
Equipment $620 costs may be spread over two
Tuition $6,000 years depending upon the
Overtime $200000 availability of classes and
personnel .
EMSA* $7,370*
EMT-II Differential* $5,070*
Total 1983-84 $390060
*To be considered at the July 19th Council Meeting.
Future FMT-II Costs
The costs of the EMT-II program should decrease slightly in 1984-85 and should
stabilize in future years at around $30,600 per year. Exact costs will vary
depending upon employee turn-over, promotions and future negotiations. .A five;
year EMT-11. cost canparison is provided In Table 1 . It should be noted that
fiscal years 85-86 and 86-87 provide for the training costs of one additional
EMT-I1 . Training may or may not be required and depends upon employee turn-over
and/or promotions. .The EMSA funding level of $6,000 is based upon the
successful implementation of a county-wide Joint Powers Agreement.
TABLE I
FIVE YEAR EMT-11 COST PROJECTION
Fiscal Years 82-83 83-84 84-85 85-86 86-87
EMT-II Trained (3) (6) (0) ( 1) ( 1 )
Equipment 90092 620 10000 1,000 1,000
Tuition 1 ,550 6,000 - I,000 1 ,000
Overtime 10,300 20,000 - 3,000 3,000
Yearly Recert. - - 3,000 3,000 3,000
EMSA Contribution 7,370 70370 6,000 6,000 6,000
Net EMT-11 Pay - 5,070 12,020 16,600 16,600
Differential
Total $28,312 $39,060 $22,020 $30,600 $30,600
I
Action
1982-83 revenue f r Cultural and Promotional Projects is projected at $239,740.
Notification and Advertising
Background
City residents sh uld be informed of the business of their municipal government.
The City of San Luis 0 ispo will provide to all interested people notice of the nature
and type of actions be ng considered by the City Council, its advisory bodies and city
staff. This notice is primarily in the form of advertisements in the local newspaper
of record (Telegram Tr bune) and written notice delivered to citizens by the United
States mail.
The city prepares advertisements which are published in the local newspaper of
record as required by tate law or city charter, set forth in elements of the general
plan or city ordinance , and in response to City Council policy. Appropriate
advertisement topics i clude, but are not limited to, the following: appointments to
vacancies on the City ouncil or advisory bodies, revenue sharing allocations, bond
assessments, agendas f r City Council and advisory body meetings, bid notices, weed
abatement program and ippeal hearings.
Policy Statement
The city's policy is to advertise all matters of significant neighborhood or
community public inter st which appear on a City Council or Planning Commission agenda,
as well as all matters where advertising is required by law. Said advertisements
include location maps, project descriptions and posting of property, if required,
written in plain Engli h in order to fully inform all interested individuals.
All advertising s all be accomplished in an economical manner. All affidavits of
publication shall be rviewed by the City Clerk and will be available to interested
members of the public.
Action
Implementation of Ithis policy requires an expenditure of $25,000. for advertising
in 1982-83.
Fire Department EMT-II Program
Background
In 1975, the Fire Department started responding a rescue squad with Emergency
Medical Technician I (EDIT-I) personnel to auto accidents and emergency medical calls.
In 1981 the department responded to approximately 1,200 medical calls and completed
training of all personnel to an ffiIT-I level. The San Luis Obispo County Board of
Supervisors in December of 1981 approved a private nonprofit corporation to administer
an advanced Life Support Program (EMT-II) .
B-2
I
The local medical community has estimated this program, if implemented, can save
twenty lives a year in the City of San Luis Obispo.
Policy Statement
The City of San Luis Obispo will provide EMT-II service through the city's Fire
Department. A maximum of nine fire fighters shall be trained to a level of EMT-II
during the next two years. These personnel, in conjunction with ambulance-trained
personnel will provide advance life support to the citizens of the city within six
minutes of a request.
The Fire Department shall not transport any patients except in a life or death
situation when no ambulance is available and shall consider appropriate user fees for
medical services provided. The city has the expectation that the County of San Luis
Obispo will participate as a lead agency in the EMT-II program.
Action
The cost for this increased level of service during fiscal year 1982-83 will be
approximately $26,900. The Fire Department costs are to be provided from the general
fund and will cover class tuition and overtime for the additional required training.
Expendable medical supplies, in-service training, and program administrative costs
are to be borne by the base station hospitals.
Utilization of Volunteer Resources
Background
The city recogniz s the need to place greater emphasis on volunteerism. As
leisure time increases in the society in general, a special effort will be required
to encourage people to spend a portion of that time in public service.
Policy Statement
The City of San Luis Obispo will encourage and stimulate volunteer participation
to supplement, but not replace, services of city staff. The apprpriateness of the use
of volunteers is not tc be construed as leading to the creation of an unpaid labor
force nor the foreclosing of career opportunities.
The use of volunteers will create and promote in the community an understanding of
city government, its needs and its purposes. As volunteers., individual community
members can experience first hand the problems and rewards of working on behalf of
city government. Volunteers will see that creative problem solving is required to
work within the constraints of organized governmental services. Volunteers may also
become creditable advocates for the city.
The volunteer program is designed:
To provide work experiences in a career field for students, women and men re-
entering the work world, and persons of retirement age who are still interested
in community sere e.
To "provide voluntrs with meaningful and rewarding experiences through service
to city government
B-3
ATTACHMENT #2
I''i411`n n. September 10 1984
�►�,;�iI�;�I;,�.,,
city of San Luis OBISPO
COUNCIL AGENDA REPORT
FROM: Michael P . Dolder , Fire Chief By: Erwin Willis ,
Battalion Chief
SUBJECT: Cost Recovery for Emergency Medical Services
CAO RECOMMENDATION :
Direct staff to prepare a draft ballot measure
( authorizing a maximum monthly emergency medical service
assessment fee of 1 .00 for occupancy units served by city
utilities) for possible inclusion at the general municipal
election in November of 1985 .
Background
In 1975 , the City Fire Department began responding a rescue squad
with Emergency Medical Technician I ( EMT-I) personnel to vehicle
accidents and emergency medical calls . During the first year of
providing Basic Life Support , the Fire Department responded to 58
medical emergencies . Over 1 ,200 EMS calls were responded to in 1982.
Medical responses currently account for 60-80% of the Fire Department
emergency calls for service .
Ir. 1982-83 Council approved various management and budget policies
which included providing an EMT-II level of Advanced Life Support
through the City Fire Department . Additionally, the policy statement
gave direction to consider appropriate user fees for medical services
provided .
The Fire Department ' s emergency medical service provides one fire
engine , one rescue squad with a total of 4 to 5 persons with EMT-I
and EMT-II skill levels. The cost of personnel and equipment
averages $40 .00 to $70 .00 per medical emergency. The yearly cost for
EMT-I and EMT-II services is $55 ,000 and $39 ,900 respectively with a
combined medical emergency service cost of approximately $94 ,000
annually. Over the last three years the city has invested over
$ 100 ,000 to develop and provide EMT-II services.
The EMT-II costs are essentially the same as the cost projections
that were given to Council at the July 19 , 1983 meeting. At the same
meeting , staff was again directed to continue working on methods of
financing the City EMS program which might include a ballot measure
(Attachment 1 ) .
In researching EMS funding methods, we have found several cities
which instituted cost recovery programs to defray EMS costs and
collection methods for these various cities include:
A. A fee-for-service program (a specialized fee is charged per EMS
call which is billed to the patient and is similar to the system
used by private ambulances.
B. A subscription program ( an annual subscription is paid by each
participating household and is similar to an insurance policy) .
CI
ty of San tuts OBispo
COUNCIL. AGENDA REPORT
C . A monthly or yearly assessment fee (each household or occupancy
served by city utilities is charged a fee for EMS Service . )
A specific example would be the City of Fullerton (Attachment 2)
which took the approach of combining two programs into one : a
fee-for-service and a subscription program. The goal of the
Fullerton fee program is to make the paramedic service
self-supporting.
Any one or combination of the fee generation methods could be
implemented in San Luis Obispo .
Alternatives
Alternative 1 . Implement a fee-for-service program charging $50 for
Basic Life Support Service (EMT-I) and $75 for Advanced Life Support
Service (EMT-II) .
Alternative 2 . Implement a voluntary subscription program charging
$1 .00 per occupancy unit (dwelling or business) served by city
utilities (currently 18 ,826 units exist) . Subscriptions would be
collected through the bi-monthly utilities billing system.
Non-subscribers would be charged a fee-for-service similar to
Alternative 1 .
Alternative 3. Draft a ballot measure which could be put on March ,
185 election . The ballot measure would authorize a maximum
assessment fee of $1 .00 per occupancy (dwelling or business) per
month served by city utilities (currently 18 ,826 units exists) . The
ballot measure would include language for charging monthly fees based
on the annual EMS program costs not to exceed $1 .00 per month . The
current cost is estimated to be 40 cents per month per occupancy unit
serviced by city utilities .
Alternative 4 . Do nothing and continue subsidizing the emergency
medical services from the general fund .
Pro & Con of Alternatives
1 . Pro The user of the EMS service directly pays for the service
provided . Approximately 50% of those using the service will
have health insurance which could pay the fee-for-service .
No ballot measure would be required although Proposition 36
(Jarvis IV) , if approved in November , could void this option
as curently presented .
Con Collection of fees will be difficult at best . Most
communities operating a fee-for-service system experience a
50 to 60% collection rate. Billing for fees would place an
additional workload on both the Fire Department and Finance
Department. Current staffing in the Finance Department may
not be adequate to complete the billing process.
ams
;,ry�rtiiili!Iluiil�u �l�lll city of san Luis OBISPO
COUNCIL AGENDA REPORT
Citizens with low or limited incomes may be discouraged from
using the service since the Fire Department fee would be in
addition to the transport fees already charged by ambulance
companies.
2. Pro A subscription program which operates as a voluntary fee
would avoid violating Proposition 13 prohibitions . The
$ 1 .00 per month fee would generate $12.00 per year for each
participatintg occupancy. Service provided to subscribers
would be on an as needed basis and no additional charges
would be assessed to a subscriber regardless of the number
of calls . A fee-for-service would be charged to
non-subscribers .
Con As in the Fullerton Plan (Attachment 2) , combining an
optional subscription program with a fee-for-service would
not require a ballot measure . However , a direct billing
process would still be required for non-subscribers . The
impacts on the Finance Department may be reduced , however ,
dual records could compound the billing system procedures .
Collection rates on non-subscribers might be significantly
lower than the 50% norm since people more apt to use this
service would choose the less expensive subscription option .
3 . Pro An assessment fee would require a 2/3 voter approval and
would provide Council with a clearer understanding of the
community' s interest and concern for EMS care. The ballot
measure would include language to base the monthly fee on
the annual cost of total City EMS program. General fund
subsidies would be kept to a minimum. Implementation of an
assessment fee would require the least amount of staff time
and would generate the highest revenue return .
Con The assessment fee only provides funds for current EMS costs
and does not reimburse the general fund for prior year
expenditures. Although low or fixed income residents would
be impacted by the maximum annual fee of $12 .00 . The impact
would be the least of all the revenue producing
alternatives .
One time computer modifications would be required to
implement the assessment fee program.
4. Pro Users of the Fire Department' s Emergency Medical Services
would not have to pay for the service . No additional staff
work would be required .
Con The general fund would continue to subsidize the Emergency
Medical Services provided by the Fire Department .
�-a
city of San Luis OBIspo
COUNCIL AGENDA REPORT
Fiscal Impact
Historical Costs of Emergency Medical Services
FY 1982-83
EMT-I Services $55 ,250
EMT-II Services $26 ,098
Total FY 1982-83 EMS Costs $81 ,348
FY 1983-84
EMT-I Services $48 , 850
EMT-II Services $24 , 110
Total FY 1983-84 EMS Costs $72 ,960
FY 1984-85 Estimates
EMT-I Service Estimates
EMS Dispatch Training $ 5 ,000
1200 EMS Calls at
$40/call $48 ,000
Bi-Annual EMT-I
Recertification $ 2 250
Sub-Total EMT-I Costs $55 ,250
EMT-II Service Estimates
Operating Equipment $ 17000
Tuition $ 3 ,000
Overtime $10 ,000
EMS Agency Contribution $ 31530
*Equipment Replacement
Reserve $ 1 ,500
*Administrative Cost $ 61000
EMT-II Pay Differential $12 ,020
*Additional Equipment
Maintenance $ 2 .000
Sub-Total EMT-II Costs 391050
Total Estimated Costs FY 1984-85 $94 ,300
Items with an asterisk are costs now accounted for under EMS instead
of emergency fire response .
All���'I� city of San tuts OBlspo
COUNCIL AGENDA REPORT
The various alternatives could produce the following revenues :
Alternative 1 Approximately -$30 ,000 to $42 ,000 (50% collection.
rate)
Alternative 2 Approximately $180 ,700 (80% voluntary subscription )
plus fees-for-service collected
Alternative 3 Actual costs of service this year which are $94 ,000
Alternative 4 -0-
Additional costs would be incurred by the Finance Department for
computer reprogramming . The Finance Director has indicated that the
modification could be made , but that the cost is unknown at this
time .
Recommendation
Direct staff to prepare a draft ballot measure (authorizing a maximum
monthly emergency medical service assessment fee of $1 .00 for
occupancy units served by city utilities) for possible inclusion at
the general municipal election in November of 1985 .
Attachment
1 . Council Minutes for July 19 , 1983
2. Western City/August 184 City Scene Article "85 Percent of
Single Family Homes Subscribe to Fullerton ' s Paramedic
Program" .
V, ATTACHMENT 1
Passe and adopted on the following roll call vote:
AYES`, Councilmembers Dovey, Dunin, Griffin and Mayor Billig
NOES: `.None .
ABSENT: Councilman Settle
Council also`•..agreed that Mayor be directed to write a letter to the Architec-
tural Review 'Commission urging them to use a variety of materials and
colors in futut, projects (4-0-1).
2. TREE COMMITTEE APPEAL
On motion of Councilwoman Dovey, seconded by Councilman Dunin, to continue
the appeal by Gerald Shusta of a Tree Committee decision regarding tree
pruning requirement at 98 Palomar drive to the August 2, 1983, Council
meeting in order to a1�ow additional review by the City Attorney's office.
�'ti
Motion carried, all ayes',, Councilman Settle absent.
e
3. FUNDING REQUEST FOR E.M.T. II PROGRAM
A) Mike Dolder, Fire Chief, reviewed the council agenda report (file 4!725)
reporting on the status of the E.M.T. II Program including a request for an
additional $7,370 for Emergency Medical Agency.
Ann Crossey, Personnel Director, reviewed a resolution in the Council's
packet which would amend the Memorandum of Understanding with the Firefighters'
Association to delete pay differential for E.M.T. I's and establishing pay
for the E.M.T. II's.
Dr. Bernhardt explained that the County had placed conditions upon their
approval of funding that there be participation by the various cities.
After brief discussion, it was moved by Councilwoman Dovey, seconded
by Councilman Griffin, to receive and file the report on the E.M.T. II
Program. Motion carried, all ayes, Councilman Settle absent.
B) On motion of Councilwoman Dovey, seconded by Councilman Griffin, the
following resolution was introduced: Resolution No. 5171 (1983 Series) , a
resolution of the Council of the City of San Luis Obispo amending the
Memorandum of Understanding with the Firefighters' Association, establishing
pay for E.M.T. II's.
Passed and adopted on the following roll call vote:
AYES: Councilmembers Dovey, Griffin, Dunin and Mayor Billig
NOES: None
ABSENT: Councilman Settle
C) On motion of Councilman Griffin, seconded by Councilman Dunin, that the
Administrative Officer be authorized to transfer $7,370 from the Venture
a -�9
Citv Council Minutes
Tuesday, July 19, 1983 - 7:00 p.m.
Pape 6
and Contingencies Accounts to the Fire Department Budget for the San Luis
Obispo E,1S Agency. Motion carried, all ayes, Councilman Settle absent.
Councilman Dunin requested that staff make a feasibility study of the use
of E.M.T. II`s in other cities and suggested that this item be submitted to
the San Luis Obispo voters as to their willingness to support its continuance
financially.
Council concurred (4-0-1).
4. WORD PROCESS IG/OFFICE AUTOMATION
Council considered specifications for the acquisition of word processing/office
automation equipmen .
Dave Ion, Financial alyst spoke on behalf of the Information Management
Committee, presenting' he council agenda report (file #108) and recommended
that Council adopt a r solution that would find the use of Request for
Proposals most advantag ous to the City, approve the RFP specifications,
approve the use of Publi Technology, Inc. in the evaluation process and
authorize staff to soliC t proposals.
Councilman Griffin suggest d an amendment to page 4-14, Section III FINAL
CALCULATION, item D. to ria as follows: "Prospective vendors will be
ranked by the City accordin to initial evaluation
calculations by Public Techn logy; Inc."
After brief discussion, it wa moved by Councilwoman Dovey, seconded
by Councilman Dunin, to adopt he following resolution: Resolution No.
5172 (1983 Series) , a resoluti of the Council of the City of San Luis
Obispo authorizing the use of R quest for Proposals procedure for a Word
Processing/Office Automation Sy-, em.
Passed and adopted on the followi g roll call vote:
AYES: Councilmembers Dovey, Duh Griffin and Mayor Billig
NOES: None
ABSENT: Councilman Settle
On motion of Councilman Griffin, seco'n ed by Councilman Dunin, to approve
the RFP specifications and approve the se of Public Technology, Inc. in
the evaluation process authorizing stat to solicit proposals.
Motion carried on the following roll call vote:
AYES: Councilmembers Griffin, Dunin, AF1 y and Mayor Billig
NOES: None
ABSENT: Councilman Settle
Councilman Dunin commended the Management In€o tion Committee on having
done the analysis in house and was especially,pl ased that an outside
consultant was not required and would like to�see future projects be done _ J —,3 O
in a similar manner. Q� �7
I ATTACHMENT 2
t
85 Percent ®f Single-Family Homes
Subscribe t® Fullerton's Paramedic Program
lion fees totalled 5325.000. The cullet- papers in the city provided detailed
i . By Chi-is Mever tion rate on direct charges was better than articles explaining the fees and the
55 percent. subscription program. To supplement
In July, 1983.the City of Fullerton put To avoid violating Prop. 13 prohibi- this publicity the city used a direct mail
into effect a fee for paramedic services. tions on special fees, the annual fee was campaign to notify each of the city's
While this concept is not new, Fullerton made optional. and the fee was inten- 40,100 households of the neo• fees and
tool:an unusual aproach which combines tionally set at a very low rate to encour- optional subscription coverage. Two
two programs in one: a fee-for-service age participation. mailings were directed at residents of
and a subscription program. To insure that the program recognizes multi-family units to encourage their
The fee-for-service program is similar the needs of special groups, reduced participation in the subscriber program.
to those in effect in a number of cities. rates are made available to Social Secu- For the upcoming year a direct mail bro-
A flat fee of either S60 orS90(dependin_ rity disability recipients,persons over 65 chure!mail-in application has been de-
on the severity of the incident) is who are able to prove hardship and veloped and is expected to at least double
charged. There is no itemized charge for MediCal and MediCare beneficiaries subscription penetration among this
special procedures (oxveen. IV's, etc.). (MediCal and MediCare do not cover group.
Because Fullerton paramedics serve in a paramedic charges). The Boal of the Paramedic Fee Pro-
dual fire-fighter:paramedic role and are gram is to make the Paramedic Service
fully integrated into engine companies. Public Support Essential self supporting. Revenue is to be in-
the city does not provide transportation Public support has been an essential creased by increasing the number of
for patients to the hospital. Private part of the success of Fullerton's pro- subscribers. rather than by raising f
ambulance companies are available to gram. A thorough public information The citv's Boal of obtaining 100 pert
provide this service when it is needed. program encouraged public perception subscription from residents will result in
The subscription program, on the of the fees as fair. necessary. and. be- 100 percent program funding. Until this
other hand, is similar to an insurance cause of their optional nature. more like goal is achievel paramedic service is
policy. Each participating= household— an insurance premium than a govern- subsidized by a modest amount from the
or dwelling unit — (regardless of the mental fee. general fund.
number of family members) pays a SI'_ A public hearing was conducted on the (Chris Idever is the Assistant to the
annual subscription fee in May or June. program, and the three major news- Croy Manager of Fullerton.)
If a resident wishes to subscribe after the
registration period. a SIO late fee is as-
sessed. Service is provided to subscri-
bers on an as-needed basis. Regardless �. J - �' y
of the number of calls made during the
course of a year. no further charges are _ -
levied.The fee was arrived at by dividing
the total cost of the Paramedic Program
by the total number of households in the G -�
city. Because of the number of house- b
holds involved. individual future sub-
scription fee increases should be �4
minimal.
Surpassed Expectations ! l
i
After nearly a year of operation, the
program has surpassed all expectations
v _
in terms of revenue production and en-
joys wide support in the community.
Eighty-five percent of single-family Lifesaving Endeavor—Fire Captain Robert Hn/jtutut. Parking PutrolOJficer
dwellings and fifteen percent of multi- +blass. and Fire Engineer Terry Stringham demonstrate polentied lifesaving procedr,,.s
family units totalling 23.400 households provided!n• Fullertonz paramedic progrant. While this event was a .simulation of aid
have subscribed. First year revenues to it possible heart atrack victim, the city's paramedics respond to appramnateh 3,600
from both direct charges and subscrip- acttual cnterr rne.y falls each cera-. Sal
iR
Au,t:rr.rt 19,44AVevrern On,
ATTACHMENT #3
FEASIBILITY STUDY FOR THE OPTIONAL
COUNTY-WIDE CONVERSION TO
PARAMEDIC ADVANCED LIFE SUPPORT AMBULANCE
AND FIRE DEPARTMENT PERSONNEL
Prepared by:
San Luis Obispo County
Emergency Medical Services Agency, Inc .
Revised: January 27 , 1988
March 17 , 1988
INTRODUCTION
In 1974, the State Department of Health Services promulgated guidelines
and regulations for pre-hospital emergency personnel working in
ambulance companies and fire departments . These regulations resulted
in the designation of Emergency Medical Technician or EMT-I as the
provider of Basic Life Support (BLS ) services . (See Appendix 1 for
SB-125 , a digest of emergency medical service regulations ) .
The first class of San Luis Obispo County EMT-I providers was trained
in Santa Barbara the following year. For the next eight years , San
Luis Obispo County provided pre-hospital care at the BLS level.
This changed in March 1983 following County approval of the training
and deployment of Limited Advanced Life Support (LALS ) or EMT-II level
personnel . The distinction between EMT-I and EMT-II providers is quite
detailed and includes differences in training, experience, and scope of
practice.
Simply stated, the EMT-I is trained to render first aid, CPR,• and
resuscitation while assessing pulse , blood pressure , and consciousness .
Their objective is to provide Basic Life Support during transport to an
acute care hospital.
The EMT-II receives additional training to administer intravenous
therapy, specific medications, and advanced life support treatments in
radio consultation with hospital-based physicians and nurses. Their
objective is to provide Limited Advanced Life Support at the scene of a
medical emergency and during the transport to an approved receiving
facility.
During this period ( 1975-1983 ) , the population of San Luis Obispo
County increased 31% from 130 , 000 to 170 , 000 . Statistics on emergency
calls were not maintained until 1984 when 9 , 247 calls were logged with
the County Medical Communications Center (Med Com) .
As the County population continued to grow at the rate of approximately
3-5% per year (currently estimated at 200 , 000 ) , the number of
emergency calls increased at roughly three times that rate , or 10-12%
per year. Statistically, one out of every four emergency calls placed
in San Luis Obispo County requires Advanced Life Support responders .
Currently, emergency medical services are provided by a combination of
fire departments , law enforcement agencies , and public and private
ambulance companies . Together they employ a total of 420 EMT-I and 45
EMT-II level personnel to cover the 3 , 300 square miles comprising San
Luis Obispo County.
The projected rate of growth for the County remains steady at 3-5% per
year targeted mainly for the Five Cities and Paso Robles areas , subject
to available water resources.
PROPOSAL
This study evaluates the feasibility of upgrading the education and
training of emergency medical services personnel working in San Luis
Obispo County from the EMT-II to the EMT-P or paramedic level .
Many questions have been raised regarding the need for this conversion.
They include:
2 a_.3 y
o What difference would paramedics make to the survival rate of
persons needing emergency medical assistance?
c How would the conversion from EMT-II to paramedic be handled?
e Is the conversion mandatory?
• How are paramedics different from EMT-II ' s?
• If our system works, why should we make any changes?
• Is the EMT-D (defibrillation) a less costly alternative to EMT-P?
o What are the benefits to the citizens of San Luis Obispo County?
o What are the costs associated with this upgrade?
These questions are answered on the following pages .
Survival Rates
Monthly reviews of ALS calls conducted by Twin Cities Community
Hospital has revealed that the survival of two patients per month, on
the average, may have been altered by the increased skills and
capabilities of an EMT-P.
Ongoing reviews of ALS runs in the cities of San Luis Obispo, Los Osos ,
and Morro Bay have revealed that 28% of the runs would have benefited
from paramedic skills had they been available.
Conversion
The conversion from Limited Advanced Life Support or EMT-II to Advanced
Life Support or paramedic trained personnel involves several steps.
They include:
3
1. A recommendation from the Emergency Medical Services Agency
Board of Directors to the County Administrator and city fire
chiefs that this conversion be made. (This recommendation would
require endorsement by the County Health Officer and County
Medical Association) .
2 . County Board of Supervisor and local city council approval .
3 . Development of curriculum, tests , and course schedules to
convert interested EMT-I and EMT-II personnel to paramedics .
The conversion process would be completed over a two-year period to
provide each candidate ample opportunity to upgrade their skills.
Not Mandated
The decision to upgrade to paramedic personnel would be made
individually by local city councils and the County Board of Supervisors
for unincorporated areas . The proposed conversion is not mandated by
Federal or State regulations . If an individual local government whose
fire service responds to ALS calls chooses not to upgrade, the only
consequence is that they may be required to relinquish medical scene
control to a paramedic ambulance responder. Local governments whose
fire service does not respond to medical calls will be unaffected by
the paramedic conversion.
EMT-II vs . EMT-P (Paramedic )
Training and certification requirements for emergency medical services
personnel are outlined in Division 2 .5 of the Health and Safety Code.
The following is a summary of the training requirements beyond the
EMT-I level needed to achieve EMT-II and EMT-P certification. ?//
4 ?�O
EMT-II EMT-P
Classroom 256 hours 304 hours
Clinical 86 hours 172 hours
Field Internship 480 hours 480 hours
TOTAL 822 hours 956 hours
The additional 134 hours of training received by the paramedics enables
them to perform a variety of advanced life support procedures not
available to EMT-II 's. The expanded scope of practice for paramedics
follows on the next page. It is important to note that EMT-II 's in
good standing currently working in San Luis Obispo County who possess a
minimum of two years field experience and recertification within the
last 18 months can achieve paramedic status by enrolling in a 48-hour
conversion class . At the conclusion of the conversion course ,
candidates for paramedic certification must pass a comprehensive
certification test encompassing EMT-I , EMT-II , and EMT-P scope of
practice.. Any candidate failing to achieve a minimum passing score of
80 percent will be required to repeat the certification test within two
weeks and obtain a minimum passing score of 85 percent.
Candidates failing both certification tests have failed the EMT-P
conversion course. They may elect to take the next scheduled paramedic
training class but are ineligible for future conversion courses .
The reason these EMT-II 's can convert after a 48-hour class is because
they have received education and training beyond the minimum
requirements outlined above (California Health and Safety Code ,
Division 2 . 5 , Chapter 1 , Section 1797 . 3 allows a local EMS Agency to
adopt additional training standards for EMT-II and EMT-P level
providers ) . The local decision process to exceed the minimum standards
follows .
02 3 7
Additional training to expand the paramedic scope of practice may be
suggested by base station physicians, other emergency physicians ,
MICN's , EMS Agency staff or other concerned parties. The suggestion is
then brought before the EMS Agency Medical Director. If warranted, the
Medical Director will bring the proposed addition to the Medical
Standards Review Committee. They will consider the action and make a
recommendation to the EMS Agency Board of Directors . The Board of
Directors will consult the County 'Health Officer and 'vote on the
proposal . If passed, EMS Agency staff will incorporate the new
curriculum into the agency training programs and provide immediate
updates for existing field personnel.
Expanded Scope of Paramedics Practice
Drug Administration
Dopamine HCL Mannitol
Diphenhydramine Metaraminol Bitartrate
Diazepam Verapamil
Isoproterenol Phenobarbital
Calcium Chloride Metaproterenol Inhalant
Bretylium Tosylate Aminophylline
Hydrocortisone Terbutaline
Dexamethasone Procainamide
Oxytocin Glucagon
Meperidine HCL
Advanced Life Support Procedures
Q Perform pulmonary ventilation on an unconscious breathing adult by
use of nasotracheal intubation.
• Perform pulmonary ventilation on an unconscious infant or child by
use of oral endotracheal intubation.
• Perform carotid massage or valsalva maneuver or both of these
procedures for supraventricular tachycardia.
6 �?'✓
o Perform synchronized cardioversion on a patient with a
tachyarrhythmia who has deteriorating vital signs and/or a
deteriorating level of consciousness.
o Perform needle thoracostomy for pleural space decompression.
o Perform needle cricothyrotomy for complete airway obstruction.
• Apply rotating tourniquets .
" Perform any additional pre-hospital emergency medical care treatment
procedure( s ) or administer any additional drug( s ) on a trial basis
when specific conditions are met.
Why Change the System?
The reasons to consider updating the skills and scope of practice of
the emergency medical services personnel working in San Luis Obispo
County include:
u The rapid County growth rate and increasing population.
o The large increases in both total emergency calls and calls requiring
Advanced Life Support responders .
o The topography of San Luis Obispo County is irregular, response
distances can be quite long and transport times extended. (See
Appendix 2 for statistics on the location of ambulance calls for the
first six months of 1987 ) .
° As many as 40% of the County residents live in unincorporated and
rural settings (Appendix 3 ) .
c All the counties bordering San Luis Obispo provide paramedic
responders. In fact, 60% of California's 58 counties employ
paramedics rather than EMT-II ' s ; no hard data is available to
demonstrate a reduction in morbidity or mortality in those counties
where this conversion has taken place .
7 0�-3 `7
u Recruitment of emergency medical services personnel from out of the
county would be greatly facilitated if paramedics could be employed.
(This poses an ongoing problem for local ambulance services because
there isn't an adequate pool of EMT-II personnel in any of the nearby
counties) .
o The intent of the State Legislature is to promote EMT-P providers
rather than EMT-II (Health and Safety Code Div. 2. 5 , 1797 .2 ) .
o The facilities and instructors rdgii red' tb teach both EMT-II and --
paramedic classes are available through the San Luis Obispo County
EMS Agency, and to the extent that 15 or more eligible candidates
apply for training at the EMT-II/paramedic level, the EMS Agency is
prepared to offer these classes . EMT-II candidates will be allowed
to attend paramedic training classes and will be certified at the
level desired by their sponsoring agency.
• Many currently employed EMT-I and EMT-II providers have expressed a
desire to upgrade their skills to the paramedic level .
EMT-D
The EMT-D designation denotes an EMT-I who has successfully completed
defibrillation training using a cardiac defibrillator. This training
cannot be considered an alternative to paramedic training because it
only addresses cases of ventricular fibrillation - a very small
percentage of total Advanced Life Support calls . However, the EMT-D
serves a very useful purpose in rural settings populated by senior
citizens and many counties have augmented the training of EMT-I 's to
include defibrillation. A proposal to include defibrillation training
for public safety personnel working in San Luis Obispo County is
included in Appendix 5.
8 �-y0
Benefits
Citizens of San Luis Obispo County will benefit from this conversion
because the emergency medical assessment skills and life-saving skills
of the paramedics is superior to those of the EMT-II's . An increase in
the quality of the pre-hospital care provided to County residents will
reduce the morbidity and mortality rates , particularly in those rural
and remote areas of the County where response time and transport time
is extended. Generally, the benefits of paramedic responders are felt
to be greater in remote areas for this reason. It was previously noted
that 40% of the County's residents live in rural settings.
Letters of support for this upgrade have been received from emergency
physicians , ambulance agencies, practicing EMTs , consumers , and the
County Health Officer.
Financial Impact of Paramedic Conversion
There are three major cost components associated with the conversion to
paramedic level ambulance and fire department personnel. These are
salary costs, training costs, and on-going costs related to the
conversion.
Since every provider has a different salary scale and policy regarding
reimbursement of educational expenses , the financial impact to each
provider was calculated separately.
There are two tables below, the top one depicts conversion costs for
current EMT-II 's , the lower table reflects conversion costs for
EMT-I's. Information in the tables was provided by each of the
agencies listed. For purposes of comparison, a table summarizing the
current costs of upgrading from EMT-I to EMT-II is included in
Appendix 6.
9
CONVERSION OF EMT-II TO PARAMEDIC
STUDENTS EMT-11 CONVERSION AVERAGE ' TOTAL COURSE TOTAL ANNUAL
HOURS 48 HOURLY SALARY COST TRAINING SALARY
(PAID HOURS) SALARY $300 COST- DIFFERENTIAL
SAN LUIS AMBULANCE 12 2882 $7.50 $2,160 $3,600 $5,760 SEE FOOTNOTE 5
FIVE CITIES AMBULANCE 5 144 $6.15 . $886.. __..41,500 $2,386 - . _...
MORRO BAY FIRE 4 192 $15.03 $2,886 $1,200 $4,086
ATASCADERO FIRE 5 240 $12.00 $2,880 $1,500 $4,380
SOUTH BAY FIRE 3 144 $15.93 $2,294 $900 $3,194
*SLO CITY FIRE 10 480 $14.50 $6,960 $3,000 $9,960 $12,000 3
CAMBRIA 4 192 $11.00 $2,112 $1,200 $3,312
------- ------ ------- -------- -------- -------- --------
SUBTOTAL 43 1680 $11.73 $20,177 $12,900 $33,077 $12,000
*SLO CITY FIRE 9 432 6,264 2,700 8,964 10,800
CONVERSION OF EMT-I TO PARAMEDIC
STUDENTS EMT-1 CONVERSION AVERAGE TOTAL COURSE TOTAL ANNUAL
HOURS 476 HOURLY SALARY COST TRAINING SALARY
(W/O INTERN)' SALARY $2,000 COST DIFFERENTIAL
- -------- -------- -------- --------------
SAN LUIS AMBULANCE 5 1190 $5.00 $7,140 $10,000 $17,140
FIVE CITIES AMBULANCE 0 0 $0.00 $0 $D $0
MORRO BAY FIRE 1 476 $15.03 $1,154 $2,000 $9,154
ATASCADERO FIRE 1 476 $12.00 $5,712 $2,000 $7,712
SOUTH BAY FIRE 1 476 $15.93 $7,583 $2,000 $9,583
SLO CITY FIRE 1 416 $14.50 $6,902 $2,000 $8,902 $1,200
CAMBRIA 0 0 $0 $0 $0
------ ------ ------- -------- -------- -------- -------
SUBTOTAL 9 3094 $12.59 $34,491 $18,000 $52,491 $1,200
TOTAL COSTS $54,668 $30,900 $85,568 $13,200
Footnotes:
° The tables are intended to reflect costs only during the projected
two-year conversion period.
1 All average hourly salaries are at overtime rates .
2 San Luis Ambulance and Five Cities Ambulance intend to pay roughly
50% of the total class hours.
3 Only the San Luis Obispo City Fire Department could quote the
.---di-f-fersnt-ial--to be-paid to new paramedic-s-:- - -Ot-trer- -f-i-re--departments-
also plan to pay a differential .
No costs were allowed for the field internship requirement of 480
hours by the EMT-I 's who become paramedics . These individuals will
function as EMT-I 's until they have met this requirement, so no
additional costs are expected. It is possible that a newly trained
paramedic may have to ride with an ALS unit out of his/her regular
area to meet the required minimum of ALS calls. There is no way to
quantify this uncertain cost. Similarly, there are no incremental
costs in educating field training officers and handling
recertification as the EMS Agency currently performs these functions .
5 San Luis Ambulance has completed its salary scale adjustments and no
further salary increases are anticipated as a result of the paramedic
conversion.
In addition, the President of San Luis Ambulance has stated that no
rate increases will be requested on the basis of the paramedic
conversion.
� � a- 4.3
The total training cost associated with the County-wide .conversion to
paramedic providers is estimated to be $85 , 568. Ongoing salary
differentials among the fire department paramedics will increase this
cost by at least $13 , 200 per year and possibly much higher when Morro
Bay Fire Department, Atascadero Fire Department, and South Bay Fire
Department finalize their paramedic salary differentials.
Unfortunately, none of the paramedic conversion costs are reimbursable
under the provisions of Senate Bill 90 since this is not a State
mandated program.
To the extent that one or more of the providers listed elects .not to
convert to paramedic personnel, the cost will decrease.
It is important to note that training costs related to San Luis
Ambulance and Five Cities Ambulance are not tax supported; therefore,
the impact of this conversion to tax-based city budgets is $60 ,282.
CONCLUSION
San Luis Obispo is a rapidly growing county with a current population
of 198,000 and an area of 3 ,300 square miles.
Pre-hospital emergency medical services are provided throughout the
County by a combination of fire departments , law enforcement agencies ,
and public and private ambulance companies .
12 �— �/
Emergency medical service personnel are either EMT-I or .EMT-II who
provide Basic Life Support or Limited Advanced Life Support services ,
respectively.
This study- outlines the steps required to convert existing personnel to
Advanced Life Support providers and estimates the costs of the
conversion .
The reasons for considering an upgrade to the paramedic level include
the expanded scope of emergency procedures performed by paramedics , the
increasing number of ALS calls received by the 911 operators at Med
Com, the rugged topography and long transport times common in San Luis
Obispo County, the availability of facilities and instructors to teach
the paramedic curriculum, and the desire of currently employed EMT' s to
become paramedics. All bordering counties have converted to paramedic
providers.
The total training cost of the conversion ( including salary and course
costs ) is estimated to be $85 , 568 during the proposed two-year
transition period. Ongoing salary differentials will add to this cost.
Each fire department and ambulance service will decide whether they
have the case load and resources to justify this conversion and whether
they wish to participate in a conversion to paramedic Advanced Life
Support personnel.
13
APPENDIX 1
SENATE BILL NO . 1.25
M
Senate Bill No. 125
CHAPTER 1260
An act to repeal Sections 1760, 1760.6, 1761, 1765, 1767, and 1769 of,
and to add Division 2.5 (commencing with Section 1797) to, the
He-Jath and Safety Code,relating to emergency medical services,and
malting an appropriation therefor.
(Approved by Governor September 47, 19&0. Fi ed with:
Secretary of State September:9, 1550.1
LEGISLATIVE COUNSEL'S DIGEST
SB 125, Caramendi. Emergency medical care personnel.
(1) Under etisting law, the State Department of Health Services
is required to maintain, in ccoperation with local agencies, an
( emergency medical services program. Existing federal law provides
`.� for regional emergency medical care systems. Existing state late does
not provide for the training in approved training programs and the
certification of prehospital emergency medical care personnel,
except county pilot programs for mobile intensive care paramedics
and educational or training plot programs approved by the Office
of Statewide Health Planning and Development.
This bill would regtlire the Emergency Medical Service Authority,
created by the bill in the Health and Welfare Agency, to estab:sh
planning and implementation guidelines, as specified, for
emergency medical service systems, as defined, and adopt rules and
regulations and minimum standards for training and practice,
training programs, and for the education and cer iRca:ion of
prehospital emergency medical care personnel, as specified, excep:
as provided in the bill.The local EM'S agency, is defined,designated
pursuant to the bill by the count)-, as specified in the bill, would be
responsible for administration of emergency medical services, and
the county health officer or county designated physician would be
responsible for determining that the operation of training programs
are in compliaurc with state standards, for certifying an individual
upon completion of an approved training program, and for issuing
certificates to qualified persons.The state standards for advanced Iu'e
support and limited advanced life support personnel would be as
provided in the bill until new standards are developed by the
Emergency Medical Services Authority, approved as specified, and
adouted.
The bill would authorize a county, as a condition of employment
in an advanced life sut)porr or limited advinced life support
prehospital care system, to require additional training and
quaidiication which are greater than those provided in the bill.
The bill would authorize procaron, suspension, or revocation of
any certificate after a hearing on specified grounds by a counry.
211—I00 Iteprvited I13a0 30)
Ch. 1260 —2—
The
2_The bill would require the state authority to promulgate
regulations to provide for the assessment of emergency medical
facilities.The authority would be required to make specified annual
and biennial reports to the Legislature relating to certain of such
activities.
This bill would authorize the Director of the Emergency Medical
Service Authority to coordinate emergency medical services
systems, as defined, and contract with medical consultants.
The bill would create the Interdepartmental Cor xr ittee on
Emergency Medical Services.
The bill would create the Commission on .Emergency Medical
Services, with specified duties.
(2) Existing lavv limits liability for firemen,policemen,other local
law enforcement officers and paramedics, as de5ned, for civil
damages for emergency services.
This bill would provide for immunity from liability for civil
damages allegedly resulting from training programs and additionally
limit liability for actions or certificated persons to gross negligence
or other actions not performed in good faith except at an emergency
department and other places where medical care is usually offered.
(3) Existing law provides immunity from liability for civil
damages resulting from any act or omission for any person who
renders emergency care at the scene of an emergency in good faith.
Persons, other than specified persons who are liable only for grossly
negligent acts, rendering such care for compensation are excepted
from such existing immunity.
This bill would repeal certain of such provisions, and; instead,
provide immunity from liability for civil damages resulting from any
act or omission for any person who renders emergency care at the
scene of an emergency,except in emergency departments and other
places where medical care is usually offered, in good faith and not
for compensation and, for physicians and nurses, for giving
errcrgency instruction to designated prehospital ernergency
medical care personnel, and, for such personnel, for following such
instnrctions.
The bill would also repeal and reenact provisions providing limited
liability for specified emergency and public safety persons for
rendering emergency inedical services at the scene of an
emergency, except that the bill would delete services performed at
emergency departments iutd other places where medical etre is
usually offered from such limited liability.
(-t) Under existing lave,Sections 2:,)31 and 2114 of the Revenue and
Taxation Code require the state to reimburse local agencies and
school districts for certain costs mandated by the state. Other
provisions require the Department of Finance to review statutes
disclaiming these costs and provide, in certain cases, for making
claims to the State Board of
statutory Control for reimbursement. The
ry provisions requiring reimbursement are supplemented by
21 n
-3— Ch. 1250
a constitutional requirement of reimbursement effective for statutes
enacted on or after July 1, 1980.
This bill provides that no appropriation is made by this act
pursuant to the constitutional mandate or Section 2?wl or • 2^', but
recognizes that local agencies and school districts may pursue their
other available remedies to seek reimbursement for thesecosts.
This bill would appropriate $94,482 from the Gener l Fund to the
Emergency Medical Service Authority for the purposes of this act.
Appropriation: yes.
The people of the State of California do enact as follows.
SECTION 1. Section 1760 of the Health and Safety Code is
repealed.
SEC.2. Section 1760.6 of the Health and Safety Code is repealed.
SEC. 1 Section 1761 of the Health and SafetyCode is repealed.
SEC. 4. Section 1765 of the Health and Safety Code is repealed.
fC. ec SEC. 5. Section 1767 of the Health and Safety Code is repealed.
• SEC. 6. Section 1769 of the Health and Safety Code is repealed.
SEC.7. Division 2.3 (commencing with Section 1,97) is added to
the Health and Safety Code, to read:
DIVISION 25. EMERGENCY .MEDICAL SERVICES
PART 1. EMERGENCY MEDICAL. SERVICES AND
E.-IERGENCY MEDICAL CARE PERSONNEL
CHAPTER 1. GENERAL PROVISIONS
1797. This part shall be known and may be cited as the
Emergency Medical Services System and the Prehospital
Emergency Medical Care Personnel Act.
1797.1. The Legislature finds uid declares that it is the intent of
this act to provide the state %ith a statewide system for emergency
medical services by establishing within the Health and Welfare
Agency the Emergency Medical SerNice Authurity, which is
responsible for the coordination and ilitegration of all state activities
concerning emergency medical services.
1797.2. It is the intent of the Legislature to maintain and promote
the development of EMT•P paramedic programs where appropriate
throughout the state and to initiate EMT•II limited ad%•anced life
support programs only where geography.. population deceit}', and
resources would not make the establishment of a paramedic program
fc:uible.
The provisions
this part
preclude adoWion additionaltralgsandardsfoE\ T•II and EMTP by localE\1S
agencies.
1797.4. In the event of any conflict between the pro%isions of this
a-y9
Ch. 1260
part and Chapter 9 (cornmencing with Section 1750), the provisions
of this part shall prevail.
CHAPTER 2. DE.rlvrctotiS
1797.50. Unless the context otherwise requires, the definitions
contained in this chapter shall govern the provisions of this part,
1791.52. "Advanced life support"means special services designed
to provide definitive prehospital emergency medical care inclucLng,
but not limited to, cardiopulmonary resuscitation, cardiac
monitoring, cardiac defibrillation, advancedairway management,
intravenous therapy, administration of specified drugs and other
medicinal preparations, and other specified techniques and
procedures administered by authorized personnel under the direct
supervision of a base station hospital.
1797.54. "Authority" means the Emergency Medical Service
Authority established by this part.
!(tb1797.56. "Authorized registered nurse"means a registered nurse
.. who meets the qualifications specified in the Wed worth-To«zuend
Paramedic Act, Article 3 (commencing with Section 1480) of
Chapter 2.5 of Division 2.
1797.58. "Base station hospital" or"base station hospitals" means
a Hospital or hospitals which, upon designation by the local ENIS
agency and with a written contractual agreement%with the local E.\fS
agency,is responsible for directing the advanced life support system
or limited advanced life support system assigned to it or t.5em by the
local EMS agency.
1797.60. "Basic life support" means emergency first aid and
cardiopulmonary resuscitation procedures which, as a mi:umtun,
include recognizing respiratory and cardiac arrest and starting the
proper application of cardiopulmonary resuscitation to maintain life
without invasive techniques until the victim may be transported „r
until advanced life support is available.
1797.62. "Certificate" means a specific document issued to an
individual denoting competence in the named area of prehospital
service.
1797.64. "CO`missioii" means the Commission on Emergency
Medical Services created pursuant to the provisions of Section 17S9.
1797.66. "Competency based curricttltun" mens a curriculum in
which specific objectives are defined for each of tine separate skits
taught in training programs with integrated didactic and practical
instruction and successful completion of an examination
demonstrating mastery of every skill.
1747.63• "Director" means tine Director of the Emergency
Medical Service Authority.
1797.70. "Emergency"means a condition or situation in which an
individual has a need for immediate medical attention, or where the
potential for such need is perceived by emergency medical
o?,-jU
C
—5— Ch. 1260
personnel or a public safety agency.
1757.72. "Emergency medical services" means the services
utilized in responding to a medical emergency.
1791.74. "Emergency medical services area" or "E-MS area"
means the geographical area of a county or a health service area
previously designated pursuant to the National Health Planning and
Resources Development Act of 1973 (42 U.S.C. 300k et seq., P.L.
93-641).
1797.76. "Emergency medical service plan"means a plan for the
delivery of emergency medical services consistent with state
guidelines addressing the components listed in Section 1797.103.
1797.78. "Emergency medical services system" or "system"
means a specially organized arrangement which provides for the
personnel, facilities, and equipment for the effective and
coordinated delivery in an EMS area of medical care services under
emergency conditions.
1791.80. "Emergency Medical Technician-I" or "EMT-I" means
kth an individual trained in all facets of basic life support according to
standards prescribed by this part and who has a valid certificate
issued pursuant to trhis part. This definition shall include, but not be
limited to, EMIT-I (FS) and EM'i-I-A.
1797.52. "Emergency Medical Technician-II"or"EMT-II"means
an EJfT-I with additional training in limited advanced life support
according to standards prescribed by this part and who has a valid
certificate issued pursuant to this part.
1797.84. "Emergency Medical Technician-Paramedic" or
"EMT-P" or "paramedic" means an individual who is a mobile
intensive care paramedic, as defined in Section 1481, and whose
scope of practice to provide advanced life support is according to
standards prescribed by this part and who has a valid certificate
issued pursuant to this part.
1797.86. "Health systems agency"means a health systems agency
as defined in subsection (a) of Section 300(1)-1 of Title 42 of the
United States Code.
1797.88. "Hospital—me-Li-is wi acute care hospital licensed under
Chapter 2 (commencing with Section 1250) of Division 2, with a
permit for basic emergency sen•ice.
1797.90. "Medical control" means the medical management of
the emereencv medical services system pursuant to the provisions of
Chapter 5 (commencing with Section 179.9).
.1797.92. "limited adv:Lnced life support" means special service
desi;•ned to provide prehosuital emergency medical care limited to
techniques and procedures that exceed basic life support but are less
than advanced life support and are those procedures specified
Pursuant to Section 1797.171.
1797 94. "Local EMS agency" means the agency, department,or
office having primary
responsibility for administration of emergency c/
medical services in a county and which is designated pursuant to �J
:.:cu.�tc 1x111 ltj
fieu yuu of : t;cLLL)fuo Relating to
Cr:,n:;purLatiun
Health & :.ial',Ay Code
1797. 'Phu Ilesll.t 11el'al•Lment :;troll plan, implernent, and evaluate
un emurterrcy medico 1 services system . . . consisti.r }, of an
ur�• ini_. . i paLtern of readiness .and response services based un
public avid private agreements and uperational procedures. (Personnel
requirements as listed under Manpower. )
1797.22 The Health Department shall establish policies and procedures to
adjure medical control of advanced life support personnel.
1798 1,11c i:c,•iiLfi OffL;ter ;;hall be responsible for medical control,
medical direction and management, of the emergency mulival servic_s
system.
1793.170 The Health Department authorized to develop triage and transfer
protocols to facilitate delivery of pateints to appropriate
designated facilities within and without the County.
-2-
1798.2 The base sLaLiori huspiLal shall implement the policies and
procedures of the flealth Department for medical direction of
hospital ALS personnel.
1798.4(b) 1n each instance where ALS procedures are initiated without voice
contact, requirements for base station hospital emergency physician
to evaluate the Paramedic's report and forward the report and
evaluation to the Health Officer within 72 hours.
1798.100 A designated base station shall provide medical direction of the
ALS for the area defined by the Health Department in acconiance
with policies and procedures established by the Health Department.
1798.102 The base station shall supervise the prehospital treatment, triage
and transport, ALS, and monitor personnel program compliance by direct
medical supervision.
1798.104 The base station hospital shall be responsible for provision of EIS
prehospital personnel training and education in accordance with
Health Department policies and procedures.
1798.170 The Health Department is authorized to develop triage and transfer
protocols to facilitate prompt delivery of patients to appropriate
designated facilities within and without the County.
1798.172(a)The Health Department shall establish guidelines and standards for
completion and operation of formal transfer agreements between hospitals
with varying levels of care in Kern County. These guidelines shall
include provision suggested written agreements for the type of patient,
necessary initial care treatments, requirements of interhospital curt,
and associated logistics for transfer, evaluation, and monitoring of
the patent.
1798.172(b)Notwittistanding the provisions of subdivision (a), and in addiLion to
the provisions of Section 1317, a general licensed scute carr nosp aal
shall not transfer such a person for nonmedical reasons to r.�nother
health facility unless that other facility receiving the person agrees
in advance of the transfer to accept the transfer.
1798.200, 206, 208 Perialities for violations of the rules and regulations.
1799.100, 162, 104(x) Liability limitation of emergency department staff.
57.3
1•I�1S DIY ._ �,.'N 3.;
Senate Bill 125
Resume of Sections Relating to Facilities
Health and Safety Code
Section:
1797.56 "Authorized registered nurse" defined as Mobilt intensive Cart "burse:
1797.58 "Base station hospital" defined as a hospital which, upon designation
by the Health Department and with a written contractual agreement with
the local Health Department, is responsible for directing the advanced
life support system assigned to it by the Health Department.
1797.88 "Hospital" defined as an acute care hospital licensed under Chap:.e:• 2,
(commencing with Section 1250) of Division 2, with a permit for
basic emergency service.
1797.90 "Medical control" defined as the medical management of the emer4oency
medical services system by the Health Officer (Section 1797.202).
1797.94 "Local FMS Agency" defined as the department having primary =esnor_sibil-ity
for administration of emergency medical services in a county and
which is designated -pursuant to Chapter 4, (conanencing with Sectio- ?797.200).
Kern County Health Department so designated Rov artier 1_3, 1980.
1797.151 The FMS Authority, (Section 1797.100), shall coordinate through the
Health Department, medical and hospital disaster preparedness with
other local, state, and federal agencies and departments having a
responsibility relating to disaster response. . . .
1797.204 The Health Department shall plan, implement, and evaluate ari FMS system,
in accordance to this part, consisting of an organized pattern of
readiness and response services based on public and private agreements
and operational procedures.
1797.206 The County Health Department is responsible for implementation
of ALS systems and for monitoring of training programs.
1797.214 The county or Health Department may require additional training or
qualifications than those provided in this chapter as a condition
precedent for certification in the ALS prehospital ::are system.
1.798 The medical direction and management of an Z!S 5ys_em w-der -ie
control of the Health Officer.. Methodology for control defined.
�- sy
-2-
1798.2 The base station hospital shall implement the policies and
procedures of the Health Department for medical direction of
hospital ALS personnel.
1798.4(b) In each instance where ALS procedures are initiated without voice
contact, requirements for base station hospital emergency physician
to evaluate the Paramedic's report and forward the report and
evaluation to the Health Officer within 72 hours.
1798.100 A designated base station shall provide medical direction of the
ALS for the area defined by the Health Department in accordance
with policies and procedures established by the Health Department.
1798.102 The base station shall supervise the prehospital Lrea ;e +r-aoe
and transport, ALS, and monitor person_*i-1 p=ug!•am cc, al'_ _c -Y
medical supervision.
1798.104 The base station hospital shall be responsible for provision of FMS
prehospital personnel training and education in accordance with
Health Department policies and procedures.
1798.170 The Health Department is authorized to develop triage and transfe_-
protocols to facilitate prompt delivery of patients to aporopr?_ate
designated facilities within and without the County.
1798.172(a)The Health Department shall establish guidelines and standards for
completion and operation of formal transfer agreements between hosoi+als
with varying levels of care in Kern County. These guidelines shall
include provision suggested written agreements for the type of patient,
necessary initial care treatments, requirements of interhospital care,
and associated logistics for transfer, evaluation,
the patient. _
1798.172(b)Notwithstanding the provisions of subdivision (a), and in addi.Lion to
the provisions of Section 1317, a general licensed acute care hospital
shall not transfer such a person for nonmedical reasons to another
health facility unless that other facility receiving the person agrees
in advance of the transfer to accept the transfer.
1798.200, 206, 208 Penalities for violations of the rules Lind regu:l"i_r:
1799.100, 102, 104(x) Liability limitation of emergency department stavl'.
!V.6 DIVISION 12/80 ��
MT-P or Paramedic
'Tire ful.lowiiig are in addition to the attached EMT-I regulations.
1797.3 'Thu Health Department may adopt additional training standards
for EMT-P.
1718-52 "Ativar>Ced life suporL" defined as special services designed to
provide definitive prehospital emergency medical care. Further
defines such care.
1797.84 "Emergency Medical 'Technician - Paramedic or "EMT-P" or "paramedic"
defined as an individual who is a mobile intensive care paramedic,
as defined in Section 1481, and whose provision of advanced life
support is according to the standards in this law and who has a
valid certificate issued pursuant to this law.
1797.94 "Lural EMS agency" is defined. Kern County Hea1Lh Department was
desioruted as local EMS agency by the Board of Supervisors on
November 18, 1980, as required under 1797.200, Health Officer as
Medical Director. (1797.202)
1797.172 Training standards as in Section 1481.1 until new state minimum
standards are developed, adopted, and approved.
1797.177 Nu individual shall hold himself or herself out Lo be an EIVIT-I,
EMT-P, or paramedic unless that individual is currently certified
by the Health Department.
1797.178 No person or organization shall provide advanced life support unless
an authori,ed part of the emergency medical services system of the
Health Department.
1797.206 The County (Health Department) is responsible for implementation
of advanced life support systems and for monitoring of training;
programs.
1797.208 The County (Health Department) is responsible for determining that
Lire operation of the EMT—P training program is in compliance with
Lire law, and for approving the program.
1797.210 The HeaJLh Officer shall issue a certificate upon pmol ,,1' satisfactur
completion arid passage of examination fur competence. he certificaLe
shall bt: 'pruof of the individual's initial compcLencv ..0 perform ai.
the delis: atcd level. 'fire county health Officer Departrneirl.)
s1,a11 recertify LMT-0's, and EMT-P' s through pa:s:ap,z of t:ompetency
examinations at 'east every two years.
1797.212 The Couuity (Health Department) may establi:;tn a 1'ee lr ;tl il_ for
eer•Lification.
1797.214 The County (Health Department) may requiru additional training or
qualifications greater than those specifies' as �-, coiidiLi.un� for
�s�
-2-
certification within the advanced life support systew in
Kern County.
1797•`18 The County (Health department) may authorize an advanced life
support program which provides services utilizing INT-P. . . .
1797.220 The Health Department, using state minimum standards, shall
pulicies and procedures to assure medical control of advanced lift.
support personnel.
1798 The Health Officer shall be responsible for medical control,
direction and management of the emergency medical service- syz:L:-;,i.
1798.2 and
1798.4 Methodology of medical control.
1798.200 and
1798.202 Grounds under which the County (Health Department) may place or,
probation, suspend or revoke certification.
1798.204 Proceedings for action.
1798.206 Any person who violates any provision is guilty of a misdelneaior.
1798.208 Conditions under which restraining order or injunctions may
issued.
o?-S7
SENATE BILL 125
Resume of Sections Relating to
Manpower and Training
Health & Safety Code
1797.62 "Certificate" defined as a document denoting competence in the
named area of prehospital service.
1797.66 "Competency based curriculum" defined as a curriculum in which
there are defined specific objectives for each of the skills
taught in training programs with integrated didactic and practi„al
instruction and successful completion of an examination demonstrati-ng
mastery of every skill.
1797.70 "Emergency" defined as a condition or situation in which an
individual has a need for immediate medical attention_; or wke.a
the potential for such need is perceived by emergency medical pe=sonn_e'_
or a public safety agency.
1797.72 "Emergency medical services" means the se r: _ces uti,_zec =r
responding to a mec'=c?_ emergency.
1797-78 "Emergency medical services system"
specifically organized arrangement WhiCh provides for pCr•soniiel,
facilities, and equipment for effective and coordinated delivery
in an EMS area of medical care services under emergency conditions.
EMT-I
1797.60 "Basic life support" is defined as emergency fir6L aid anc
procedures which, as a minimum, include recognizing respiratory arc
cardiac arrest and starting proper application of CPR to ma;nte4n
life without invasive techniques until the vic'.iin may be transoortad
or until advanced life support is available.
1797.80 "Emergency Medical Technician-I" or "EMT-I" defined as an individual
trained in all facets of basic life support accordir_g to prescribed
standards and has a valid certificate issued as required. T_:_=
definition includes, but is not limited to, &wr-' (u'S) end
1'
based on statewide standards,
1797.177 but must be currently certified as an EMT-I by the Fern County
Health Department.
1797.173 EMT-I training and testing for fire service personnel may be offered
at State Board of Fire Services approved sites, and CHP officers
may be trained at CHP academies.
'_797.208 The Health Department is responsible for determining that operation
of the EMT-I training program is in compliance with the law, and
for approving the training program. CHP Academy is exempt frorr. this
provision.
-2-
1797.210 The Health Officer shall issue a certificate to an individual
upon proof of satisfactory completion and passage of competence
examination. *Health Department shall recertify FMT—I's every
two years through passage of an examination for competency.
1797.212 The Health Department may establish a fee schedule for certification.
1797.214 The Health Department may require additional training or qual_fications
greater than those required by the state i.n an advanced '_ife support
prehospital care system.
1798.200 Grounds for which the Health Department may place un prcbat'_ : a:^_y
certificate holder, or suspend or revoke any certificate issued.
1798.202 Health Officer may place on probation, suspend, or revoke the approval
of any training program for failure to comply with the provisions
of this law, rules and regulations adopted pursuant to the law. e
1798.204 Proceedings for action.
1798.206 Any person violating the rules and regulations is gu;'_:y o°
misdeameanor.
1798.208 An injunction or restrairing order may be obt-ined to _ :j
anyone who hae-.engaged, or is about to engage, in any �:Lc!, or
practice which constitutes, or will consititut� a vio'__`.io-_ =r•.;r
of the rules and regulations.
�-S9
r
APPENDIX 2
RUN REPORT STATISTICS
1981 RUN REPORT STATISTICS
Location
Ambulance Area AS AG AT CA CY G OU 0I GC LA LO NC 118 MO
1 - Cambria/No Coast 0 0 O SO 1 0 0 0� �0 0 0 0 0 0
% of area 0.0% 0.01 0.0% 73.5% 1.5% 0.0% 0.0% 0.0%. 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
2 - Paso /No County' '0 0 / 0 0 0 0 0 0 5 0 0 0 0
% of area 0.01 0.01 2.5% 0.0% O.O% 0.01 0.0% 0.01 0.0% 3.2% 0.0% 0.0% 0.0% 0.0%
3 - Morro/South Bay 0 0 D 20 0 . 0 0 0 0 0 11 3 99 0
% of area 0.0% 0.0% 0.0% 9.8% 0.0% 0.01 0.01 0.0% 0.0% 0.0% 37.61 1.5% 18.3% 0.0%
- Atas./CA Val 0 0 115 , 0 0 0 0 0 0 0 0 0 0 0
t of area 0.0% 0.0% 65:0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
S - S.L.O./ Central 13 0 S 3 S 0 3 2 0 0 iS 6 23 0
% of area 1.51 0.01 1.7% 1.0% 1.7% 0.0% 1.0% . 0.7% 0.01 0.0% 5.2% 2.1% 8.0% 0.01
6 - 5 Cities/So Co 1 SO 0 0 0 0 ii 0 51 2 0 0 0 0
% of area 0.1% 19.9% 0.0% '0.0% 0.0% 0.0% 1.1% 0.0% 20.3% 0.8% 0.01• 0.0% 0-OV. 0.01
total all areas it 50 121 73 6 0 11. 2 51 7 92 9 122 0
total per cent 1.2% 1.1% 10.8%.' .6.1% 0.5% 0.0% 1.2% 0.2%. /.1% 0.6% 8.0% 0.8% 10.6% 0.0%
AS Avila Bch CA Cambria G Co Jail 01 Diablo NPP LA Lakes MC Mens Col. MO Mont Or
AT Atascadero CY Cayucos OU Ounes 13C Grover City LO Los Osos M8 Morro 84y NI Mipo.o
1981 RUN REPORT STATISTICS
Ambulance Area NI OC PB PR SG SH SL SM SS TE CO 00 unk TOTAL
I - Caebria/110 toast 0 0 0 0 0 0 0 0 5 0 6 1 2 68
% of area 0.0% 0.0% 0.0% 0.0% 0.0% 0.01 0.0% 0.0% 1./% 0.0% 6.8% 5.9% 2.9%
2 - Paso /NO County 0 0 0 %112 7 S 0 0 0 9 12 2 1 157
% of area 0.0% 0.0% 0.0% 71.3% 1.5% 3.2% 0.0% 0.0%. 0.0% 5.7% 1.6% 1.3% 0.6%
3 - Morro/South Bay 0 0 0 0 �O 0 3 0 0 0 1 0 2 20S
% of area 0.0% 0.0% 0.0% 0.0% 0.0% 0.01 1.$% 0.0% 0.0% 0.0% 0.5% 0.0% 1.0%
1 - Atas:/CA Val 0 0 0 1/ 0 0 0 13 0 10 20 - 0 S 177
% of area 0.0% 0.0% .0.0% 7.9% 0.0% 0.0% 0.0% 7.3% 0.0% 5-6% 11.3% 0.0% 2.8%
S - S.L.O./ Central 1 0 1 S 0 0 190 1 0 1 10 1 / 289
% of area 0.3% 0.0% 0.3% 1.7% 0.0% 0.0% 65.7% 0.3% 0.0% 0.3% 3.51 0.3% 1.11
6 - S Cities/so Co 37 28 61 0 0 0 0 0 0 0 9 0 1 ..251
t of area 11.7% 11.2% 21.3% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 3.6% 0.0% 0./%
total all areas 38 28 62 131• 7 S 193 1/ S 20 SB 7 15 1147.
total per cent 3.3% 2./% 5./% 11.1% 0.6% 0./% 16.8% 1.2% 0./% 1.7% 5.1% 0.6% 1.3%
e OC Oceano PR Paso Rob. SH Shandon SS San Simeon CO County area crv?
PO Pic. m.n cr c... rin,,.1 a a n TF Temoleton 00 Out of Co
APPENDIX 3
POPULATION ESTIMATES
AND PERCENT INCREASE
a [ arP4 �A A 9m
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7
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APPENDIX 4
EMS AGENCY CONTRACT WITH
SAN LUIS OBISPO COUNTY
(Available for Review at
EMS Agency Office)
APPENDIX 5
DEFFRR ILLATION. TRAINING
Fire Chiefs Association of San Luis Obispo Cc►zYEl�j•
In association with the California Fire Chiefs Association
lrroyo Grande F.D. October. 13 , 1987
tt.scadero City F.D.
.ta■cadero State Hospital F.D.
a.ila Beach F.P.O.
:01if. Man's Colony F.D.
:.lib. Poly State Univ. F.D.
:. brla F.P.D.
EMSA BOARD OF DIRECTORS
m
:•mv Roberts F.D. P.O. BOX 14060
:ayucos F.P.D. San Luis Obispo, CA 93406
:alif. Department of Forestry
rover City F.D.
?"a Bey F.D. LADIES AND GENTLEMEN:
c.ano F.P.D. '
.so Robles City F.D.
iamo Beech F.D. The County Fire Chiefs at their regular meeting of
an Luis Obispo City F.D. October 9, 1987 discussed the need for the current
.n Luis Obispo County F.D. EMT-p feasibility study to broaden its scope to .
an Miguel F.P.D.
into Margarita V.F.D. include the possible implementation of public -
.uth Bay F.P.O. safety defibrillation.
smpleton F.P.D.
.S. Forest Service
The following are the reasons viewed by our organization
to be important enough to request this now be included
in the EMT-P study:
" 1. The State has adopted guidelines which include
automatic or semi-automatic defibrillation by
public safety personnel as an option which can
be adopted by local EMS agencies.
2. The concept has been endorsed by:
A. The �American College of Emergency Physicians
B. The American Medical Association
C. The American Heart Association
3 . Medical evidence shows a need for early
defibrillation is critical.
4. Due to a. number of impacts, advanced life support
cannot be provided to all areas of our county.
S. Public safety personnel act as first responders
in virtually all areas-of-our county. -
6. Public safety personnel are far more numerous
and can often intervene in cardiac arrest
situations prior to the arrival of advanced life
support units.
EMSA BOARD OF DIRECTORS
Page Two
7: This concept could possibly save more lives in our county
than the conversion from EMT-II to EMT-P.
8. Standards for training in the use of defibrillation by
: public safety personnel currently exist and could be promptly
instituted by the EMSA.
9. Participation would be optional to each jurisdiction. The
financial impacts would be a local consideration only.
The overwhelming amount of acceptance of this skill nationwide,
along with the medical community endorsements mandate we study
this option with possible implementation.
While we study the EMT-P conversion-,,•a great deal of emphasis
has been placed on improving patient care. we believe as an
organization that we may well find the implementation of a
Public Safety, First Responder or EMT Defibrillation program
may save lives county-wide and greatly enhance either the EMT-II
or EMT-P program this county chooses as the standard for advanced
life support.
Your consideration of this matter will be greatly appreciated.
I am available to discuss this topic by calling 773-4657.
Sincerely,
Paul M. Henlin
President, Fire Chiefs Association
of San Luis Obispo County
PMH: jr
c: EMSA EMT-P Feasibility Sub-Committee
APPENDIX
CONVERSION OF EMT- I TO EMT-II
CONVERSION OF:EXT-1 TO EMT-II
STUDENTS EXT-1 CONVERSION AVERAGE TOTAL COURSE TOTAL ANNUAL
HOURS 342 HOURLY SALARY COST TRAINING SALARY
(W/O INTERN) SALARY $1,500 COST DIFFERENTIAL
SAN LUIS AMBULANCE S 8S5 $6.00 $5,130 $10,000 $15,130
FIVE CITIES AMBULANCE 0 0 $0.00 $0 $0 $0
MORRO BAY FIRE 1 342 $15.03 $5,140 $2,000 $7,140
ATASCADERO FIRE 1 342 $12.00 $4,101 $2,000 $6,104
SOUTH BAY FIRE 1 342 $15.93 $5,448 $2,000 $1,448 1
SLO CITY FIRE 1 342 $14.50 $4,959 $2,000 $6,959 $1,200
CAMBRIA 0 0 $0 $0 $0
TOTAL COSTS 9 2223 $12.69 $24,781 $18,000 $42,781 $1,200
ATTACHMENT #4
SIERRA- nl..+C .'+ 9323 TECH CENTER DRIVE PHONE
SACRAMENTO SUITE 1200 (916)
VALLEY SACRAMENTO.CA 95826 366-2064
. NEVADA CO.
PLACER CO. � >
SACRAMENTO CO.
SIERRA CO. ! �
BUTTER CO.
YOLO CO.
YUBA CO.
4
J
a
e
1 �
ii SIERRA-SACRAMEM VALLEY EMIGENCY MEDICAL SERVICES
to
: ! SPFX::M MEppRp:
iJ
. i
I �
! EEA.SMILMY OF EMTL-II TO PARAMEDIC CONVERSION
( )
I �
May 12, 1988
p_ (WiTHOM APPENDIX)
� s
, i
{
I
t :
1 �
, s
. I
I :
r , Dave Shelby.
Regional t Executive Director
I Sierra-Sacrmianto Valley EMS Agency
I
Sacramento, Ca.
� i
re
—70
MEDICAL - PATIENT CARE CONSIDERATIONS
The absolute impact of a transition from EMT-II to Paramedic care is
difficult to determine based on published reports. Although the benefits of
Advanced Life Support compared to Basic Life Support have been well
documented, a paucity of information exists regarding benefits of one level of
ALS compared to another (i.e. EMr-II vs. EW-P) . This is due in part to the
lack of standardization among intermediate levels of prehospital care, and
also to the sometimes subtle differences between intermediate and paramedic
levels.
In order to address this issue on a local level, the Sacramento County
Emergency Medical Care Committee established a Paramedic Subcommittee with a
primary task to assess the patient care considerations such a transition could
represent. A study plan was designed involving retrospective review of IIMT-II
Response Reports by each of the Sacramento Base Hospital Medical Directors.
Two Base Hospitals completed this project; Methodist Hospital and the
University of California, Davis Medical Center. The EMr-II Medical Directors
at. these hospitals conducted independent audits of EMr-II Response Reports to
determine how many patients, and which patients, might have benefited frau .
drugs and/or procedures which were only available in a paramedic scope of
practice.
In his memo of January 7, 1988, John Tucker, M.D. reported his findings
based on review of 92 patients receiving care from EMT-IIs assigned to
Methodist Hospital in South Sacramento. Dr. Tucker concluded:
-- of the 57 cases involving respiratory distress, 40, or 70%, would
likely have benefited from use of nebulized bronchodilators,
which are available only to paramedics,
— of the. 3 cases involving status epilepticus, paramedic airway
Procedures might have helped 21,
— of the 12 cases involving major trauma, 6 may have benefited frau
the paramedic airway or external jugular prooedures, and
— of the 20 cases involving unstable: cardiac patients, 11 would
likely have benefited from the paramedic drugs Verapamil or
Bretyllium.
Dr. Tucker's overall evaluation was that 59 of the 92 cases he reviewed
may have benefited from paramedic drugs and/or promIxes.
6 � - / /
In a separate study, Michael Gillogley, M.D. reviewed the records of 276
patients who received care from EMT-IIs assigned to the University of
California, Davis Medical Center. In his letter of December 3, 1987, Dr.
Gillogley reports:
— of 206 cases involving severe respiratory ccmproa-ze, 172 would
Likely have benefited frrm paramedic nebulized bronc-hod;lator
therapy,
-- of 26 cases involving status epilepticus, 24 might have
benefited from paramedic benzodiazepine therapy,
— sane of 28 cases associated with unsuccessful IV field care may
have benefited from external jugular IV procedures.
Dr. Gillogley concludes that a large group of patients in the Sacramento
cOMMInity who suffer frau respiratory disease, status epilepticus, and/or poor
Peripheral IV access would benefit from additional prehospital interventions
available to paramedics.
The complete text from both medical review studies is included in the
Appendix. Although neither study was presented as scientific or cxmprehensive,
substantial evidence strongly suggests that a significant number of patients
entering the prehospital care system in-'Sacramento would likely benefit from
the additional drugs and/or procedures available within a paramedic scope of
practice. This is true for patients with poor peripheral IV access,
respiratory disease, and/or status epilepticus.
7 - 7A
ATTACHMENT #5
SCOPE OF PRACTICE FOR THE PROPOSED PARAMEDIC PROGRAM
AS IT DIFFERS FROM EXISTING EMT II SCOPE
The following is a brief overview of the proposed paramedic scope of practice as it
extends beyond the current EMT II scope of practice. This is a list that was approved by
medical standards committee as of June 27, 1988. The list may change by one or two
drugs being deleted as the paramedic program is instituted.
PROPOSED DRUGS;
DOPAMINE HCL; This is used to increase cardiac output and dilates vessels in the brain,
heart and kidneys (the big three on the organs of life list). Used safely to increase
cardiac output for cardiogenic and septic shock (weak heart and systemic problems from
infection).We have no EMT II drug to use in these situations.
DIPHENHYDRAMINE (benadryl); Used to relieve respiratory arrest or difficulty from
upper airway swelling from allergic reaction. EMT II drug currently used, epinephrine,
can only be used in the most severe of situations and can have serious side effects on
older people (+ 35-40 yrs.) and people with cardiac problems. Benedryl is only
contraindicated in newborns and asthma attacks.
DIAZEPAM (valium); Used to stop seizures in epileptic and to sedate conscious patient
prior to cardioversion. No current EMT II drugs to do this; we can't stop seizures and
can't cardiovert patients until they slip into unconsciousness.
BRETYLIUM TOSYLATE; Used to control v-fib and v-tach ( the two really serious and
treatable arrhythmias) that do not respond to lidocaine and defibrillation (current EMT II
practices)
METAPROTERENOL INHALANT; Used to relieve difficulty breathing in the serious
asthmatic and COPD'er (emphysema, bronchitis) when no IV is available. EMT II drug,
epinephrine, can only be used safely in the very serious asthma patient with no history
of heart trouble and not over 30-35 Yrs.
AMINOPHYLLINE; Used to relieve breathing difficulty in the asthmatic and COPD patient
when IV is available; this is the drug of choice to assist patients with breathing
problems from asthma and COPD. EMT II drug, epinephrine not used for COPD and can
only be used safely on the young patient with no heart trouble, and only in the most
serious of situations.
CALCIUM CHLORIDE; Used to encourage a heart that has stopped beating to resume
activity with more power than it would have on it's own. Controversial drug that is
losing favor in many studies. No EMT-II drug that performs the above mentioned actions
in the same way.
ISOPROTERENOL (isuprel); Primarily used to increase heart rate in a heart that is
beating too slow. This will relieve the effects of a low cardiac output. EMT-II drug that
c2i -13
is used in similar situations is atropine.
GLUCOGON; Injectable sugar solution used for intra-muscular injections in the non-alert,
hypoglycemic diabetic that does not have an IV established. Current EMT II drug, D-50,
can only be used through IV and Glucose Syrup can only be given to an alert patient.
ADVANCED LIFE SUPPORT PROCEDURES PROPOSED;
ADULT NASOTRACHEAL INTUBATION; Used to provide the best airway possible to the
unconscious patient with c-spine trauma or massive oral trauma. EMT II procedures use
EGTA (tube in the esophagus to stop vomiting and is not an assured airway to the
lungs) and oraltracheal intubation (contraindicated in c-spine injury)
INFANT AND CHILD ORAL ENDOTRACHEAL INTUBATION; This best possible airway is
not available for infants and children as an EMT II.
CAROTID MASSAGE AND VALSALVA MANEUVERS; These easy maneuvers can stop life
threatening tachyarrythmias by simply massaging the patients neck or asking the patient
to bear down as in a bowel movement. EMT II's can not perform this type maneuver and
can not treat any of the tachyarrythmias except v-tach.
CARDIOVERSION ON THE CONSCIOUS PATIENT; After sedation with diazepam
cardioversion of life threatening tachyarrythmias not responding to other treatment can
be done on the conscious patient. EMT II's must wait until the patient deteriorates to
an unconscious state before providing the maneuver.
NEEDLE THORACOSTOMY (stick a needle into the chest wall); This life saving measure
inflates a collapsed lung within seconds; without the procedure the patient is in great
distress, fear and could die. Not available to EMT II's.
NEEDLE CRICOTHYROTOMY(stick a needle in the throat); Used to restore breathing in
the patient with an upper airway obstruction. No EMT II skill available.
ABILITY TO PERFORM ADDITIONAL SPECIAL SKILLS AS SPECIAL SITUATIONS
WARRANT AND AS SPECIFIC CONDITIONS ARE MET; An example would be certain
antidotes for hazardous materials and poisons.
ATTACHMENT #6
ADVANCED LIFE SUPPORT ANALYSIS
SAN LUIS OBISPO CITY FIRE DEPARTMENT
JANUARY 1987 THROUGH JULY 1987
The following is a statistical compilation of ALS runs in the City of San Luis
Obispo, occurring between January through July of this current year. It is meant to
supplement the report by Medic Tim Hallmark, in which he did an analysis of calls in
which he was personnally involved. These calls are not the experiences of a single medic
but are reflective of calls responded to by the entire medic staff here at the department.
In order to keep the volume of the report at a managable size, just the current year was
used for statistics. Also, to keep the size of the report down, and to keep the amount of
speculation to the minimum, the report covers the same categories of ALS runs used by
Medic Hallmark in the compilation'of his report. Though there is no "hard" evidence that
paramedic procedures would have altered the outcome of these patients, the fact remains
that the potential for further treatment exsists in these cases.
TOTAL NUMBER OF ALS CALLS: 183
TYPES. OF ALS CALL ENCOUNTERED:
CARDIAC ARREST: V-FIB/IDIOVENTRICULAR: 6
ASYSTOLE-6
HEAD INJURIES: I
HYPOTENSION: 7
PREMATURE VENTRICULAR CONTRACTIONS: 11
SIEZURE DISORDERS: 8
SHORTNESS OF BREATH: 16
TOTAL. 65 PATIENTS
THE 65 PATIENTS ABOVE REPRESENT 35% OF THE ALS PATIENTS TREATED BY THE
SLOFD THIS YEAR.
Je ry Jaes, En ineer/Medic
SLOF 003
��
ATTACHMENT #7
Tr -! S COVIRACT entered this 5,11__ day of _ May
1976 , by and bet'::een the CI I OF _ SAN LUIS OBISPO ,
a general law cit, locatea i -, -..he County of San Luis Obispo ,
State of Califor:, ia ( hereinaf�er called "City " ) , and the COUNTY
OF SA-111 LUIS OBIS?O , : ^olitiral subdivision; and one of the
counties of the Stat:: of California ( hereinafter called "County" ) ;
WITNESSETH :
HHEREAS , County has duly adopted an Ambulance Ordinance
as set forth in Chapter 6 . 60 of the County Code , and pursuant to
such Ordinance County has also duly adopted an Emergency Medical
Response ;Manual ( hereinafter called " Ei1RM" ) , and
WHEREAS , in order to have uniform ambulance operation
procedures in the entire County of Sari Luis Obispo , it is neces -
sary that all cities within the County of San Luis Obispo , and
the County , enter into contracts pursuant to Government Code
Sections 51300 through 51303 , inclusive , for the performance
by the appropriate County officers and employees of the cities '
ambulance functions , and
!•11'-iEREAS , Government Code Section 35794 also permits City
to contract for ambulance service to serve the residents of City
as conv.,nience requires , and
! .HEREAS , it is in the interest of the taxpayers and residents
of the County and of such cities , and it is in the public interest
that such contracts be entered into by County and such cities .
i;0!1 , THEREFORE , in consideration of the Tutual covenants ,
conditions , promises and agreements herein set forth , City and
County hereby mutually covenant and agree as follows .
�— #76
1 . a the recital i t `ort! lr:dbU'+'2 are ruc ,
correct. anv r; .
[ . That r)U _ _ rit t rll'('nC CCC1F 2. i Jrl th roU r'n
51303; . ;t _ lusivr.. and t^ Gr_ :r _ , r;' ,i�n : cel Se : tio _ 7 County
Sila11 by ll5 d7pr'Upr'latF U" ri _ %5 nC _rcicy es ;�= r`:)rn 1•ilthln
City ali of City ' s ambulance functions , including ; but not limiter
to , those '^eferred to lr. Go `:- r:7enti •^_ de ct un 3794
3 . That City and Court, h e r-a b;v agree that •_urlrc the term
of this Contract , tiie provisions of the County Aruulance Ordinarce
( namely , Chapter 6 . 50 of the County Code ) and as hereafter amender
and of the E ,iRhi and as hararzfter ar,ended , shall be and are in ful '
force and effect within Cite ; and Chapter 5 . 60 of the County Coda-
and
od:and as hereafter amended , and the E RP' of County and as hereafter
amended , are both hereby exeressly incorporates harein by referen
as though here fully set forth .
4 . The tern of this Contract shall be for five ( 5 ) year
from and after the date set forth hereinabove , and such tern shal
be automatically renewed for additional periods of five ( 5 ) years
each unless the legislative body of either County or City votes
not to renew the term at a meating more than one ( 1 ) year before
the expiration of any five year period and duly notifies the
other party hereto within thirty ( 30 ) days after such vote .
5 . The fol 1ov:ing County officers and emplcyees shall
exercise within City the peters , duties an_ functions hereinafter
specified :
a . The San Luis Obispo County E-;erge cy Madical
Care Cor.mittee shall exercis= within City all of
the powers , duties and functions conferred on such
Ccn.:ittee by such Chapter 6 . 60 ar,_ as hereafter
amended , and by the EIiR •i and as hereafter mended ,
- 2- -oil
L n
o be
j agency
b Tyre CO u[I L
s h a I o e p c)vi e r s , du ti
a 11 d-j f u n L:t I r-,!-, e r- -j b,'- SJ C h
Chapter 6 . 60 ar as 'Ie f d and by the
. h
E MI R i',, acid h C bE. �- x e r c I s e d
ir, County .
c . The County rLral D- 5_ c rj. Center shall exercise
Within City of tha ; ,jwey s , duties , and functicn�
r
conferred cr.
. ,_1: Cert.cr by s u ch pter 6 .60 and
hereafter ameroat , and by the PIR1,; and as hereafter
amended , to be exercised within County .
d . The Board of Supervisor's of Count.,;- shall exercise
within City all of the powers , duties and functions
conferred on such Board by such Chapter 6 . 60 and
as hereafter amended , and by the and as hereat
amended , to be exercised aithin County .
e . The County Cor-m-unicat-Ion Director shall exercise
duties and function;
-.,a rs ,
within Cit; a of the- po�
conferred on such Director by such Chapter 6 .60 anc
as hereafter and by the and as
hereafter ar--2r �ed , to be exercised -:ith-In County .
6 . This Contract may ;rlly be arnended or repealed by the
mutual v.,r-Itten agreement of tath parties hereto .
7 . it is understood a ;--d agreed by County a-IU-' City that
City -shall have no obligat '. r)n or duty pursuant to this Contract
pay any money tc County for any pul—Pose hereunder .
0 . County shall defend : indemnify and save harmless City
and i ,-1 u , 11 , r r) . a g e n t r I, m p I o%,.-.": ') 'i I
j ow ; ric! -�rjainszt an,, and
all chilli .. , demar -J -- I . -� 2 X �e T! : udr-Innt - cause
-
of action and dar,lac;,2s i r c r, v riarlGer + of this Cont
L
or out o"
f!E P C' C "Ma7 jECI h e pro-
visions hereof , -, ncl udl ric not > i tcd Ln anv act or- omission
to act or. the part of Coun %r it_tt
. - agents or employees or in-
dependent contractors direcz' ; res .ocinsible tc County .
9 . Neither Party here ::, shall -assion or transfer this
Contract or any interest h� resin w-1znovt the prior written consent
of the other party , except as -,ay LI—_ otner,.-ji sc, specifically per-
mitted L-%,w such Chapter 6 . 6C and as hereafter amended or by such
EMRM and as hereafter amended .
10 . This Contract shall be binding or the assigns , transfere
and successors of the parties hereto .
11 . No waiver by either party hereto of any failure by the
other party to comply :pith an.. term or condition hereof , shal
be or shall be deerred to be a waiver cy such first party of any
similar or other failure by such other party to comply with any
term or condition herec* .
In witness whereof , City and County have executed this
Contract on the day and Year first hereinabove set forth
City G.
a jv c r of City
ty
Count; of Sari Luis Obispo
Sy : Isl Hans Heilmann
Chairman of the Board of
Supervisors of County
- 4-
'2
AP p r o v c2d as to forr,
by t:i-. City Attorney
t h Ci t:
of
ZI-ci V nttor ey
Approved as to form
ROBERT N . TAIT
District Attorney
By
—Depl tcruty District tney
ORDINANCE' NO. 572 ( 1976 Series)
AN ORDINANCE OF THE CITY OF SAN LUIS OBISPO
TRANSFERRING AND CONSOLIDATING A."•:BULANCE
REGULATORY FUNCTIONS TO THE COUNTY OF SAN
LUIS OBISPO.
BE IT ORDAINED by the Council of the City of San Luis
Obispo as follows :
SECTION 1 . Pursuant to the provisions of City Charter
Section 903, and in accordance with the Joint Powers Agreement
approved on May 5, 1976 , the City hereby transfers and consol-
idates its ambulance regulatory functions to the County of San
Luis Obispo. It is understood that the County will regulate
said functions in accordance with all applicable laws , including
Sar_ Luis Obispo County Code Chapter 6 . 60 , Ambulances , and the
Emergency Medical Response Manual for the County, as they are
now, and as they may hereafter be amended.
SECTION 2. This Ordinance, together with the ayes and
noes , shall be published once in full , at least three days
prior to its final passage, in the Telegram-Tribune, a news-
paper published and circulated in said City, and the same
shall go into effect at the expiration of thirty days after
its said final passage.
INTRODUCED AND PASSED TO PRINT by the Council of the
City of San Luis Obispo at an Adjourned Meeting thereof held
on the 5th day of May, 1976 , on motion of Councilman Gurnee,
seconded by Councilman Petterson and on the following roll call
vote :
6) 2- Series)
k),,-dinancc 'lo . 7 k
AYES Councilmen (-,rahcjm . ;urnee : Petterson and
Mavor Schwart-.
NOES : None
ABSENT: Councilman Norris
Mayor
C�.ty Clerk
q
0
i
RESOLUTION NO. 3048 ( 1976 Series)
A RESOLUTION OF THE COUNCIL OF THE CITY OF
SAN LUIS OBISPO APPROVING A JOINT POWERS
AGREEMENT U:ITH THE COUNTY OF SAN LUIS OBISPO
FOR REGULATION OF AMBULANCE SERVICE.
BE IT RESOLVED by the Council of the City of San Luis
Obispo as follows :
This Council hereby approves a Joint Powers Agreement with
the County of San Luis Obispo Relative to the Regulation of
Ambulance Service and the Licensing Thereof as contained in
Division VIII of the Emergency Medical Response Manual for the
County of San Luis Obispo, dated March 18 , 1976 . The Mayor is
authorized to execute said Joint Powers Agreement on behalf of
the City.
On motion of Councilman Gurnee, seconded by Councilman
Petterson, and on the following roll call vote:
AYES : Councilmen Graham, Gurnee, Petterson and
Mayor Schwartz
NOES : None
ABSENT: Councilman Norris
the foregoing Resolution was passed and adopted this 5th day of
May, 1976 .
M yor
ATTEST:
�ty Clerk
R 3048
f _
FINALLY PASSED this; 17th day of May 1° 76
by the followin.- rcll call vote :
AYES : Councilmen Gurnee, Graham, Norris, Pettersoo
and Mayor Schwartz
NOES : None
ASSENT: None
r ;
\YO? - KENNETH E. SCHWARTZ
ATTEST:
. 'CITY CLERK - J.H. FITZPATRICK
ATTACHMENT #8
FIREMEN'S ASSOCIATION
748 PISMO STREET • SAN LUIS OBISPO. CALIFORNIA 93401
• :� - _ (803) 3436046
i
August 12, 1988
Michael Dolder, Fire Chief
San Luis Obispo Fire Department
748 Pismo Street
San Luis Obispo, CA 93401
Dear Chief Dolder:
After reviewing the Council Agenda Report on Paramedic conversion, the SLO
Firemen's Association vigorously supports the conversion of our EMT-II's to Paramedics.
The Association would like you and your staff to do the same. The Advanced Life
Support System (EMS) since its inception, has been very successful, performing beyond
the original expectations. Since 60% of our responses are medically related, it is one of
our best public services.
Other alternatives presented in the Agenda Report look workable with a close eye
on our firefighting manning levels. We view the alternative EMT-P Program, with an
EMT-1D back-up as a superb EMS system that this department should provide to the
citizens of San Luis Obispo at some future time.
I would like to thank you for the opportunity to review the report and make
comments. We look forward to future opportunities to do the same.
Sincerely, `,
1�"/ " G Z�'
BOB WILKINSON,
President
RJW:p js
p5-(32)
� 8J
ATTACHMENT #9
�IGdII�I�IIIIIIflI�����������IIIII�I�IIIIiIIII I Of SAn MIS OBIS O
cl�rAl
yp
990 Palm Street/Post Office Box 8100 • San Luis Obispo, CA 93403-8100
To: Mike Dolder
From: John Du
Date: November 12, 1987
Subject: Requested Review of Paramedic
Services Feasibility Study
1. What difference would paramedic services make to the survival rate of
persons utilizing the emergency medical providers.
2. Are the benefits different in different parts! of the county, and
between city and rural areas of the county?
S. If an individual local government chooses not to participate in the
upgraded service, what is the consequence to them, to others.
What is the best method to calculate the value of changing to paramedic
service:
a. additional lives saved?
b. cost of saving these lives?
c. who should bear this cost?
If "the interest of the State Legislature is to promote (paramedic)
providers", is the additional cost reimbursable under the provisions of
Senate Bill 90?
Is there any "loss data" on morbidity and mortality rates, in those other
areas where conversion to paramedic services has taken place?
Presumably, the ambulance companies (the private providers) will charge
their customers more for providing paramedic service, (over time, if not
Immediately) .
a. will this additional cost be charged to those requiring a lower
level of service?
b. will some part of the additional fee be provided to the public
agency providers to partially reimburse them for this additional cost?
A major reason for the paramedic proposal is the curtailment of training
opportunities for the EMT-II level; Is this the problem that needs
addressing rather then a change in service level?
Several reasons are listed (pgs. 6, 7 a 12) to consider updating the
skills and scope of practice of the emergency medical services personnel;
not included is a supported statement of public need and benefit; should
one be provided in specific terms. ���
Rdauested :Rev.iew of Paramedi"c Services Feasibility Study.
November 12, 1987 .
Page .Two -Has the contention of the Fire Chiefs Association that. the addition of
defibrillation to the present system coald save as many lives as the
conversion to paramedic services been researched as an• al-ternative?
Overall, the report is not a "feasibi-lity :study_" as such; and appears to
be. more "provider then "benefit driven (more an observation then a
criticism) .
1
1
J
ATTACHMENT #10
August 31, 1988
Michael Dolder, Fire Chief
San Luis Obispo Fire Department
748 Pismo Street
San Luis Obispo, CA 93401
Dear Chief Dolder:
On August 24, 1988 the Citizens Advisory Committee met and reviewed the proposal to
upgrade the Fire Department's Emergency Medical Service level from the current EMT-II level to
the EMT-P (Paramedic) level. The committee was unanimous in its feelings that the conversion
cost of $19,764 was more than justified by the additional service that would be provided by the
higher level of medical care. When considering that the cost to upgrade this program is less than
one percent of the Fire Department's budget and the EMS program makes up 60% of the Fire
Department's calls; then the logic of upgrading seems even more compelling.
Sincerely, /
is
LLI�CM P,YI'ER
Chairman.;
ATTACHMENT 11
San Luis AmbulancE SErvicE, Inc.
P.O. BOX 954 • 3220 SOUTH HIGUERA STREET. SUITE 325 • SAN LUIS OBISPO.CA 93406 80S 543-2626
SERVICE RATE SCHEDULE
APPROVED BY THE COUNTY BOARD OF SUPERVISORS. PURSUANT TO
SECTION 6.60.060 OF THE COUNTY AMBULANCE ORDINANCE.
EFFECTIVE DATE, NOVEMBER 11 1987.
INDIVIDUAL CHARGES SLO DIV. MB DIV. ATAS DIV. PR DIV.
BASE RATE TRANSFER $154.00 $154.00 $154.00 $154.00
BLS BASE RATE 229.00 229 .00 229.00 229.00
ALS BASE RATE 375 .00 375.00 375.00 375.00
( INCLUDES EMERGENCY,
EMT-II , EKG, DEFIB,
M.A.S.T. TROUSER)
PATIENT MILES 7 .90 . 7.90 7.90 7.90
OXYGEN 40.00 40.00 40.00 40.00
NIGHT (7PM - 7AM) 50.00 50.00 50.00 50.00
WAIT TIME ( Z HOUR) 60.00 60.00 60.00 60.00
STAND-BY (PER HOUR) 75.00 75 .00 75.00 75.00
EKG (NON ALS) 65 .00 65 .00 65.00 65 .00
IV MONITORING (NON ALS) 65.00 65 .00 65.00 65.00
NOTE: Frank Kelton, owner of San Luis Ambulance, states.
they are not anticipating any increase in rate
when they up-grade to Paramedic service.