Loading...
HomeMy WebLinkAbout6.2 Countywide Paramedic Emergency Svc "Zo CITY OF DUBLIN AGENDA STATEMENT MEETING DATE: May 9 , 1983 SUBJECT Staff Report on Countywide Paramedic Emergency Medical Services Program EXHIBITS ATTACHED Report from County Administrator dated March 25 , 1983 RECOMMENDATION �� None at this time FINANCIAL STATEMENT: None at this time DESCRIPTION The County of Alameda Health Care Services Agency has been working with Cities in the County in the development of a paramedic program as approved by the voters in November 1982 . Staff will be meeting on May 6 , 1983 with City Managers and Fire Chiefs of Livermore , Pleasanton, and DSRSD to discuss the impact of the County ' s report on valley Cities . Staff will make an oral report to the City Council on Monday evening with respect to the outcome of the May 6 , 1983 meeting, and the paramedic program in general . --------------------------------------------------------------------------- COPIES TO: / ITEM NO. 6 • 02.E RECEIVED COUNTY OF ALAMEDA MAR 311983 OFFICE OF THE COUNTY ADMINISTRATOR CITY OF DUBL!M MEMORANDUM March 25, 1983 TO: City Managers Fire Chiefs _ FROM: Mel Hing, County Administr��r,Le. SUBJECT: County Paramedic Program As we discussed, I am forwarding a copy of the final report prepared by the Health Care Services Agency (HCSA) on the County Paramedic Program for your review and comments. The report has been revised based on the guidelines submitted to Ben Mathews by Lee Riordan and Chief Neville on behalf of the City Managers and County Fire Chiefs' Association. I believe the report adequately addresses the concerns raised about the program's impact on fire department operations. The Health Care Services Agency's responses to the concerns raised by the cities are discussed in the report as follows: • Page 13 - The intent of the program is to allow fire department units to leave the scene upon arrival of a paramedic unit; • Page 7 - The standard response time of paramedic units will be within 10 minutes from the time of dispatch; • Page 5 - The County will cover EMT-I firefighter training and recertification exclusive of personnel related costs; • Page 11 - Fire departments will not be requested to assist in patient transports unless medical procedures absolutely require assistance which is not expected in more than 5% of total transports; • Page 13 - Cities operating their own ambulance services will be given the opportunity to equitably participate in the program. However, if you have any additional questions or concerns, please feel free to contact Adele Fasano of my staff at 874-6482 and if necessary, a special meeting to review the report will be arranged. -2- Pursuant to our discussions, County representatives expect to make a presentation of the final HCSA program proposal at the April Mayors' Conference. Subsequently, the report will be forwarded to the Board of Supervisors for approval and each city will be formally requested to consent to the establi.shment of the service area. I want to thank you for your continued cooperation in developing operational guidelines for the County Paramedic Program for which the residents of Alameda County have clearly expressed their support. MH:AF:lb cc: Carl Lester Ben Mathews 2023C ALAMEDA COUNTY HEALTH CARE SERVICES �► AGENCY ��- �� ,p{RiEX.??{]E74HXX�§91)X9XQG&ctor Carl N. Lester , Agency Director AGENCY HEADOUARTERS 499 Fifth Street Oakland, California 94607 (415)874-6828 March 25 , 1983 TO: City Managers Fire Chiefs FROM: Ben H. Mathews , Administrator , Emergency Medical Services SUBJECT: Revisions to the Countywide Paramedic Assessment District Program Plan Budget: 1 . Current program costs are those budgeted for FY 1983/84 2 . Ambulance subsidy increase for paramedic service is reduced to 10 percent. 3 . Budgeted funding for the direct operation of the training program has been deleted. 4 . Firefighter first-responder EMT-I training and equipment cost has been increased approximately $52 ,000 . (See Appendex B) Recommendations from the Cities : Guidelines recommended by the City Managers and Fire Chiefs are discussed and recommendations address these guidelines, including a three-person paramedic unit. County Counsel opinion on State legislation and County authority is appended . (Appendix A) BHM/ms Attachment 236A ALAMEDA COUNTY HEALTH CARE SERVICES AkENCY COMMUNITY HEALTH SERVICES COUNTYWIDE PARAMEDIC EMERGENCY MEDICAL E ]RVICES BENEFIT ASSESSMENT DISTRICT PROGRAM : LAN On November 2 , 1982 , the voters of Alameda County ap? roved Measure C (79%) advising the Board 'of Supervisors to establish a countywide par- amedic emergency medical services program which will provide prehos- pital advanced life support to victims in response t( emergency calls and to be financed by a benefit assessment on real property within the county not to exceed ten dollars annually for each b(: nefit unit in accordance with the schedule of benefit units define(. as a guideline in Board Resolution No.. 194046 . Advisory Measure C was based on a proposal developed by the Health Care Services Agency and reviewed and recommended by the Emergency Medical Care Committee. This preliminary proposal recommended that the emergency ambulance services provided under County contract could be upgraded to include paramedic advanced life support prehospital care, and that the County cost of this EMS program could be financed through a countywide benefit assessment of approxima- ely $6 .70 per benefit unit. The projected costs included the current program costs and the new costs associated with the paramedic prog:. am. This report reviews the current EMS System in AlamedE County, the changes and additions which will be required to prov A e countywide paramedic service, some of the alternatives consider( d, and the Agency 's recommended methodology for implementing a countywide para- medic program. Legal Authority The County Services Act, Government Code Sections 25: 10 et. seq. pro- vides that the Board of Supervisors may create a courty service area for emergency medical services to include advanced 1= fe support para- medic services and finance the service area with a benefit assessment. A city may be included in a county service area by a majority vote of the city council. " California Health and Safety Code Emergency Medical Services and Emer- gency Medical Care Personnel Act (Sections 1797 et. Eeq. ) authorizes the County to establish an integrated emergency medical services pro- gram including ambulance service, paramedics , and baEe hospital ser- vices. This legislation designates the County Health Officer respons- ible for approving ALS programs , ­"including training and certification of personnel, and for assuring that such programs are effectively organized, coordinated, and monitored to assure apprcpriate medical control of the system. (Appendix A) Existing Emergency Medical Services System Prehospital Care in Alameda County Alameda County has a countywide Emergency Medical Services (EMS) Sys- tem which provides coordinated response to medical emergencies in Page 2 accordance with minimum State Laws and Regulations. In September , 1982 , a Pilot Paramedic Service was initiated in sel cted areas of the County in accordance with a plan recommended by the nergency Medical Care Committee and authorized by the Board of Supery sors. The pre- hospital care response components of the County EMS Istem typically consist of the following sequence of events in respo se to a "911" medical emergency request: 1. Emergency request received at any of the si teen "911" public safety answering points (PSAP) in Alameda C snty. 2 . The local public safety jurisdiction initia as a first-in re- sponse unit to the scene to provide medical aid and concur- rently requests the County Central Medical mergency Dispatch (ALCO-CMED) to dispatch an ambulance. (In Dst instances, the first-in unit will be a fire department snit with a re- sponse time capability of four minutes or 1 ss. ) 3 . ALCO-CMED initiates the requested ambulance Erom the appro- priate EMS Zone ambulance provider or the a. :)ulance unit which is providing back-up to the EMS Zone E the Zone Provider 's units are already engaged. The countywide average response time for th emergency ambu- lance is six minutes. ' Ninety-five percent E the requests , receive an ambulance response within ten mi ites or less. 4 . The emergency medical technicians (EMT-IA) taffing the emer- gency ambulance will assume responsibility Dr the patient, assess the patient 's condition, continue me ical aid initia- ted by the first-in responder , and prepare ie patient for transport to the nearest appropriate hospit. L emergency de- partment. The patient will receive only ba. ic first aid until arrival at the hospital if the ambula. --e is staffed by EMT-IA personnel . An average of 13 .4 minutes is spent at the . gene by EMT-IA ambulance personnel with patient assessment first-aid, and preparation for transport. 5 . The patient is transported to the nearest a :)ropriate hos- pital emergency department for definitive m. �ical care. Paramedic Service Upgrading prehospital emergency medical care with Emergency Medical Technician-Paramedic (EMT-P) personnel enables more ( Dmprehensive assessment of. the patient and the initiation-.of definitive care at the scene and during transport to the hospital. This assessment and treatment must be under the direction of base hospitiL emergency phy- sicians and mobile intensive care nurses certified b, the County Health Officer . This service is now being provided i 3 a pilot program in EMS Zones II , IV, V, and VII . (Oakland, Emeryvil: a, Hayward, and the unincorporated area of Eden Township) Page 3 Proposal for Countywide Paramedic Service The program for countywide paramedic service proposed by the Agency would: 1 . Upgrade the existing EMT-I emergency ambulance service to paramedic ambulance service. 2 . Ensure the availability of Advanced Life Support and Basic Life Support Training Programs for prehospital care personnel. 3 . Provide EMT-I training to fire departments to achieve and maintain EMT-I trained firefighter personnel (who provide first-in medical aid response) .. 4 . Expand and upgrade the radio communications system equipment and operations required for the paramedic program. 5 . Provide financial assistance to designated Advanced Life Sup- port Base Hospitals which provide medical direction and par- ticipate in continuing education programs for prehospital care personnel. 6 . Provide staffing to the Agency 's Emergency Medical Services Program to assure effective medical direction, monitoring and coordination of the EMS System. The estimated annual budget for establishing a countywide EMS Benefit Assessment District would include all new program costs resulting from the upgraded service and the existing County EMS program costs, in- cluding ambulance subsidy. The current dry run costs paid by cities would be picked up by the assessment district resulting in a savings to the cities. Countywide EMS - Paramedic Program Costs (revised from previous proposal) BUDGET SUMMARY: FY 83/84 Budget Current EMS Program Cost $1,717 ,950 New Program Costs 1,133 ,450 Total Annual Program Costs (First three years) $2 ,851 ,400 Contingency Fund (10%) 285 ,140 Total Program Budget, First Year $3 ,136 ,540 Total No. of Assessment Units (reported by the Assessor) : 485 , 119 Annual Benefit Assessment: $3 ,136 ,540/485 ,119 = $6 .47 Page 4 BUDGET DETAIL: Item Current Program FY New Program 83/84 New Cost Total Costs (% of Total) (% of Total) (% of Total ) Paramed}c Emergency Ambulance Subsidy $ 877 ,000 $ 87 ,700 $ 964 ,700 (51.0 ) ( 7 .7 ) (30 .8 ) Central Dispatch (CMED) 449 ,100 100 ,000 549 ,100 (26 .1) ( 8 .8 ) (17 . 5 ; EMS Administration: Salaries and Benefits 179 ,370 103 ,250 282 ,620 Services & Supplies 68 ,585 20 ,000 88 ,585 Personnel Testing & Certification 35 ,000 35 ,000 (14 .4 ) (14 .0) (13 .0 ) Communications. - Radio Equipment ($855 ,000 -- 3 year procurement plan) 0 285 ,000 285 ,000 (25 .1) ( 9 .1) Communications Equipment Mainten- ance and Amortized Replacement 25 ,895 100 ,000 125 ,895 ( 1.5 ) ( 8 .8 ) ( 4 .0 ) Firefighter First Responder Training and Equipment 0 227 ,500 227 ,500 (20 .1) ( 7 .3 ) Base Hospit�l .Contracts 5 @ $35 ,000 0 175 ,000 175 ,000 (15 .4 ) ( 5 .6 ) Indirect County Cost 118 ,000 118 ,000 ( 6 .9 ) ( 3 .8 ) TOTALS $1,717 ,950 $1,133 ,450 $2 ,851, 400 Contingency Fund (10% of Total Cost) 285 ,140 One Year Total Program Cost $3 ,136 ,540 1Paramedic emergency ambulance subsidy is estimated as a 10 percent increase over existing subsidy. '' This amount includes the dry run cost currently paid by cities . See discussion on Ambulance Subsidy on page 5 2Currently three base hospitals provide this service at no cost to County. Expanded program responsibilities may justify some subsidy from the benefit assessment. 0 Page 5 ESTIMATE OF ASSESSMENT UNITS (r vised by County Assessor 2/22/83) Non- Residential Residential Jurisdiction Units Units Total Units Alameda 25 ,559 2 ,237 27 ,796 Albany 5 ,998 868 6 ,866 Berkeley 43 ,583 6 ,594 50 ,177 Dublin 4 ,248 752 5 ,000 Emeryville 2 ,339 1 ,200 3 ,539 Fremont 47 ,001 3 ,764 50 ,765 Hayward 34 ,234 5 ,378 39 ,612 Livermore 16 ,449 1 ,530 17 ,979 Newark 10 ,116 967 11,083 Oakland 141 ,110 23 ,546 164 ,656 Piedmont 3 ,889 74 3 ,963 Pleasanton 11,450 1,084 12 ,534 San Leandro 27 ,084 4 ,241 31,325 Union City 12 ,168 1 ,178 13 ,346 Unincorporated 40 ,708 5 ,770 46 ,478 TOTAL 425 ,936 59 ,183 485 ,119 Comments on Proposed Budget: Paramedic Emergency mbulance Subsidy: Emergency Ambulance ubsidy (uncollectiable and dry run costs) for FY 1982/83 is budget d at $874 ,000 . Cities are currently paying the dry run cost which i approximately $250 ,000 . The proposed program will eliminate the c st to cities for dry runs . A 10 percent increase in subsidy is budget d as a new cost. Actual cost will be determined after contracts are warded through a Request for Proposal bidding process . The propos 1 assumes that the major costs for prehospital care and transport w 11 continue to be paid by fees billed to patients and insurance. Fire Service Personn 1 EMT-I Training and Equipment: This is recommended o improve emergency patient care provided by firefighter personne in their role as first-in responder . Although EMT-I training is no required for fire service personnel, at least eight of the 17 fire departments in Alameda County are now requiring EMT-I training . The amount budgeted for EMT-I firefighter training would provide initia EMT-I training (96 hours) for firefighters not currently trained an recertification training required biannually for all firefighters . B dget estimates assume a cost of $300 per student for the 96 hour cour e , if provided to on-duty personnel with a mini- mum class of 12 stud nts. Recertification training cost is estimated at $100 per student. Fire departments would have the option of on- duty training or cla ses scheduled for off-duty personnel where EMT-I incentive pay i.s pro ided. Page 6 Also included is fun, ing to provide essential EMT-I medical equipment on etch fire vehicle ised as a first-in response unit. (Portable suc- tion and blood press; :e equipment, extrication and traction splints, etc. (Budget .detail kppendix B) Base Hospital Subsid- : The iospitals design. =ed as paramedic base hospitals by the County are requ_.red to provide f l-line medical direction of paramedics and to participate in paramedic training and continuing education programs. ThesE hospitals incu, expense not recoverable from hospital fees. The subs. dy is estimated at the cost of one full-time nursing position for as mi ny as five base iospitals. Direct County Costs CommLnications Equip> ant Maintenance and Amortization: Countywide paramedic service wi_ L require an expanded radio telemetry system. The proposed budget . icludes the cost of upgrading this system, sup- plyirg the paramedic: field radios, and providing ongoing maintenance and replacement. Thf Central Medical Emergency Dispatch activity will incrfase with paramedic service due to use of telemetry. To handle this increased activ. =y, one additional post position is needed at the CMED The agency 's respons. A lity for certification of personnel and medical control, monitoring z id coordination of the program would require ad- diti( nal positions wiich are estimated as a new cost. The' provision of a County operated ')aramedic training program is deleted. An amount of $; 5 ,000 is .budgetf3 to cover anticipated costs related to the test- ing znd certification of ALS prehopsital care personnel . In order to ensure that the training needs of the proposed program are satisfied, the agency intends t( explore several possible alternatives to a County operated training program. Cont: ngency Fund A contingency fund is budgeted, as allowable by the laws governing special assessment d: 3tricts . This contingency fund is budgeted at 10 percent of the progrE a budget and could be used for program expendi- ture; only with a 4/1 vote of the Board of Supervisors . If the con- tingency fund and otl2r budget funds are not expended during a fiscal year , such remaining _funds would roll forward into the next year . Shou_9 a surplus occi : in excess of the allowable 10 percent contin- gency , this surplus % )uld be applied to the district budget and could result in a reduced Essessment in the following year . A contingency fund is recommended since the program is new and contractual cost for ambulance, hospital, and training subsidy are not known. PARAPEDIC PROGRAM ST74DARDS AND OPERATIONAL CONSIDERATIONS The proposed paramed: : program is based upon the premise that para- medic service will bE provided by the provider (s) of emergency ambu- lance service in acct -dance with State and County requirements, and that fees for service will be charged which will fund a major portion Page 7 of the cost of the service. Funds generated by the proposed benefit assessment district will cover any subsidies needed to assure avail- ability and quality, and the County costs of system administration, coordination, monitoring , maintaining the radio communications system, first-responder EMT-I training and equipment and other costs associa- ted with the Countywide EMS System. variation in costs associated with geographical and demographic dif- ferences (i .e.. , population density, call volume, and socioeconomic factors) may require a difference in subsidy level and should be spread over the countywide base, since an objective of the assessment district is to provide a uniform level and availability of service. Such variation, however , should be cost effective in comparison to other similar geographical areas of the county. Municipalities opting to provide paramedic emergency ambulance service would be included in the assessment district under the same agreements, standards and oper- ational requirements that are established for private ambulance con- tractors, and at a subsidy level comparable to that established for service areas served by a private contractor . Legal Requirements and Standards for Advanced Life Support Paramedic Programs California Health and Safety Code authorizes the County to approved paramedic programs and designates the County Health Officer respons- ible for certifying paramedic personnel and for establishing and main- taining medical control of paramedic programs . The following stand- ards are applicable to any potential provider of paramedic service and have direct bearing on the cost of providing paramedic service: Training: A prerequisite for paramedic training is EMT-I certification and one year of experience. The County paramedic training program requires a minimum of 850 hours with most students averaging 1,000 hours. Paramedic certification requires a minimun of 80 on-duty hours and par- ticipation in a minimum of eight ALS transports per month. Continuing education is required to maintain certification. (A minimum of 30 hours with at least 16 hours of attendance at base hospital paramedic run reviews and critiques. ) Operational: Response time: The paramedic ambulance shall be able to respond to 95 percent of requests in the service area within ten (10) minutes from the time of dispatch. Page 8 Staffing: Paramedic units shall be staffed with two certified paramedics (EMT-P) . One paramedic takes primary responsibility for patient care, the other paramedic handles radio communication with the base hospital , medical equipment and medications, and assists the patient care paramedic. Transport Capability: Paramedic teams must have the capabili- ty to transport the patient. This is essential for critical trauma. Skills Maintenance: Paramedic personnel require continuous experience to maintain competency with advanced life support skills . Skills maintenance is best achieved by insur- ing that paramedic personnel assign- ments provide regular and frequent patient care. Alameda County Emergency Medical Service Prehospital Baseline Data The following data base is used for the purpose of developing cost comparison estimates for County emergency ambulance .paramedic service. The Alameda County EMS System currently responds to approximately 60 ,000 medical emergency requests each year . In response to these re- quests, an average of 25 emergency ambulance units are available and required to provide the required ten-minute response time. For pur- poses of comparison, 25 paramedic units are used as an optimum number , however , a lesser number may be possible if service areas are estab- lished to provide optimum utilization. Based upon existing methods of receiving and screening medical emer- gency requests, approximately 25 percent of the requests terminate in a dry run, with no patient transport provided. The average number of transports per day per unit based on 25 units would be 4 .8; whereas a unit should be able to effectively handle 8 transports. Operational Considerations Organization, Administration, and Medical Control: Since the inception of prehospital advanced life support in 1968 , par- amedic service has developed in California in two significantly dif- ferent operational modes: (1) the paramedic ambulance unit, and (2 ) the paramedic rescue unit. The paramedic ambulance unit mode may be operated by a private or public ambulance service, or by a public safety department (fire and police) . The paramedic rescue unit mode is operated only by public safety services, most commonly fire departments. Page 9 Both the ambulance and the rescue unit modes represent a specialized service which usually restricts their availability to emergency medi- cal response. " The exception would be those public safety rescue units which may also respond to oth-eemereencies'* handled by their agency. -- Also, both modes typically rely- oTr-the first-in--response unit, because the paramedic unit should serve a greater geographical response area to achieve cost effect -ve utiLiza.tio.n — - —. The paramedic rescue unit mode also requires the concurrent dispatch of an ambulance to provide patient transport t.o the hospital. Hence, in a system using paramedic rescue units usually three seprate units staffed by a total of five to eight personnel will be dispatched to a medical emergency -- the first-in unit, the paramedic rescue unit, and the ambulance. In systems using the paramedic ambulance mode, the first-in unit will be dispatched, but a separate patient transport vehicle is not re- quired. Some significant advantages to the paramedic ambulance trans- port mode are: 1 . The paramedic team has the ability to transport the patient immediately in instances where immediate transport is essential. 2 . The 2stablished method of payment (revenue) for prehospital paramedic service is connected with the patient transport. This represents a significant source of revenue to cover the cost of providing the service. A disadvantage of the paramedic ambulance mode is the prehospital care dependence on one or more first-in responder personnel to accompany the patient during transport to the hospital if the patient 's condi- tion requires more than one attendant (for effective administration of CPR) . A three-member paramedic unit would eliminate this disadvantage. Some advantages of the paramedic rescue unit mode are: 1 . If a patient requires transport but does not require paramedic service , the patient can be released to the EMT-I ambulance personnel for transport to the hospital; thereby rendering the paramedic unit available for response on another emergency. 2 . For a critical patient requiring CPR and ALS treatment, both .paramedic personnel can attend the patient during the trans- port; but they have to be returned to their vehicle or have someone else meet them with their vehicle at the hospital. Some disadvantages of the paramedic rescue unit mode are: 1. There is no means established to bill third party payors for paramedic services rendered separately from the transport charges when provided by another agency. Page 10 2 . In those instances were the paramedics do not attend the pa- tient during transport to the hospital and release the patient to- the ambulance personnel, there is the potential liaibility of abandonment, particularly if an error in patient assessment is made at the scene. Recommendations from the Cities The Alameda County City Managers and Fire Chiefs have reviewed the proposed program and have recommended that the following guidelines be incorporated in the formation of the benefit assessment district: -- The response time for the ambulance shall not be more than ten minutes, i.e. , the present County standard shall not be increased in time. -- Operationally, all Fire Department personnel must be able to depart from the scene upon arrival of the ambulance at the scene. -- Operationally, Fire Department personnel shall not be re- quired to assist during single patient transport, unless the medical procedures absolutely require more than two people (attendants) in the back of the ambulance, which is projected at no more than 5 percent of the total transports. -- The County shall fund the required EMT-I (FS) training and re- certification. The training scheduling shall be at the di- rection of the individual Fire Departments. The County will not be required to fund related personnel costs, e.g. , salary differentials or bonuses. -- For those cities that provide their own ambulance service (Albany, Berkeley, and Piedmont) , it is expected they will have an opportunity to equitably participate to the fullest extent they desire in the new ALS-EMS System. City and Fire Service Recommendations Discussed: The major concern expressed by the cities with implementation of para- medic service is their expectation that when the paramedics provide patient care at the scene, increased assistance will be required from the fire team, increasing the time on the scene and jeopardizing the emergency response capability of fire departments which are operating at minimum staffing levels. The Agency ' s proposed plan for paramedic service recognizes the impor- tance of the fire department first-in response and proposes that EMT-I training become a standard throughout the County for firefighters . Included in the proposed budget is funding for the cost of providing EMT-I training for firefighters and for equipping first-in fire de- partment units with medical equipment needed by firefighter EMT-I personnel. Page 11 The current practice of most fire departments in Alameda County in their first-responder role to medical emergencies is to assess the pa- tient, initiate first-aid and upon arrival of the ambulance, to assist the ambulance personnel in preparing the patient for transport and when CPR is in progress to provide one firefighter to continue CPR during transport. Two persons are required to provide effective CPR during transport. For fire departments operating units at the minimum staffing of three firefighters , this results in the engine or truck company being unavailable for service until their firefighter returns from the hospital. The critical transports requiring the assistance of a firefighter represents no more than five percent (5%) of the total transports. When paramedics initiate advanced life support procedures at the scene, more time on scene will result. In such instances, patient care will be greatly enhanced if the two paramedics have assistance from EMT-I trained first-responder personnel. Based on the pilot par- amedic program experience to date and experience in other counties, paramedic care on scene will be required for no more than 50 percent of the responses , resulting in an average increase in time on the scene of approximately eight (8 ) minutes . With on scene assistance from the first responder fire company, this would result in a similiar increased time on the scene for the fire unit with an approximate average total time on the scene of 29 minutes. The guidelines recommended by the City Managers and Fire Chiefs rela- ted to fire department on scene time and assistance during transports reflect the concern that the continued and increased participation of fire departments in the EMS System threatens the ability of fire de- partments to maintain effective fire protection and rescue capability which may result in increased costs to the cities . Three person staffing of each paramedic unit would satisfy this con- cern and allow for the prompt release of fire first-in responders in almost all cases. Such a unit would be staffed with two certified paramedics (EMT-P) and one driver-assistant with EMT-IA training (EMT-IA would be required to qualify for the ambulance driver 's license) . This staffing would add an additional cost of approximately $59 ,500 per unit per year estimated as follows: 3 .5 EMT-IA positions for 24-hour staffing 3 .5 x $17 ,000 = $59 ,500 If applied to all paramedic units, the added cost for 25 units would be $1,475 ,000 or an additional $3 .00 on the benefit assessment. A three-person paramedic unit would provided the following advantages to prehospital patient care while greatly reducing, but not eliminat- ing the EMS system dependence on fire departments: 1. During transport both paramedics would be available to attend the patient, virtually eliminating the need for fire assist- ance during transport. Page 12 2 . The paramedics would always have a third team member to handle equipment, assist with patient movement and lifting , and to drive the ambulance. As a member of the team, the EMT-IA driver would be familiar with the equipment and how to effectively assist the paramedics. 3 . Ambulance companies could concentrate driver training on the EMT-IA driver personnel. The advantages of a three-person paramedic unit are obvious . The cost effectiveness, however , is difficult to justify. The benefit of the three-person unit would be applicable to approximately 40 - 50 percent of emergency patients who will require advanced life support prehospital care and the approximately 5 percent of the emergency patients requiring two attendants during transport. This added cost, if applied to all emergency transports would represent an additional $35 .00 to the cost of transport. By contrast, this added $1,500 ,000 cost would fund at most 35 firefighter positions which would add an additional person to ten fire companies or fully staff three additional fire companies . Countywide there are 87 fire stations, all of which may provide a first-in response unit to medi- cal emergencies. For comparison, if the first-in fire units respond to all medical emer- gencies and half require an average of 30 minutes on the scene, the per - sonnel cost of this service can be estimated to be $675 ,000 . (60 ,000 re- sponses/2 = 30 ,000 responses . 30 ,000 responses x .5 hours = 15 ,000 hours. Assuming $15/ho-ur per person or $45.00 for a three-person company, 15 ,000 hours x $45 = $675 ,000 . ) The above two costs do not have any practical relationhip. The added cost of a third person to the ambulance would not result in decreased fire department costs, nor would an added expenditure of equal amount to the fire departments result in any significant increase in fire depart- ment staffing . The Agency recognizes the concerns of the City Managers and Fire Chiefs -- that the paramedic program may result in greater demands on fire ser- vice; and in recognition of this concern, concludes that fire departments could not undertake the provision of paramedic service without adding additional positions to provide such service at significantly greater cost than is being proposed by the Agency. (See Fire Service as Provider of Paramedic Service, Appendix C . ) The major issue is the role of fire departments in the EMS System. This is a policy issue which can be determined only by City Councils and the Board of Supervisors . The Agency has surveyed paramedic programs in the Bay Area and found that fire departments provide first-in response, assist paramedic teams on the scene, assist with transport and have rec- ognized that their participation does result in longer on scene times when advanced life support services are initiated at the scene . The fire departments reported that their medical aid service and involvement with Page 13 paramedics im? roved with EMT-I trained personnel. All departments surveyed reported their ability to absorb the increased involvement and consider it t( be an appropriate and valuable public service. The Agency fe- 1s. that this is a resolvable issue which should not prevent the developmeit of a countywide paramedic service but cannot recommend committing to an .additional expenditure of up to $1.5 million to provide three-person . aramedic teams unless it can be demonstrated that such an additional expenditure would be cost effective. The Agency prtposes that operational guidelines and procedures be estab- lished by the County EMS and the Cities which will define the fire de- partment firs -responder responsibilities at the scene upon arrival of the paramedic ambulance. Such guidelines and procedures would provide for : -- the apid and orderly transfer of patient care responsibility to the aramedics -- the mmediate or timely release of the first responder unit, with consideration to any assistance needed by the paramedics -- the vailability of the first responder unit to respond to anot er emergency, according to fire department priority and need -- prov .sion for a firefighter first responder to assist with pa- tien . care during transport only when CPR is required, multiple pati nts are transported, or other critical and life threatening cond .tions exist. (Such assistance would be expected for up to 5 pe cent of total EMS transports. ) It is the Cou :ty 's intent to allow fire department units to leave the scene followi .g the arrival of the paramedic unit. The County is commit- ted to resoly : any problems with the Cities including additional benefit assessment fu :ding to cover any added cost if it becomes necessary. During the phase-in of paramedic service and the implementation of guide- lines and procedures for first-in responders, the Cities and the County should monito - the effect of paramedic service on fire department opera- tions and res )lve any problems which are identified. Cities curren =ly providing fire department operated emergency ambulance service would be provided the option to upgrade the emergency ambulance service from ;MT-I (A) to Paramedic (EMT-P) providing the paramedic ser- vice would meet the State and County requirements and that the cost to the benefit assessment district would be comparable to the district costs for contract :osts for paramedic service with private contractors . Thes Cities would nave the option to request a higher assessment within their respective Ci =ies to cover any additional or higher costs resulting from the fire department operated services. The Agency 's goal, in response to the November , 1982 , vote , is to provide Alameda Counts with a functional and cost effective medically directed prehospital care system with advanced life support paramedic services . Page 14 The benefit assessment district proposed will work only with the par- ticipation of the cities of Alameda County since the majority of EMS demand occurs in the cities and a significant percent of the program costs are for' the services required to support the system. The alter- native to a countywide coordinated and tax supported system with para- medic service, would be the existing basic life support service with the possibility of cities independently funding the high cost of para- medic service. The Agency must emphasize that paramedics do not function independently. Only the County has the legal authority to authorize paramedic service and the County through the County Health Officer has the responsibility to assure that paramedic services are medically directed and in compliance with the State and County standards. Summary and Recommendations: The Agency ' s proposed program would establish a cost effective County- wide paramedic service which would provide advanced life support pre- hospital care within the existing EMS System. The Agency recommends : 1 . That the proposed program be presented to the Board of Supervisors and to the Cities of Alameda County. 2 . That funds generated by the benefit assessment be utilized to provide a uniform level of paramedic service throughout the County, with the necessary support services which are a County responsibility. 3 . That consideration be given to Cities currently providing emergency ambulance service to participate in the assessment district, providing that such ambulance service would deliver the same improved level of prehospital care at no greater cost to the assessment district than would be required if the service would be provided under contract with a private pro- vider , and that such service would meet all medical standards established by the State and the County. 4 . That the County and the Cities establish operational guide- lines and procedures to keep fire department on-scene time to an acceptable level during the phase-in period of paramedic services. If it is demonstrated that either patient care or fire protection are being compromised, benefit assessment funding will be added to correct the deficiencies if necessary. 5 . Upon determination to form the assessment district that all services to be contracted should be selected through a Request for Proposal process , utilizing performance standards and functional service areas. The Emergency Medical Care Committee of Alameda County should develop recommendations on both performance standards and functional service areas. BHM/ms 3/28/83 " APPENOEX A • COUNTY C®�J SEL O p �4sp^N• �i DATE: March 15, 1983 ALAMEDA .COUNTY HCSA EMS ADMIN. TO: Mel Hing, County Administrator E FROM: Richard J. Moore, County Counsel 1983 SUBJECT: County Paramedic Program RECEIVED You have asked two questions concerning the County paramedic program, the first of which was answered in my letter of January 31, 1983. The second question is whether a city has the authority to establish its own para- medic program and to levy special assessments to finance it. Speaking generally, a city has "home rule" powers which enable it to undertake any program the city deems beneficial for its citizens. However, under the preemption doctrine a city may not so act where the state has "occupied the field" in a matter of statewide interest. In order to determine whether preemption applies, it is necessary to review the particular statute. Again speaking generally, if the legislation deals with a subject which may reasonably be considered of statewide importance, or which arguably requires action in a geographical area greater than any particular city, and if the .legislation indicates an intention to preclude city intervention, then preemption exists and a city may not act in the area "occupied" by the state. In this case, the legislation clearly indicates an intention to preclude city action. Moreover, the geographical area of concern is greater than any particular city. The Emergency Medical Services System and the Prehospital Emergency Medical Care Personnel Act- was added in 1980, Health and Safety Code 51797, et seq. Section 1797.1 provides: The Legislature finds and declares that it is the intent of this Act to provide the state with a sta-tewide system for emergency medical services by establishing within the Health and Welfare Agency the Emergency Medical Service Authority, which is responsible for the coordination and integration of all state activities concerning emergency medical services. Section 1797.2 provides: It is the intent of the Legislature to maintain and promote the development of EMT-P paramedic programs where appropriate throughout the state and initiate EMT-II limited advance life-support programs only where geography, population density, and resources would not make the establishment of a paramedic program feasible. ..: - -:--._.: . . -=-rte- :•• - .. - Mel Hing March 15, 1983 Page Two It is thus clear that the state intends to act on a statewide basis on a problem which the Legislature defines as one of statewide interest. This is typical language which the _7 courts have said indicates an intention to occupy the field. Section 1797.94 provides: ."Local EMS Agency" means the agency, department, or office having primary responsibility for administration of'-emergency medical services in a county and which is designated pursuant to Chapter 4 (commencing with Section 1797.200). Thus the state intends to designate the agency which is to implement the state's program. Section 1797.200 provides: Each county may develop an emergency medical services program. Each county developing such a program shall designate a local EMS Agency which shall be the county health department, an agency established and operated by the county, an entity with which the county contracts for the purposes of local emergency medical services administration, or a joint powers agency created for the administration of emergency medical services by agreement between counties or cities and counties pursuant to (joint powers authority) (emphasis added.) Accordingly, the county is the state-designated agency to run this program. It is true that if a city or fire district had, as of June 1, 1980, contracted for or provided prehospital emergency medical services, the county is required to enter into a written agreement with that city or fire district regarding the provision of those services. (Section 1797.201) That section continues by providing, however, that in any case the medical direction and management of an emergency medical services system shall be under the medical control of the medical director of the EMS Agency, discussed in §1797.200 above. It is our conclusion that unless a city or fire district comes within the provisions of §1797.201, the county is the agency primarily responsible for the administration of this program. Assuming that a city comes within this exception which allows the city to maintain the program, you then asked whether a city can levy special assessments to finance the program. Chartered cities have broad home rule powers to fashion new taxes, assessments, and fees for revenue purposes. (Rivera v. City of Fresno (1971) 6 Ca1.3d 132.) General law cities require enabling statutes for those purposes. We are unaware of any statute enabling a city to levy a benefit charge or a fee for an "extended service" against real property, such as for paramedic services, like the one contained in the County Service Area Law. (Gov't. Code 525210.77x). However, a city may finance such a service out of its general fund, and may increase general revenues by the levy of certian non-property taxes, (e.g., a business license tax), without two-thirds voter approval as required by Article XIII A, section 4 of the California Constitution. (City and County of San Francisco v. Farrell (1982) 32 Cal.3d 47.) Cities may also levy "special taxes" earmarked for specific purposes with two-thirds voter approval. (Gov't. Code §50075.) Accordingly, if a city is entitled to participate in the program, it appears likely that the city will have the capacity to finance it. RJM:BZ:bjh " APPENDIX B • FIREFIGHTER FIRST RESPONDER EMT TRAINING 1500 - Firefighter personnel 60 percent require basic EMT training Estimated cost/person $300 . 00 900 x $300 .00 = $270 ,000 40 percent require recertification course 600 x $100 .00 = 60 ,000 Estimated Training Cost first 2 years $330 ,000 Annual Cost $330 ,000/2 = $165 ,000 First responder EMT-I Equipment Cost 125 units @ $500 per unit = 62 ,000 First-Responder Total Annual Cost $227 ,500 APPENDIX C Fire Service as Provider of Paramedic Service: A Cost Comparison with Contract Am u ance Services Since the early development of the Alameda County EMS System, the question of ''whether f-i- partments should provide paramedic ser- vice" is still being .asked- The_. recently instituted pilot paramedic program was undertaken by the contract ambulance providers and base hospitals-. vd-thout add iti.onal-_compensation .f.rom the�ounty with the expectation that the increased costs of providing the- service would be covered by increasing the user fees for service. With the posi- tive vote of Measure C , there are indications that some fire depart- ments may want to be considered as the agency to provide paramedic service in their jurisdiction of service . The Agency 's preliminary report discussed the pros and cons of fire operated paramedic service. and identified some of the costs in com- parison with the projected costs for providing paramedic service with private ambulance contractors . Except for the cities currently operating emergency ambulance service, it would not be financially feasible for fire departments to consider operating paramedic ser- vice without adding additional personnel at substantially increased cost. The proposed benefit assessment could not begin to cover this increased cost, thereby requiring additional expenditures of city dollars. The following illustrates the comparative training and operating costs between private ambulance contractor and fire department para- medic operations : Comparative Paramedic Training Costs: Fire Service Contract Model Ambulance Model Training Cost/Paramedic $ 4 ,000 $ 4 ,000 Salary @ $15 . 00/hour; 1 ,000 hours training time 15 ,000 N/A Total Training Cost/Paramedic $ 19 ,000 $ 4 ,000 Less tuition paid by trainee (not tax dollars) N/A (2 ,000 ) Net tax supported cost $ 19 ,000 $ 2 ,000 Tax cost to train 175 paramedics $3 ,325 ,000 $ 350 ,000 The above illustrates a training cost ratio of 9 .5 :1 for the fire service model vs . the contract ambulance model. Fire service training costs could be reduced to the extent that fire depart- ments , fire personnel , and union agreements would be able to reduce or eliminate compensation for training time. Unlike EMT-I training, paramedic training cannot be provided to on-duty person- nel . Not included in the above comparison is the normal trainee attrition of 20 to 25 percent experienced in training paramedics . (Not all trainees accepted for paramedic training successfully complete the requirements . ) Also not included are any costs associated with EMT-I training which would be required for those fire service personnel lacking EMT-I certification. Parmedic Service Operation Cost Comparison : The following are estimated staffng cost for a fire department operated paramedic service and contract ambulance paramedic pro- gram. These estimates assume that fire department operated programs would .require specialized paramedic positions. Fire Department Contract Ambulance Number of Units 25 25 Number of Paramedic/Unit 7 7 Total Number of Paramedics 175 175 Average annual salary and benefits $48 ,000 $25 ,000 Annual staffing cost, 175 paramedics $8 ,400 ,000 $4 ,375 ,000 Average Staffing cost per transport, 43 ,800 transports/year $192 . 00 $100 .00 The average cost per transport is based on an equal distribution of transports for 25 units. Actual staffing costs per transport would vary according to utilization of individual units . In- creased utilization of individual units would significantly reduce this cost. Training costs and operation costs for equipment, vehicles , fuel maintenance, supplies , insurance , billing, facilities , and manage- ment are not included.