Annual Report

Ex ec u t i v e Su m m a r y

Performance Based EMS:

Patient Focused – Value Demonstrated – Outcome Driven

Prepared By: Clark Regional Emergency Services Agency’s EMS Program

2010

Emergency victims have little opportunity and less in-clination to “comparison shop” for ambulance service.

Persons dialing 9-1-1 have no way to choose from

competing ambulance services and no way to know which firm is closest and ready to respond.

The primary cost of ambulance service is the cost of

providing geographic coverage which is only in-creased when multiple firms duplicate coverage.

Unregulated competition of ambulance service

No prioritization of medical calls

No response time standards

No regulation of rates

No incentive for superior performance

No protection from service deterioration or loss

the performance based ambulance contract: BEFORE

Managed competition of the right to provide

service and external oversight of performance

Medical Priority Dispatch and Accreditation by

the National Academy of Emergency Dispatch

Stringent response time standards

Rates externally established

Earned extensions for superior performance

Protection from service deterioration or loss

a performance based ambulance contract: TODAY

Saving the Brain One of the clinical ad-

vancements implemented in 2010 involves paramedics reducing a patient’s body tem-perature when they have a return of spontane-ous circulation following a cardiac arrest. By lowering a patient’s temperature, the brain de-mands less oxygen and reduces re-perfusion damage, thereby improving neurological out-come.

Accredited Center of

Excellence for the 3rd Time As a result of the ambulance contract require-ments and the ambulance contractor paying for the medical priority dispatch program, Clark Regional Emergency Services Agency has been accredited by the National Academy of Emer-gency Dispatch since 1994. 2010 marks the third time the Academy has recognized CRESA compliance to the Medical Priority Dispatch System and the associated “20 Points of Excellence” which includes train-ing, certification and compliance to protocols.

Prescriptive Response This

past year over 350 medical call types were re-prioritized based on

the severity of the patient in an ef-fort to better determine an efficient use of EMS resources with the goal of “sending the right thing to the right person in the right way at the right time.” Dr. Jeff Clawson, 1991

Optical Laryngoscope This past year optical laryngoscopes were introduced for use on difficult airways by pro-viding a video view of the glottic opening. Compared to conventional direct laryngo-scope, an optical laryngoscope requires mini-mal head and neck positioning which makes it also helpful on patients with suspected neck injuries.

From “A-B-C” to “C-A-B”

Based the new AHA guidelines, the focus is on high quality CPR. This past year the Medical Program Director re-tooled our response on cardiac arrest patients from the Airway-Breathing-Circulation (ABC) sequence to Circulation-Airway-Breathing (CAB) where chest compressions are initi-ated sooner and without interruptions. Research is showing this change in se-quence and focus on compressions is re-sulting in more lives being saved from car-diac arrest.

Request for Service:

Emergency Non-Emergency Total

Responses 30,681 6,294 36,975

Transports 24,365 6,168 30,533

Zone Hot Cold (Emergency) Scheduled Unscheduled

Urban 90.4%/7m59s 91.0%/11m59s 92.0% / 10m 94.1% / 60m

Suburban 90.4%/10m59s 96.2%/17m59s 96.3% / 10m 98.7% / 60m

Rural 92.5%/17m59s 98.9%/29m59s 100% / 15m 100% / 90m

Response Time Performance: All Zones Above 90%

12 Lead EKG Improved diagnostics to reduce time to administration of thrombolytics for

certain heart conditions

Intraosseous Infusion Delivery of fluids and medications when an IV can’t be accessed

Rapid Sequence Intubation Use of a paralytic when an intubation is needed on a patient with a gag re-

flex

CO2 Capnography Enhanced monitoring of blood O2 and CO2

Continuous Positive Air-

way Pressure (CPAP) Supportive oxygenation for respiratory patients

Induced Hypothermia To protect the brain post cardiac resuscitation.

Advanced Clinical Care:

Patient Focused - Value Demonstrated -

Outcome Driven

IV = Intravenous line ET = Endotracheal Intubation IO = Intraosseous infusion RSI = Rapid Sequence Intubation

Patient Focused - Value Demonstrated -

Outcome Driven

2.0%

11.0%12.1%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

National Ave. 2009 2010

Cardiac Arrest Survival

Clinical Performance

EMS Administrative Board Members:

Dan Keteri, SWMC; Mike Plymale, Plymale Inc PS; Jerry Nies,

Nies Community Insurance; Nancy Nellor-Restinas, Nellor Retsi-

nas Attorneys at Law; and Vicki Scheel, Ft. Vancouver Convales-

cent Center

EMS Administrative Board Decisions

involving EMS system business, finance and contract administration need to be made by individuals with expertise in business, finance, law and health care administration. The EMS Administrative Board is composed of citizen volunteers appointed by the County Board of Commissioners. This Board is responsible for: developing and administering the competitive process to award the District’s ambulance con-tract; conducting ongoing ambulance contract administration and oversight; and recommend-ing policy decisions to the EMS District Board (Board of County Commissioners).

Clark County Medical Program Director Begin-

ning the moment the call is received for medical assistance and continuing to the moment the patient comes under the care of

an acute care facility, the combined activity of the con-trol center personnel, first re-sponders and ambulance crews is nothing more nor less than the MPD’s practice of medicine. Lynn Wittwer, MD is the MPD for all EMS pro-viders in Clark County. He is

assisted by Marc Muhr, EMT-P. Dr. Wittwer is appointed by the State Sec-retary of Health and is separately un-der contract with Clark County to pro-vide medical oversight of CRESA’s EMD program and the District’s ambulance contractor’s clinical care and proce-dures. The MPD's authority includes: oversight of EMS training, continuing education and certification; establishing clinical protocols and standards for equipment and supplies; quality assur-ance; and clinical research.

EMS system design and administration is

quite complex and best carried out by

medical and business authorities that of-

fer the necessary expertise.

Leadership

How the Money is Used Unlike most re-

tail services, the cost of providing ambu-lance service is not based on each time pa-tient care is provided. Rather, the main cost involves providing the coverage necessary to meet the response time requirement and level of clinical care. In 2010, it cost ap-proximately $135 per hour to have an am-bulance staffed and ready to respond.

Where the Money Comes From Ambulance service nationwide continues to face funding challenges caused by the changes in how Medicare reim-burses ambulance service1, that Medi-caid pays approximately 18 cents for each dollar billed, and the growing un-der or uninsured (“Private Pay”) due to the economic recession. Despite these challenges the EMS District #2 ambu-lance contract receives $0 subsidy.

How to Lower the Price The am-

bulance contract allows each partici-pating jurisdiction the option to lower the fees charged through subsidy pay-ments (for example, a subsidy of $14.07 per transport would lower the average charge in half). EMS District #2 currently receives no subsidy.

1 The US Government Accountability Office (GAO) reported that Medicare reimbursement was 6% below the aver-age cost of urban ambulance service in 2007.

Fiscal Responsibility

Supporting Local Fire Agencies To enhance our ability to provide timely Advanced Life Support (ALS) response, the District’s ambulance contractor Ameri-can Medical Response (AMR) provides ALS medical supplies to all fire first re-sponse agencies; and partnerships with Fire District #3 and Clark County Fire and Rescue for paramedic staff or ambu-lance service.

Public Access to Defibrillation As part of its proposal, AMR initially deployed 50 Automatic External Defi-brillators (AEDs) to fire and law en-forcement agencies. An additional 20 AEDs were placed on Clark County Sheriff units using funds from late re-sponse time fines.

Public CPR AMR provides CPR courses throughout the

year and focuses on high risk populations.

Child Safety Seat Inspections AMR provides a certified child safety seat

inspector and logistical support at monthly clinics.

Community Partnerships

Decreased Funding Public and private EMS providers continue to face serious funding issues nationwide. There are a variety of causes for this, but the two main reasons involve changes in the Medicare fee schedule that was fully implemented in 2010 and the recent economic recession. As a result, the ability to collect the fees to pay for ambulance service continues to decline.

Work to Reduce Impact In 2010, a Contract Extension Negotiation Taskforce looked at a variety of options in-cluding: 1) increasing ambulance rates; 2) looking at service alternatives; and 3) explor-ing service efficiencies.

The District approved a number of cost reduc-tion measures recommended by this group in-cluding: 1) moving the suburban and rural re-sponse standards back to the times estab-lished in the RFP; 2) reducing the Contract Ad-ministrative Fee; and 3) removing the Clinical Upgrade Reserve. In addition, patient care was maintained, or enhanced by: requiring the monitoring of patient intervention and scene times for critical patients.

Finally the District approved the Contract Ex-tension Negotiation Taskforce recommenda-tion that encourages public-private partner-ships by adding two minutes to the para-medic ambulance response time when para-medic first response is on-scene first within a given standard. This will not only reduce costs for the ambulance contractor but in-turn the cost savings will provide some funding for first response providing this service.

Challenges and Opportunities

Clark Regional Emergency Services Agency 710 West 13th Street Vancouver, WA 98660 Phone 360-737-1911 Fax 360-694-1954

ems.cresa911.org