TCEMS 2012 Annual Report Final - tuolumnecounty.ca.gov

Tuolumne County Emergency Medical Services Agency

2012 Annual Statistical Report

February 27, 2013 Prepared by: Clarence I. Teem, MS, EMT-P, EMS Coordinator Tuolumne County Emergency Medical Services Agency 20111 Cedar Road North, Sonora California 95370 (209) 533-7460

Tuolumne County EMS Agency 2012 Annual Report Page ii

Tuolumne County EMS Agency 2012 Annual Report Page iii

Table of Contents INTRODUCTION…………………………………………………………………………...…..1 OVERVIEW OF CALL VOLUME ……….…….…………………………….………….….....3 CALLS BY TYPE…. ……….…….…………………………….…………….........................4 LEVEL OF CARE/RESPONSE TIMES………………………………………………………6 PATIENT AND HOSPITAL DATA………………………………………………………...….7

EMS PATIENT DEMOGRAPHICS ………………………………………………………….10 TRAUMA SYSTEM…………………………………………………………………………....11 S-T ELEVATION MYOCARDIAL INFARCTION (STEMI)………………………………...13 ADVANCED LIFE SUPPORT MEDICATIONS…………………………………………….14 INFREQUENTLY USED ALS SKILLS………………………………………………………17 SUMMARY…………………………………………………………………………………......18

Tuolumne County EMS Agency 2012 Annual Report Page 1

INTRODUCTION

The 2012 Annual Statistical Report compiles and condenses an entire year’s worth of data (call volume, response time and patient demographic information) about the Tuolumne County EMS system. The data included in this report is derived from pre-hospital patient care records (PCRs) completed by Tuolumne County Ambulance Service personnel, unless otherwise noted.

Since July 1, 1993, Tuolumne County Ambulance has collected PCR data using the software program EMS DataPro® (formerly the EMS Database System) provided for their use by the Tuolumne County EMS Agency. Once entered in EMS DataPro®, the data is submitted in an electronic format to the Tuolumne County EMS agency where the data is imported into a central version of EMS DataPro®. The EMS agency then validates the data.

In September 2000, Tuolumne County Ambulance, with the assistance of the EMS agency, initiated a program for completing PCRs using EMS Outfielder® (a laptop based PCR data entry program developed by CompuCounsel, now called Inspironix, of Sacramento in conjunction with Manteca District Ambulance). EMS Outfielder® has replaced hand-written PCR forms and billing tickets. EMS Outfielder® provides immediate data availability for daily quality assurance/quality improvement reviews and imports patient billing information directly into the billing system used by Tuolumne County Ambulance.

The Tuolumne County Emergency Medical Services (EMS) System is comprised of four 9-1-1 answering points including Tuolumne County Sheriff’s Dispatch, City of Sonora Police Department Dispatch, CHP Dispatch (located in Merced County) and Mariposa County Sheriff’s Dispatch.

• Ambulance dispatching is provided by the Tuolumne County Sheriff’s Dispatch Center.

• Basic life support (BLS) first response services are provided by Tuolumne County Fire Dept., Tuolumne City Fire Dist., Columbia College Fire Dept., Twain Harte Fire Dist., Columbia Fire Dist., Sonora City Fire Dept., Miwuk-Sugarpine Fire Dist., and the Groveland Fire Dist.

• U.S. Forest Service, Tuolumne County Sheriff’s Search and Rescue, Don Pedro Recreation Agency, Dodge Ridge Ski Patrol provides specialized BLS response services.

• Tuolumne County Ambulance Service provides advanced life support (ALS) service. Mercy Medical Transport from Mariposa County provides the Lake Don Pedro area ALS Ambulance service.

• PHI provides air ambulance services with day-to-day mutual aid from the California Highway Patrol (CHP) Air Operations Division, Air Methods, CALSTAR and R.E.A.C.H. Air Ambulances.

In June 2003, grant funds were made available to the Tuolumne County EMS Agency for the purpose of purchasing and installing EMSystem™ communication software and related computer hardware for the emergency departments of Tuolumne General


Hospital and Sonora Regional Medical Center and the EMS agency office. In early 2004, EMSystem™ linked Tuolumne County’s EMS system with the other ten (10) counties of OES Region IV, enabling Tuolumne General Hospital, as the county’s Disaster Control Facility, to view real-time emergency department availability when determining patient disbursement during a multi-casualty incident (MCI).

In 2004, The Tuolumne County Emergency Medical Services System developed and implemented a Trauma Plan, in conjunction with Memorial Medical Center, Doctors Medical Center of Modesto, Mountain Valley EMS Agency, El Dorado County EMS Agency, Central California EMS Agency, Northern California EMS Agency, Sacramento County EMS Agency, and Santa Barbara County EMS Agency. The Trauma Plan provides a framework that assures that the citizens and visitors of Tuolumne County receive comprehensive prehospital and hospital trauma care. Tuolumne County relies on Trauma Centers throughout Northern California for in-hospital trauma care. Air Ambulances are used as the primary means of transportation for patients meeting Tuolumne County’s major trauma patient criteria.

In July 2007, Tuolumne General Hospital closed leaving only one acute care hospital in Tuolumne County. Sonora Regional Medical Center assumed the duties of the county’s Disaster Control Facility and Mountain Counties South Control Facility.

In 2008, EMSystem was expanded to include data elements for the Department of Health and Human Services HAvBED (Hospital Available Beds for Emergencies and Disasters). This capability allows for accurate and consistent polling of hospital resources nationwide.

In June of 2009, Tuolumne County EMS Agency was instrumental in the development of the Central Regional Trauma Coordinating Committee (CRTCC), a twelve county regional committee. The purpose of the committee is to standardize and improve the provision of trauma care within the region. The CRTCC, working in coordination with four other Regional Trauma Coordinating Committees and the State EMS Authority to build a strong, cohesive statewide trauma system.

In 2010, Tuolumne County EMS implemented an S-T Elevation Myocardial Infarction (STEMI) triage policy. This allows Paramedics in the field to transport, usually by air ambulance, a patient experiencing a serious cardiac event to be transported directly to a hospital capable of Percutaneous Coronary Intervention (PCI). Decreasing the time from the recognition of a STEMI to PCI greatly decreases the injury to the cardiac muscle and increases the survival rate of these patients.

In September of 2011, Tuolumne County adopted the CRTCC Trauma Triage Criteria. This criteria is based on the Centers for Disease Control (CDC) trauma triage guidelines. Studies are underway, at the time of this report, to compare the efficacy of the previous and current Trauma Triage Criteria.

OVERVIEW OF CALL VOLUME As illustrated in the graphs below, 2012 was the busiest year to date; in 2012 there was an 8% increase in calls for EMS services from 2011. Since 2002, there has been a 51% increase in the call volume. Unless otherwise specified EMS requests include both scene and transfer call types.

Call Volumne 2002 - 2012

61405534

51395256484947654645478045674385

6624

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

2012 Call Volumne by Month

483 491580 587 602 583

494

622522616529515

Janu

ary

Febru

ary

March

AprilMay

June

July

August

Septem

ber

October

Novembe

r

Decem

ber



2012 Calls by Station

474

14001499

3251

Station 10 Sonora

Station 11 East Sonora

Station 20 Mono Vista

Station 41Groveland

As illustrated above, Station 10 responded to the majority of all EMS requests.

Legend Response Area 2,274 square miles AMBULANCE STATIONS

Station 11 East Sonora

Station 10 Sonora

Station 41 Groveland

Station 20 Mono Vista


2012 Call Volume by Medic Unit

87

474

1380

16

16071374

1623

63

Not Enter

ed

Medic

10

Medic

11

Medic

12

Medic

13

Medic

14

Medic

20

Medic

41

2012 Call Volume by Population Density

Rural1%

Wilderness4%

SCC1%

Urban21%

Suburban73%

The breakdown of EMS requests by location reveals that the majority (73%) of requests occur in the suburban areas of Tuolumne County, where the majority of Tuolumne County residents live.


2012 Calls by Map Page Chart #1

4 5

20 23

11

2

8

CarsonIceberg -

No. of Stan.River

CarsonIceberg -

So. of Stan.River

CherryValley

Jacksonville Strawberry Don Pedro DodgeRidge


28

46

34323127

24

Chinese Camp

Columbia College

Long Barn Moccasin Smith Station

Emigrant/ YNP

Ponderosa Hills



51 61

103

142

201185226

SCC Cedar Ridge

Pinecrest Miwuk- Sugarpine

CrystalFalls

Columbia Mono Vista


648

1180

2174

231323 335 346

Twain Harte

Jamestown Tuolumne City

Groveland Mono Village

Sonora CDF/CO

Sonora City


2012 Mutual Aid Responses

87

3 3

Mariposa Co Mariposa Co - LakeMcClure/Hwy 132

Mariposa Co - Coulterville Area

Mariposa Co - Greeley Hill Area

A breakdown of requests by day and time of day shows that call volumes may vary widely during the week, with the highest volumes on Fridays and Saturdays.

2012 Call Volume by Day of the Week

941 933 946993

930869

1012

Sunda

y

Monda

y

Tues

day

Wed

nesd

ay

Thur

sday

Frida

y

Saturd

ay


Calls by Type In 2012, scene emergencies accounted for 79% of the total EMS requests for service. Transfers make up the remaining 21% of EMS requests for services. Interfacility Transfers (IFT) have increased by 2% over last year.

2012 Calls by Type

Home/SNF to Hosp

1%

Nurse Trans<1%

Hosp to Landing Site

<1%

Intra Campus Trans<1% Hosp to

home/SNF3%

SCC to Hosp<1%

CCT<1%

Inpatient Trans<1%

Other1%

IF Trans16%

Scene79%

74% of all requests for service resulted in the delivery of advanced life support (ALS) procedures and/or medications administered to the patient.

2012 Calls by Level of Care

BLS26%

ALS74%


Response Times The California Emergency Medical Services Authority (EMSA) has established recommended guidelines for Code 3 response time standards to EMS requests, based on population density. The EMSA recommends that EMS responses meet these response time guidelines at least 90% of the time.

BLS 1st Response

BLS AED 1st Response

ALS Amb

Urban

5 minutes

5 minutes

8 minutes

Suburban

15 minutes

ASAP

20 minutes

Rural

15 minutes

ASAP

20 minutes

Wilderness

ASAP

ASAP

ASAP

Urban = 101 to 500 people per mile2 Suburban = 51 to 100 people per mile2 Rural = 7 to 50 people per mile2 Wilderness = less than 7 people per mile2

SCC = Sierra Conservation Center (secured facilities may be exempted from response time requirements)

Urban Suburban Rural SCC Wilderness Min: 0.00 mins 0.00 mins 1.00 mins 5.00 mins 2.00 minsMax: 65.00 mins 76.00 mins 47.00 mins 30.00 mins 105.00 minsAve: 6.54 mins 10.67 mins 26.92 mins 16.71 mins 31.91 mins90 %ile: 11.00 mins 17.00 mins 38.00 mins 21.00 mins 49.00 mins

Code 3 Response Time by Population Density 2002 - 2012

0

10

20

30

40

50

60

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Min

utes

Urban Suburban Rural SCC Wilderness


PATIENT AND HOSPITAL DATA The chart below shows the patient distribution by receiving facilities, including transfers.

Sutter-Amador Hosp 1 Other Fresno Co. Hosp 3 Kaiser Medical Center Walnut Creek 1 Mercy Hosp, Merced 3 Contra Costa Co. Hosp 1 Mercy General Hosp 3 Clovis Community Hosp 1 Kaiser Hosp, Sacramento 4 Madera Community Hosp 1 Mercy San Juan Hosp 4 Central California Children's Hosp 1 Methodist Hosp of Sacramento 4 Kaiser Hosp, South Sacramento 1 Valley Children's Hosp 6 Sutter General Hosp 1 St Josephs Medical Center 8 Shriner's Hosp Sac 1 Lucile Packard Children's Hosp 8 Other San Francisco Co. Hosp 1 Other Santa Clara Co. Hosp 8 St Joseph's Behavioral Health 1 Kaiser Hosp of Manteca 10 Santa Clara Valley Med Center 1 VA Med Center Palo Alto 15 Other Santa Cruz Co. Hosp 1 San Joaquin General Hosp 18 Stanislaus Behavioral Health 1 U.C.S.F. Med Center 20 Other Alameda Co. Hosp 2 California Pacific Medical Center 23 Mt Diablo Hosp 2 Oakland Children's Hosp 28 Sutter Roseville Medical Center 2 Stanford University Hosp 28 Other Sacramento Co. Hosp 2 U.C. Davis Medical Center 37 Dameron Hosp 2 Modesto Rehab Hosp 115 Sequoia Hosp 2 Other Hosp Not Listed 120 San Jose Medical Center 2 MMC 144 Oak Valley Hosp 2 DMC 510 Mark Twain-St. Josephs 3 SRMC 4128

Call Disposition The table below illustrates that 74%, a 2% increase compared to 2011, of all requests for service resulted in the patient being transported to an emergency department.

Non-Hosp Med Facility

<1%

Hosp (non-ED)5% SNF

4% Rendezvous Point

1%Other Location

<1%Other Amb<1%

AMA9% Dead On

Scene1%No Patient

1%Pt Released

1%Cancelled2%Home

1%Other

1%

ED74%

Poisoning/Overdose category does not differentiate between accidental and intentional ingestion or overdose. Nor does it differentiate between prescription and illicit drugs. Medication reactions and anaphylaxis are included in the Medical category.


2012 Patient Primary Illness/Injury Type

Medical36%

Trauma27%

Neuro13%

Cardiac12%

Environmental<1%

Poisoning2%

Resp9%

Obstetric<1%

Psychiatric1%

As shown in the chart below, for those patients transported to a hospital, approximately 62% of all transports are made to the nearest hospital and 14% of the patients were transported to the hospital of the patient’s or family’s choice.

2012 Patient Destination Decision

Other3%

Triage to spec care

center2%

Triage to Trauma Center

2%

Diversion<1%

Base Order2%

MD Req15%

Pt/Fam Req14%

Nearest Hosp62%


2012 Scene Description

Residence49%

SRMC21%

Roadways10%

Other2%

SCC1%

Co Jail<1%

Outdoors2%

Office3%

Park/Pool<1%

Ind/Man/Ag<1%

Hotel/Motel1%

Bar/Rest1%

Gov Build1%

Lake/River1%

Casino1%

SNFs4%

Clinic/Drs Off4%

2012 EMS Demographics

Patients greater than 64 years of age account for approximately 49% of ambulance patients. Males comprise 47% of ambulance patients and 53% are females.

2012 Patients by Age and Gender

150

488 501

51 62

1329

504519338

6363

1756

292153

0 - 5years

6 - 14years

15 - 21years

22 - 39years

40 - 54years

55 - 64years

> 64years

Male Female


TRAUMA SYSTEM

The chart below shows the mechanism of injury for major trauma victims in Tuolumne County in 2012.

2012 Major Trauma Patients by Mechanism of Injury19

65

1 1 1 1 1 1 1 2 2 2 2 23 4

Gunshot

Smoke/Fumes

Explos

ion

Animal

Riding Accid

ent

Rec/Sport

Snowboarding

Other Mec

h, Pen

etratin

g

Ped/Bike

vs. V

ehicl

e

Bike Acc

ident

Stabbing

Fall < 20 F

eet

Fire/Fl

ames

MVA < 35

MPH

MCA < 35 MPH

Ground Level

Fall

MCA > 35 MPH

MVA > 35

MPH

The Tuolumne County Trauma Plan has defined ten separate trauma triage criteria. The criteria are designed to categorize those trauma patients with an increased risk of mortality and morbidity due to their injuries. Paramedic judgment was the criteria used 62% of the time.

2012 Major Trauma Patient by Triage Criteria

Penetrating Injury

5%

Burns5%

Systolic BP2%

Skull Fx5%

Flail Chest, hemo/pneu

thorax1%

Pelvic Fx10%Mult Long

Bone Fx10%

Paramedic Judgement

62%


2012 Major Trauma Patients by Age & Gender

6 6

7

2

10

8

43 33

2

0 - 5years

6 - 14years

15 - 21years

22 - 39years

40 - 54years

55 - 64years

> 64years

Male Female

Males comprise 74% of all major trauma patients.

Major Trauma Patient by Scene Description

Nat Forest3%

Dodge Ridge2%

Business2%

Hotel/Motel2%

Ind/Man2%

Other6%

City St5%

Highway26%

Residence28%

County Rd24%

The Tuolumne County Trauma Plan has identified three major trauma patient destinations.

1. Doctors Medical Center (adult) 2. Memorial Medical Center (adult) 3. U.C. Davis Medical Center (adult & pediatric)


2012 Major Trauma Patient by Recieving Facility

20

27

41

2

SutterRoseville MC

U.C. Davis MC DMC MMC OtherHospital

S-T Elevation Myocardial Infarction (STEMI)

2012 STEMI Patients by Recieving Hospital

17

5 1

SRMC DMC MMC

In 2012, 23 patients met the STEMI triage criteria; 17 of them were transported to SRMC by ground ambulance, the remainders were transported by air ambulance to Doctors Medical Center and Memorial Medical Center. Males comprised 64% of STEMI patients, 36% female. Average age is 67 years (66 year for males, 70 years for females).


ALS MEDICATIONS The charts below represent the number of times a medication was administered and how many patients received the medication.

2012 Medications by Patients & Times Administered - Chart #1

2 2

1

22 2 2 2

D-25 Furosemide Oxytocin KCL

Patients Times Administered


5 66 6

1413

3 3

Heparin Dopamine Glucagon Epi 1:1,000




17

42

17 181414

24

44

Act Charcoal Lidocaine Adenosine Oral Glucose



48

138

4352

100

143 144

74

Benedryl Naloxone D-50 Epi 1:10,000




81

491585

302219

251 307149

Midazolam Albuterol Aspirin Ondansetron



395 419

822 833

NTG Morphine



ALS INFREQUENTLY USED SKILLS The data on Infrequently Used Skills shows that 76% of the patients that ET intubations were attempt were successfully intubated. Of these patients, half (3 of 6) had a backup advanced airway (EOA, Combitube or King Airway) successfully placed on the first attempt; the remainder were successfully managed with a BLS airway.

2012 Infrequently Used Skills by Attempts

17

3

17

9 2

ET Intubation, Oral King Airway, Combitubeor EOA

IO Access Established

Successful Unsuccessfull

2012 Infrequently Used Skills by Patient

17

3

17

62

ET Intubation, Oral King Airway, Combitubeor EOA

IO Access Established

Successful Unsuccessfull

74%

26%

100%

11%

89%

11%

89%

100%

24%

76%


SUMMARY I would like to thank Tuolumne County Ambulance Service, and Sonora Regional Medical Center for providing the data that made this report possible. I would also like to thank all of the First Response Agencies for the excellent service they provide to the County of Tuolumne. The Tuolumne County EMS System remains a strong asset to the County, its citizens and visitors. The eleven-year trend shows a general increase in calls for EMS service, particularly along the Highway 108 corridor. With the passage of the Patient Protection and Affordable Care Act (ACA) many new questions and challenges face the Tuolumne County EMS System. According to Mike Williams of the Abaris Group, by 2019 there will be 39 million newly insured person in the U.S. (43% Medi-Cal/Medicaid, 57% insurance exchange); however there will be $716 billion in Medicare cuts. Although Mr. Williams does not expect a drastic increase in EMS and Emergency Department (ED) utilization, the shift in the payor mix may adversely impact many EMS systems. Innovative hospital and EMS systems have implemented programs to decrease unnecessary ambulance and hospital utilization and decrease costs. REMSA, Reno NV, has created community health intervention teams to decrease ambulance use and hospital admissions; this program is expected to save over $750,000 in it first three years. Prosser Public Hospital District, Prosser WA, has implemented a Community Paramedic program; anticipated saving for the first three years is $385,383. University EMS (Buffalo, NY), Upper San Juan Health Services District (CO) and MedStar (TX) have all implemented innovative solutions to increase efficiencies and decrease costs. The extension of the Medicare “Super Rural add-on” through 2013 will provide some short term stability; making the “Super Rural add-on” permanent would allow long term stability to our system. The implementation of AB 678 which became California’s Ground Emergency Medical Transport (GEMT) program may also provide additional revenue for our system. The GEMT program would allow ambulance services operated by governmental agencies to submit invoices for reimbursement of costs not covered by Medi-Cal. The changing environment of the upcoming years will afford us many opportunities and challenges to improve the EMS System. The decreasing reimbursement for services rendered and increasing costs will provide many challenges to the County of Tuolumne, maintenance and expansion of the EMS system should be one of the top priorities of the County.

TCEMS 2012 Annual Report Final - tuolumnecounty.ca.gov

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