The City of Sunnyvale currently provides emergency medical services to its citizens through a combination of response by Department of Public Safety (DPS) personnel and the county's paramedic provider, American Medical Response (AMR). This service model began in the seventies and has been in a constant state of evolution ever since. This report reflects the current framework for emergency medical services, and the foundation for future considerations.

Sunnyvale is unique within Santa Clara County. It has the only Department of Public Safety, with Police and Fire Services being combined in one work force for higher effectiveness and cost efficiencies. As the countywide response to emergency medical services evolved, it typically moved to paramedic services within the Fire Services model. Sunnyvale is unique in maintaining a first response skill level of Emergency Medical Technician - Basic (EMT-B) from both Fire and Police Services, with a higher level of paramedic response on the part of AMR. This currently provides good, quality services in the most cost effective manner.

It is recommended that the Council approve the Action Plan as reflected within this report. This plan will allow the City to continue to provide the quality emergency medical services that the community currently enjoys, and form the foundation for any future service enhancements that the City might wish to consider.

To date, the City has enhanced its emergency medical services by focusing on additional skills training and the provision of critical equipment. The skills training for officers evolved from Standard First Aid to Advanced First Aid to EMT-Basic (EMT-B). With each advancement in skills, the ability of the officer to properly determine the medical conditions of the individual and the appropriate response has been enhanced. The addition of Automated External Defibrillators (AEDs) and enhanced first aid equipment provides officers with the tools to address many common emergency situations. The result is both the saving of lives and the reduction in negative post incident effects. The City currently invests tremendous effort in its emergency medical services, primarily through the cost of training, certification and re-certification at the EMT-B skill level, and the provision of equipment such as the AEDs. Most of these efforts have been absorbed within Program 422 Fire Services budget in increments throughout the years.

It is now time to add the necessary infrastructure to support the current service and skill level being provided to the community by the Department of Public Safety (DPS). The proposed Action Plan calls for the approval of oversight, quality improvement and educational services within DPS. Specifically, the recommendation requests:

• the approval of a Lieutenant's position to oversee EMS,

• the expansion of the Medical Director's oversight role,

• the creation of a new civilian position responsible for Quality Improvement,

• the creation of a new civilian position responsible for Public Education efforts

These additional resources are necessary for DPS to continue to provide services with the current skill level of EMT-B, and ensure that such services are provided in accordance with standard practices and procedures. A secondary benefit resulting from these resources will be the capacity to conduct a specific Clinical Emergency Skills Evaluation of necessary services for Sunnyvale. The evaluation would be conducted in cooperation with the department’s medical director and would provide Sunnyvale with specific data and analysis as to the demographic patterns, current and projected emergency response patterns and options for optimum service based on factual findings. Such data is not currently available for Sunnyvale.

Resources for the recommended Action Plan are available through the currently approved Emergency Medical Services (paramedic) Set Aside monies. It is not possible for DPS to absorb any additional costs within its current operating budget. As the new civilian positions are developed, the Council will approve the specific qualifications through Personnel Board action.

The City of Sunnyvale is committed to providing the most appropriate level of Emergency Medical Services (EMS) to its citizens. Since 1977, the Council has received no less than 17 major reports dealing with EMS, reflecting both the ongoing concern for optimum service and the evolutionary nature of EMS delivery systems and techniques.

Sunnyvale Department of Public Safety’s Emergency Medical Response System is the product of a long evolutionary history, starting in earnest in the early seventies. From its approximately 415 calls for service in 1971 to over 7,000 calls for service in 2002, (a 1,587% increase in calls for service) Sunnyvale DPS was and remains the primary provider of Basic Life Support (BLS) First Responder Services in the City of Sunnyvale. On July 1, 1979, Santa Clara County instituted a Countywide Paramedic program. This program was the start of the Advanced Life Support (ALS) Emergency Medical Services (EMS) system that is still in place today. Prior to that date, the system was one divided into many parts, usually by City boundaries. The development of the EMS system within Sunnyvale can be discussed as having occurred, and continuing to evolve in many phases, as summarized by the following table.

Prior to 1986, Public Safety personnel were required by California Title 22 to acquire and maintain Standard First Aid certification. Changes in state regulations in late 1986 required a skills upgrade of acquiring and maintaining an Advanced First Aid certification. The requirements for obtaining and maintaining CPR certification remained in effect. This change in certification level meant a change in training hours from the 8 hours of initial training for Standard First Aid with 5 hours of yearly retraining to Advanced First Aid’s 40 hours of initial training and 8 hours yearly of retraining. Advanced First Aid then became the base line of First Responder EMS Services for Sunnyvale and remained in effect until the mid-1990’s.

With the continuing development of technology and some changes in California’s laws and regulations, the ability to provide early defibrillation to patients experiencing Sudden Cardiac Arrest in the pre-hospital environment by Public Safety personnel became a reality through the use of Semi-Automated External Defibrillators (AEDs). The department recognized the importance of these changes and implemented Phase 3 in the development of its emergency medical services program in 1994. This phase placed AEDs in all of Sunnyvale’s fire apparatus. Now Public Safety personnel trained in Advanced First Aid and CPR also received a state mandated 4-hour class in the use of the AED. This training requirement was for all personnel who were going to use an AED and remains in effect today. Through the use of AEDs in Fire Services and later Police Services lives have been saved.

On February 6, 1997 Sunnyvale DPS began Phase 4 in the development of its EMS system by instituting an Emergency Medical Technician-Basic (EMT-B) training program. Recognizing the increasing complexity of the nature of EMS provision, this additional training was viewed as necessary to the safe and efficient delivery of EMS First Responder Services in Sunnyvale. At that time in the County, Sunnyvale DPS was the only non-EMT First Responder service. This increase in training changed the total number of hours that officers were now in EMS related training. Initial EMT training required 80 hours (Now 136 hours) of classroom and field training. Ongoing training was increased to 12 hours per year. The hours required for the training to be an EMT were reallocated from within the existing Bureau of Fire Field Operations training budget. The increase in education and skill level provided public safety personnel with additional knowledge of different diseases, medical and trauma conditions and the ability to treat these conditions. Being an EMT–B allowed DPS personnel to assist patients in the self-administration of specific medications to alleviate medical conditions, which as an Advanced First Aid provider they could not do. With the addition of EMT-B training, Sunnyvale DPS First Responders equipped with AEDs then met the basic level of training of other responding fire departments in the County.

With AEDs and EMT-B personnel now deployed in the Bureau of Fire Field Operations, DPS took note of improved technologies and research that supported the expansion of First Responder Defibrillation Programs. Increasing advancements in technology and scientific research into the application of AEDs in public settings coupled with the identification of the role of the non-traditional responder led Sunnyvale on October 20, 1998 to implement a Public Access Defibrillation Program, one of the 1^st cities in the nation to do so. This program, Phase 5a in the overall EMS program development, placed AEDs in public places operated by the City. With the recognition that time is critical in the treatment of individuals who suffer a sudden cardiac arrest, Sunnyvale placed AEDs in public places and implemented an aggressive training program. This training program was targeted to the lay-responder, City employees and Sunnyvale businesses and residents alike. The purchase of these defibrillators was accomplished from existing funds in DPS General Services Fund (RTC 98-388). Funding was added to DPS for the replacement of these AEDs. Funding and hours for the DPS Instructors came from within the existing DPS Fire Training Budget.

As the EMT-B program expanded to include officers in both Police and Fire, a study was conducted looking at response times of fire apparatus and police vehicles to calls for service of a medical nature. Identifying that police vehicles responded to calls for service in a shorter time than fire apparatus DPS undertook the implementation of Phase 5b of our EMS program development. This phase called for the placement of AEDs in all police vehicles. With the success of rapid defibrillation programs in police departments in other areas of the United States, DPS identified this service enhancement as a way to positively address the issue of Sudden Cardiac Death. Using existing funds (RTC 99-261) for the purchase of additional AEDs, DPS implemented a Police Defibrillation program, placing AEDs in its entire police fleet. Funding was also added to DPS for the scheduled replacement of these AEDs.

Now DPS was fielding officers trained to the level of EMT–B with additional training in the use of an AED. These officers were deployed in both the Fire and Police Bureau of Field Operations. Continuing to look at its response capabilities, DPS entered Phase 6 of its EMS Program development. In this phase, DPS accessed monies from the Paramedic Services Set Aside fund to retain a consultant to review and recommend options for an increasing skill level service delivery enhancement. The first product of this effort was a report generated by Fitch & Associates, LLC, in May 2001. This report was designed to provide a foundation for further analysis as to enhancement options within the DPS model. The report reviewed six possible models, with six core recommendations that were necessary and prerequisite to any further EMS enhancements. These core recommendations called for:

Following the submission of that report, Council requested additional study and evaluation. This led to the creation of an internal task force for recommendations on improvements to the level of emergency medical training and skills for public safety. This group generated over twenty (20) options for implementation in categories of: Fire based, Police based, Fire/Police combinations, and Civilian based within the Department. The group considered essential factors such as response time enhancements, service level improvements, skills enhancements, ability to fit within the Public Safety model and its impact upon resources, both fiscal and personnel.

During the same time frame, DPS initiated a Light Response Vehicle Study to determine if lighter vehicles in the Bureau of Fire Field Operations could respond to calls for service in a shorter time frame than the traditional fire engines. This study has been completed and a report to council has been prepared and submitted.

One common frustration that the DPS Task Group experienced was the lack of hard, substantiated data. A tremendous amount of data exists relative to EMS service delivery models, but the data tends to be dated, focused on specific geographic models (such as rural delivery needs), and reflect organizations that have separate police and fire services. Research clearly indicates that time is the critical factor in saving lives and quality of life relative to strokes and heart attacks. But what exact level of skill that is required at what response time is subject to debate relative to any given model. It became clear that any recommendation would be based upon assumptions of impact of skill level, not hard evidence. Consequently, many models would appear to be outstanding, but are they necessary to meet the needs of our citizens given the general medical capacity of our community? And would they warrant the cost of multi-million dollar programs?

Several themes emerged as central to the adoption of any specific model, and are reflected in the Task Group's final recommendation, which is reflected in this report's recommendations. These themes include:

To this date the service delivery enhancements have focused on the skills and tools needed to improve the level of care provided to the residents and visitors to Sunnyvale. The proposed Action Plan (Phase 7) now calls for the development of the critical infrastructure needed to oversee, evaluate and improve the delivery of service within the City. With this critical infrastructure in place DPS can embark on Phase 8 of the EMS Service Delivery program by critically evaluating the calls for service, which occur in Sunnyvale. No additional costs are anticipated for the Phase 8 evaluation, as the personnel costs are included in Phase 7. This evaluation will look at call trends, demographic distribution of call patterns, types of illness/injuries seen and the care provided by DPS employees. With this information DPS will be able to provide Council with factual data as to the types of calls occurring within the City of Sunnyvale and the skill sets utilized on those calls.

A person with a critical life threatening call for assistance in Sunnyvale will receive in response a public safety officer from the Bureau of Police Field Operations equipped with an AED and the response of 2 EMT-B personnel from the Bureau of Fire Field Operations. Following shortly behind them will be a Paramedic assigned to a Quick Response Vehicle. This paramedic is contractually required to be on scene within 7:59 minutes 90% of the time. Shortly after that a Paramedic assigned to a transport ambulance will arrive on scene. The transport ambulance is contractually required to be on scene in 11:59 minutes 90% of the time.

Santa Clara County developed a new Emergency Medical Services Agency Master Advanced Life Support Contract in 2001. The County of Santa Clara, AMR, and the individual cities of Santa Clara County (including Sunnyvale) entered into a contractual arrangement for the delivery of EMS services. This agreement is known as the Letter of Agreement Between the City of Sunnyvale and American Medical Response, Inc. with Respect to the Provision of Basic Life Support (BLS) First Response Services within the Corporate Boundaries of the City (See Attachment A - RTC 01-289a). This contract went into effect on October 1, 2001. The contract requires that DPS dispatch EMT-B personnel to all calls for service in which an ambulance is also dispatched, maintain and provide operational and clinical data as required, designate an "EMS Program Manager" to oversee the EMS program and participate in the Clinical Quality Assurance and Improvement Programs.

In an effort to support these new requirements, DPS placed a Lieutenant in the position of EMS Program Manager. The requirements of time and support of this position required a dedicated full time employee. The Lieutenant was placed in this position as a temporary assignment pending the outcome of the recommended Action Plan. As a point of reference, the Cities of San Jose, Mountain View, Santa Clara, Palo Alto, and Santa Clara County Fire Department have each placed a Battalion Chief in the position of EMS Program Manager to conform to the requirements of the contract.

The consultants’ report and the requirements of a modern EMS system also call for the placement of a Clinical Quality Improvement Coordinator and a Public Education Coordinator as well as support staff needed to run a program such as the one in place by DPS. These positions are also required and critical to the success of any future developments in the EMS service delivery by DPS.

It is the focus of DPS to save lives. The recommendations contained within this report are in alignment with this focus. It is the recommendation of the DPS Task Group that Sunnyvale can save additional lives through the adoption of the proposed Action Plan.

The proposed Action Plan has three primary components: a shift in operational focus and accompanying procedures, the completion of EMT-B skills training for all officers, and the implementation of the core recommendations as reflected in the Fitch report, which will address the necessary EMS oversight, quality control and educational measures.

The first element calls for a shift in operational focus and accompanying procedures. Currently, EMS first response services are provided primarily by Fire Services. When medical based calls are received, DPS dispatch will notify the appropriate fire station, which will respond with a fire engine and crew to the call. Dispatch also notifies AMR, who will also respond to the call. The standard for first response (DPS) time is to be on scene within 7:59 minutes 90% of the time, with paramedic services (AMR) on scene within 7:59 minutes 90% of the time. Failure to meet these standards will result in penalties imposed by the County upon either Sunnyvale or AMR. Sunnyvale DPS has met its first response requirement for the duration of our contractual agreement. AMR has met its requirement eleven out of twelve months during the 2002 calendar year. The shift in operational focus would call for police based DPS units to respond to identified Delta and Echo calls (those calls of a critical medical nature).

Time is the critical factor, especially for heart attack victims. Heart attack studies indicate that for each passing minute, there is a 10% impact variance on the victim. If response times are shortened by a minute, the victim will have a 10% increase in either survivability or less severe consequences of the heart attack. Through the use of AEDs (automated external defibrillators) equipment within police cars, it will be possible in some calls to significantly reduce the time from call for help to treatment for heart attack victims. The shift in operational focus will be for dispatch to notify both police and fire-based units for Delta and Echo calls (now totaling approximately 300 per year), and for the performance of police officers to be measured as to their effectiveness and responsiveness. Though this may appear to be a simple shift of procedures, it is in fact, a complex restructuring of priorities, expectations, systems modifications and measurements in order to be fully implemented. In addition, all police officers will need to be appropriately trained and certified.

The second element is the proper training and certification of all DPS officers to the EMT-B level. Unfortunately, DPS does not have a surplus of officers, or EMT Instructors, and in order to meet minimum staffing requirements, EMT-B training and re-certification has not been completed for all officers, particularly those with Police Services. DPS is attempting to ensure that all officers are trained and certified, but the realities of duty pressures limits the effort. DPS currently has 40 officers requiring initial training and certification and 170 officers requiring re-certification over the next two years. It is estimated that this training will be completed by FY 2005/2006, though bi-annual re-certification is ongoing and a constant pressure. All new employees will require the initial EMT-Basic training and then they will be added to the pool of employees requiring annual training and bi-annual recertification. These costs have been absorbed within Program 422 Fire Services.

The third element of the Action Plan is the implementation of the six core recommendations of the Fitch report as noted in the Background section of this report. These recommendations are required in order to address several critical issues, that of oversight, quality improvement (and control) and public education.

As noted above, time is a critical factor in saving lives. Studies indicate that it is often up to fifteen (15) minutes between the first awareness of medical symptoms or conditions and the call being placed to DPS. These are critical minutes that literally can mean life or death for heart attack victims. The only way to effectively impact this critical time is through public education. DPS currently does not have the resources to address the issue. An effective public education program is necessary to improve the quality and health of our citizens.

DPS also needs to improve its documentation of its response to medical calls and the information that is passed from first response to paramedic and hospital staff. New standards are being adopted throughout the State and country, using new technologies and skills, that if the City is found to be not in compliance, it could increase the potential liability of the City. It is the responsibility of the City through DPS to ensure that proper procedures and practices are followed and documented.

DPS is responsible to the community for all emergencies, be they medical, police or fire based. It is essential that resources be directed to medical services oversight to ensure that the Department is fully capable of achieving its mission within the community. At this time, the appropriate level is that of a Lieutenant position committed to the EMS program, with two new civilian positions (quality improvement and public education).

The implementation of the Action Plan will require operational review and modification of police, fire and dispatch policies and procedures. It will also require the training of all DPS officers to the EMT-B level of medical skill. And it will require the implementation of oversight, quality improvement and public education activities. In order to implement these activities and to be in compliance with the agreement with the County, the EMS program must be appropriately staffed with the following:

• a Lieutenant's position to oversee EMS,

• the expansion of the Medical Director's oversight role,

• a new civilian position responsible for Quality Improvement,

• a new civilian position responsible for Public Education efforts

With the full implementation of the Action Plan, the City should experience a measurable improvement in EMS related performance. It is difficult to project the exact improvement until new data becomes available. In the case of heart attack victims, this can mean life or a significant reduction in negative consequences and improvement in quality of life.

An additional benefit of implementing this required infrastructure would be the collection of EMS related data specific to Sunnyvale and the analysis of potential further enhancements for Council and public consideration. With the additional oversight and quality improvement resources, DPS will be able to conduct an intensive review of EMS within Sunnyvale. Working in conjunction with our medical director, the EMS team will conduct a Clinical Emergency Skills Evaluation. This evaluation will assess the impact of Sunnyvale's projected demographics profile (focusing on but not limited to items such as aging patterns, injury patterns, illness types), the current and projected emergency calls, the current and projected response times and the identification of any missing or lacking medical skills at each point of the EMS system. Based upon this specific data, DPS will present both the information and appropriate alternatives for additional service modification, if needed. It is anticipated that this process would include public hearings and educational meetings for both the Council and community.

The EMS Action Plan calls for both an immediate enhancement of medical services through a revision of operational focus and procedures, based upon the appropriate training of all DPS officers and the provision of necessary oversight, quality improvement and public education staff. Based upon this evolution of EMS services within Sunnyvale, then additional modifications may be considered that are specifically tailored to the needs of Sunnyvale citizens.

A total of seven (7) outcome measures for EMS services are currently included in Service Delivery Plan 42201 Emergency Medical Services in Program 422 Fire Services. These same outcome measures are included in next fiscal year's recommended budget. As part of the EMS Action Plan, department staff will work with staff in the Office of the City Manager to review these outcome measures to determine if any revisions are necessary. Any revised outcome measures will be presented to the City Council as part of a recommended restructure for the Fire Services program.

Unfortunately, a decision to not move forward will not mean the continuation of current services and standards. In accordance with the City’s agreement with the County, the City’s EMS program is currently being managed with a temporary appointment and resources from Fire Services. These resources are not within the current Operating Budget, and are contributing to cost overruns for Fire Services. Should the Council decide to not put the necessary infrastructure in place, the current EMT-B skill level cannot be sustained.

• The Lieutenant in this temporary role fulfills the position of EMT Training Program Director and Clinical Coordinator. Without this position the EMT Training Program would no longer be approved preventing DPS from holding EMT Classes.
• The Lieutenant in this temporary role also holds the position of Continuing Education Program Director. Without this position DPS would no longer be a provider agency of continuing education and thus unable to certify training for EMT Basic Personnel.
• The loss of the EMT certification program could return DPS employees to a First Responder certification. This would remove the current ability of DPS EMT-B certified employees to assist a patient in the administration of certain medications, which is allowed under the EMT-Basic Scope of Practice.
• The Lieutenant in this position maintains a State of California Paramedic License in order for the department to maintain its CE and EMT Training program. Without the additional personnel, the ability to rotate another supervisor into this position is not available, which is not keeping within the framework of the Public Safety model.
• To prepare for future growth, the requested new personnel would hold certifications or licensure that would allow for future rotation of the Lieutenant in this position. Currently the Lieutenant in this position is a Paramedic who maintains his license to allow the department to maintain these programs. The loss of this position would place the department in position without those skill sets.
• The Quality Improvement program will identify trends within our City, which involve illness/injury and care rendered. These trends could then be compared to those neighboring agencies to look for conformance to industry norms.
• The addition of the new clinical personnel will work on a surveillance reporting system on illnesses. This will provide an early warning system for a Weapon of Mass Destruction incident. Without these new positions this program would not be able to be undertaken.
• The removal of the Lieutenant in this position removes the AED Program Coordinator from existence, thus removing the regulatory required oversight of the AED program.
• Non-approval of these recommendations would require the department to renegotiate with AMR the First Responder Agreement in which DPS contractually agreed to provide EMT Basic Response Services. Sunnyvale would then be the only City with a non-EMT Basic First Response Service in the County.
• Non-approval of these recommendations would place the department in a position without the resources to prepare for any future upgrades to the EMS service within DPS that are favored by Council and residents of Sunnyvale.
• The additional clinical personnel are needed to assist the department in preparation for Homeland Security in the area of Weapons of Mass Destruction. The additional personnel are needed for the expertise and clinical knowledge that they would bring in dealing with the pharmaceuticals needed for the treatment of the variety of biological and chemical weapons and agents, which could be released.
• The Lieutenant in this position is charged with the oversight of AMR and their response to calls for service within Sunnyvale. Without this position that expertise needed for that level of oversight is not present.

The City Manager’s recommended budget for FY 2003/04 includes sufficient Emergency Medical Services (paramedic) Set Aside funds to support the proposed Action Plan and future costs. The cost estimates for the Lieutenant and Community Services Officers (CSO) are based on FY 2003/04 salary and benefit rates, and are subject to the review and classification by the Personnel Board.

Projected Personnel Costs

EMS Lt. $182,829

CSO - Quality Improvement Position 95,841

CSO - Public Education Position 95,841

Purchased Goods & Services* 11,000

* Purchased Goods & Services estimate includes the cost of expanding the Medical Director’s oversight role, as outlined in the Action Plan.

** The cost estimate includes salary and benefits for each position. However, neither the cost of finding space to accommodate these personnel nor the costs of recruiting, hiring and equipping with uniforms are included here.

Public contact was made through the posting of the Council agenda on the city’s official notice bulletin board, posting of the report on the city’s web page, publication of the Council agenda in the San Jose Mercury News, and the availability of the report in the Library and the City Clerk’s Office.

It is the recommendation of staff that the Council approve the Department of Public Safety's Emergency Medical Services Action Plan as summarized within this report (Alternative 1), including the immediate implementation of new operational procedures, the training of officers, the authorization to develop and hire new EMS related staffing positions, and the use of the Emergency Medical Services Set Aside monies as proposed.

Prepared by:
Steve Drewniany,
Lieutenant

Reviewed by:
Irwin Bakin
Director, Public Safety

Mary Bradley
Director, Finance

Approved by:
Robert S. LaSala
City Manager