Also serving the communities of De Luz, Rainbow, Camp Pendleton, Pala and Pauma

County moves to improve ambulance response times in backcountry

The San Diego County Board of Supervisors directed the county’s chief administrative officer to conduct a study in April to improve emergency medical services in the unincorporated county’s backcountry. The county supervisors voted 5-0 to accept the study and approve the initiation of the proposed implementation plan, Dec. 5, including emergency medical service boundary adjustments and the authorization of competitive bids to provide paramedic ambulance service in the proposed unified service area.

The county’s backcountry area includes desert and mountainous terrain, winding and narrow roads, driveways and other areas which are not well mapped and occasional weather constraints including extreme heat, fog, snow and ice. Many backcountry communities have relatively few residents but have numerous seasonal and weekend visitors for recreational activities.

“Providing ambulance service for the backcountry can be challenging,” Andy Parr said.

Parr became the county’s emergency medical services administrator after retiring as the fire chief of the Lakeside Fire Protection District.

“This really affects the whole region,” Supervisor Dianne Jacob said. “People from all over the county drive through the Second and the Fifth districts.”

Many of the county’s residents have ambulance service provided by their city, fire district or other agency, but many unincorporated communities are served by ambulance service providers contracted by the county of San Diego. The contractors are selected through a competitive process to provide ambulance service in specific operating areas. The four existing contract areas are the Valley Center Service Area, the Julian Service Area, the Grossmont Healthcare District Zone 2 Rural and Otay Mesa Service Area and the Ocotillo Wells, Anza Borrego State Park and Surrounding Desert Communities Service Area.

In six areas, the De Luz, San Pasqual, Ramona – outside of the Ramona Municipal Water District, which has fire protection and emergency medical service latent powers – Sycamore Canyon, El Capitan and Southern Desert areas, no provider is specifically designated to provide ambulance service and mutual aid agreements are used to service those areas. The four contract areas and the six undesignated areas total more than half of the county’s land.

The county contracts with the Borrego Springs Fire Protection District to provide emergency medical services to the Ocotillo Wells service area; the final one-year option on that contact has been exercised and expires June 30, 2018, and the supervisors’ Dec. 5 action also included an 18-month extension to Dec. 31, 2019.

The other three service area contracts either expire June 30, 2019, or have one-year options which can be extended to that date. The Valley Center Fire Protection District has the contract for the Valley Center Service Area and subcontracts to Mercy Medical Transportation, which also has the contract for the Zone 2 service area, and the Julian-Cuyamaca Fire Protection District has the contract for the Julian Service Area and operates that service with firefighter-paramedics.

The response time standards for calls are 10 minutes for urban areas and 30 minutes for rural areas. If a fire agency paramedic arrives within eight minutes, the ambulance response time standard is 12 minutes. There is no standard other than “best effort response” for the undesignated areas.

An analysis of service delivery in the contract and undesignated areas focused on ensuring the prompt arrival of care, ensuring that no part of San Diego County does not have an assigned advanced life support ground ambulance provider, supporting further integration of emergency service delivery with fire service delivery, supporting more robust performance management and operational efficiency, facilitating more meaningful EMS mutual aid reciprocation where not currently feasible and examining methods by which services are provided including ground, fire department and air ambulance services.

The findings of the analysis included: that population density and distribution is changing in the study area; that the number of 911 responses for emergency medical assistance is increasing in the study area and approximately 11,000 responses are expected during 2018; that a majority of the calls for emergency medical assistance in the study area are related to trauma or to neurological issues as cardiopulmonary resuscitation or other chest pain or respiratory issues account for approximately 19 percent of calls; that more timely medical intervention by EMS personnel can lead to better patient outcomes; that ambulance response time standards vary within the operating area; that services are frequently provided by mutual aid in the study area in which case the provider is not bound to specific response time standards; that technology provides opportunities to monitor the EMS system and improve performance; that the county's Health and Human Services Agency (HHSA) subsidizes EMS service delivery to varying degrees in the study area; that changes to fire service operations have created new opportunities for coordination, and that boundaries for exclusive operating areas require revision to ensure countywide paramedic coverage.

Based upon the findings county Health and Human Services Agency developed a proposed alternate service delivery model to provide better access and quality for EMS services in the study area. A unified service area integrates the four operating areas and six undesignated areas; although operating areas remain in place future procurements for ambulance services will allow providers to propose services for all or part of the unified service area.

The boundaries of the unified service area were adjusted to create Inland North including De Luz and San Pasqual, Inland Central including Ramona, Ocotillo Wells and Southern Desert, and Inland South including Sycamore Canyon and El Capitan areas.

The features of the unified service area concept include updating response time standards to reflect population patterns and integration of EMS and fire services, using new technology to establish updated performance management standards, streamlining the practice for HHSA to subsidize ambulance service and developing a procurement for a unified service area delivery model which aligns existing ambulance service contract dates.

The Dec. 5 action included authorization for the director of the county’s Department of Purchasing and Contracting to issue competitive solicitations for paramedic ambulance service in the unified service area and to award contracts initially from Jan. 1, 2020, to June 30, 2020, with up to five one-year options and up to an additional six-month option period.

In addition to preparing a feasibility study on the recommendations, stakeholder meetings along with 17 community forums were held.

The updated ambulance response time standards are for cases in which no fire department advanced life support services are available. The urban zone response standard remains at 10 minutes, the rural zone standard is reduced from 30 minutes to 16 minutes or 20 minutes for ambulance arrival if a fire agency paramedic arrives within 15 minutes and the “best effort” standard is replaced by response times of 25 minutes for outlying zones or 30 minutes if a paramedic arrives within 23 minutes and 45 minutes for desert zones or 60 minutes if a paramedic arrives within 45 minutes. The eastern part of De Luz has rural zone classification while the western part of De Luz is an outlying zone.

“Today’s recommended actions represent the first step in launching a uniform service model,” county HHSA director Nick Macchione said.

The city of San Diego includes the San Pasqual Valley.

“It is imperative that we send the right resources to emergencies,” San Diego Fire Chief Brian Fennessey said.

Stakeholders hope that the eventual contract addresses some concerns. One of those is the additional resources required by an agency providing mutual aid.

“If you don’t have additional resources to support it, the surrounding jurisdictions end up providing that support,” North County Fire Protection District Fire Chief Steve Abbott said.

If the North County Fire Protection District receives a call for medical service in De Luz the ambulance from Station 1 on Ivy Street is dispatched if it is available. Including the trip to the hospital, a call for service in De Luz places an ambulance out of service for other needs for approximately two hours. Approximately 50 percent of the district’s calls for medical service are in the area which would be served by the Station 1 ambulance if it is available.

“This task must be a collaborative and cooperative effort to ensure that these changes to the system benefit all,” National City Director of Emergency Services, including fire chief, Frank Parra, who represented the San Diego County Fire Chiefs Association, said.

Although input from the affected agencies would be desired, the issuance of a contact creates a conflict of interest situation which precludes the role of agencies in developing the formal proposal.

“To get input into this is really, really important, but to get input into the RFP from a potential bidder, then there’s problems,” Jacob said.

The request for proposal process will include a meeting for potential bidders, which would provide an opportunity for potentially amending the proposal criteria.

“We agreed at the fire chiefs’ request to provide a meaningful mechanism for input,” county chief medical officer Nick Yphantides said.

“There are other ways to make sure that the fire chiefs’ association participates in the process,” Jacob said.

Supervisor Kristin Gaspar expressed a preference for proactive input rather than reactive input.

“I want to make sure that this is a true collaboration that’s taking place and not the county sending material,” she said. “I just think it’s real important to get it right.”

Supervisor Bill Horn has firsthand experience about the need for emergency medical service in the backcountry. In 2006, the driver of a vehicle traveling in the opposition direction lost control and the vehicle went onto Horn’s side of the road. The head-on collision killed one of the occupants. No cellphone coverage existed in the area, so no emergency call was placed until a motorist saw the wreckage and notified the Sunshine Summit Volunteer Fire Department.

Horn, who broke his collarbone in the crash, was transported to a hospital on a Borrego Springs Fire Protection District engine. The survivors in the other vehicle were transported by a Life Flight helicopter.

“It’s a long time to wait around with that kind of injury,” Horn said. “It’s nice to have this kind of preparation made for us.”

Jacob noted that the plan is expected to cut response time in half in many areas.

“That is extremely important,” she said. “This is really forward thinking.”

“This is a big improvement,” Supervisor Greg Cox said.

Abbott doubts that the new arrangement will adversely impact the North County Fire Protection District.

“There’s nothing that’s proposed to change between what we do today and what we would do,” he said.

The changes will not result in additional service for De Luz.

“De Luz is so sparsely populated,” Abbott said. “It’s very unlikely that area will be able to support an ambulance.”

NCFPD will continue to serve De Luz.

“In that particular case the county has no way of reciprocating,” Abbott said.

“It’s an area that we serve only by mutual aid,” Abbott said. “We operate on mutual aid if not a dropped boundary line.”

The average response time for calls in DeLuz is between 20 and 30 minutes.

“That’s why the reciprocity in our district is such a big deal,” Abbott said.

The reciprocity from the Valley Center Fire Protection District and the Deer Springs Fire Protection District may be more likely to assist NCFPD.

“This would allow us to further explore mutual aid on the eastern portion of our district where in theory that same service provider could provide mutual aid to the eastern service area of our district, which is where we're going to see a lot of growth,” Abbott said. “That is a benefit to our jurisdiction to have those ambulances available to provide mutual aid for us when our ambulances are out of the area.”

Author Bio

Joe Naiman, Writer

Joe Naiman has been writing for the Village News since 2001

 

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