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HomeMy WebLinkAbout8.3 Emergency Medical Services Increase CITY OF DUBLIN AGENDA STATEMENT 5c)-o - 7V CITY COUNCIL MEETING DATE: July 24 , 1989 SUBJECT Emergency Medical Service Benefit Assessment Increases (Report Prepared by Fire Chief) EXHIBITS ATTACHED 1) County Administrator's Report 2) Alameda County Trauma Report 3) Draft Letter to Board of Supervisors RECOMMENDATION 1) Receive Staff Report Deliberate Authorize Mayor to Sign Letter to Alameda County Board of Supervisors Stating City Council 's Concerns FINANCIAL STATEMENT: If approved by Board of Supervisors, an increase per assessment unit from $6. 54 to $15.58 will occur. This adds up to a City- wide increase from $42 , 209 to $100, 553 per year. DESCRIPTION On August 8, 1989 , the Alameda County Board of Supervisors will consider a proposal from the County Administrator to increase the CSA EM 1983-1 parcel assessment by $9 . 04 in the City of Dublin for 1989-90. CSA EM 1983-1 is a County Service Area, set up for the provision of paramedic and related emergency medical services. The service area was approved after a county-wide advisory election (Measure C) held in 1982 , which received more than a two-thirds vote. The County Service Area (CSA) was then officially created by the Board of Supervisors when they adopted Resolution Number R-83-858 . Measure C, as submitted to the voters, provided that the Emergency Medical Services (EMS) Program "will be financed by a benefit assessment on the real property within the county not to exceed $10. 00 annually for each benefit unit . . . , " and the Board' s Resolution provided that "the dollar value of each benefit unit shall not exceed (10) dollars annually without voter approval. " The proposed $9. 04 increase per benefit assessment in Dublin will bring the total assessment up to $15. 58, well in excess of the $10. 00 limit voted on in 1982 . County Counsel has determined the $10. 00 limit has no legal weight and that the county can, in fact, increase the assessment without a vote of the electorate. An analysis of the increase shows that $1. 04 is necessary for continuation of paramedic services and falls within the $10. 00 limit. The basic assessment has not increased since its inception in 1983 . An additional $8. 00 is proposed for the funding of Trauma Centers. This supplemental assessment causes the total assessment to exceed the $10. 00 voter approved limit. County Counsel has also determined that EM 1983-1 assessments can be used to fund the Trauma Centers. ----------------------------------------------------------------- COPIES TO: ITEM NO. ; �Y Trauma Centers have proven to be a valuable component in the EMS delivery system. Survival rates are much higher for seriously injured patients who are transported to a Trauma Center when compared to those patients who are transported to a regular emergency room. However, Trauma Centers are very expensive to operate due to the personnel and equipment needed for immediate use. Due to this expense, Trauma Centers in Alameda County are experiencing financial difficulties. The use of EM 1983-1 funds is an attempt to alleviate the funding situation. The attached reports from Alameda County go into greater detail on all of the above issues. The proposal for raising the assessment from $6. 54 to $15. 58 seems appropriate if the goal of the assessment is to provide for an integrated EMS Program. The inability to adequately fund Trauma Centers in Alameda County will certainly result in a greater mortality rate for seriously injured people. However, exceeding the $10. 00 voter endorsed limit does cause concern. It appears a commitment was made to the voters not to exceed $10. 00 per assessment unit without first obtaining voter approval . Regardless of County Counsel 's legal opinion, at least a moral commitment was made to the voters not to exceed the $10. 00. Staff would recommend the increase be submitted to the voters for approval. Staff would further recommend the City support this increase if submitted for a vote, and that the Mayor of Dublin be authorized to send a letter to the Board expressing the above concerns. I ` AGENDA une 20, 1989 C O U N T Y A D M I N I S T R A T O R 1 I �).: • 1221 OAK STREET • SUITE 333 • OAKLAND,CALIFORNIA 94612 • 14131 272.6984 June 14, 1989 STEVEN C. SZALAY SUSAN S. MURANISHI ASSISTANT COUNTY ADMINISTRATOR COUNTY ADMINISTRATOR EiVED 1 The Honorable Board of Supervisors C�dJ County of Alameda vj•ly OF DUBLIN 1221 Oak Street Oakland, CA 94612 Dear Board Members: Subject: Trauma System Funding RECOMMENDATION: In order to provide funding for trauma center subsidy, it is recommended that your Board: 1 . Approve in principle an increase in the assessment for CSA EM 1983-1 for 1989/90 of up to $8.00 per benefit assessment unit for trauma system financing, and 2. Direct the Health Care Services Agency to report back to your Board on. July 11 , 1989 with the CSA EM-1983-1 1989-90 assessment program report, and 3. . Direct the Health Care Services Agency to report back to your Board with recommendations for use of the SB 12 EMS Fund for disproportionate emergency and trauma care. SUMMARY/DISCUSSION: On September 27, 1988 your Board authorized the Health Care Services Agency to negotiate modifications to the agreements with Eden Hospital and Children's Hospital and the Memorandum of Understanding with Highland Hospital for Trauma Center Services to include the provision for payment of subsidy based on a demonstrated financial loss to the hospital . Any subsidy would be limited to a fixed dollar amount to be determined in advance by your Board. The HCSA specifically recommended against using County General Funds for trauma subsidy. The Arthur Young Trauma Fiscal Study identified approximately $1 million of trauma specific costs for each of the trauma centers for the first six months of trauma system operation. This fiscal loss identified for Children's Hospital and Highland Hospital for trauma care approximated their respective trauma specific costs. Although Eden Hospital 's trauma specific costs were approximately the same, the analysis did not show a trauma loss for Eden when the hospital ' s fixed costs were excluded from consideration. Honorable Board. M W - 2 - June 14, 1989 County Counsel opinion regarding use of EMS District Funds (CSA EM 1983-1) for trauma system subsidy is summarized' as follows from County Counsel 's letter of May 12, 1989 (Attachment I) : 1 . The Board may allocate funds of CSA EM 1983-1 to pay "trauma specific costs" of designated trauma centers. 2. The paramedic assessment is not'a special tax requiring a two-thirds vote of the voters for its establishment or its increase.. 3. The Board may increase the benefit assessment to more than $10.00 without an election. In consideration of this opinion it is my intention to recommend that the EMS District allocation for trauma subsidy be•augmented with Special District Augmentation Funds in the final distribution of 1988/89 SDAF funds, and that an increase of $8.00 per benefit assessment be added to the FY 1989/90 assessment specifically for trauma subsidy. The EMS assessment for 1989/90 without trauma subsidy is projected at $7.58 per benefit assessment unit. The addition of $8.00 per benefit assessment for trauma, as recommended, would increase the basic benefit assessment to approximately $15.58 per benefit unit which would provide approximately $4 million of new revenue for subsidy of trauma specific costs. To allow for public input, I am also recommending that the Agency provide your Board with a report on the proposed CSA EM 1983-1 assessment program, at your meeting of Tuesday, July 11 , 1989 and that a formal hearing be set for Tuesday August 8, 1989. The Agency is continuing negotiations with the trauma centers to establish a ^ methodology and formula for determining each hospital 's actual trauma loss, it any. The hospitals are collecting more recent fiscal data on trauma for review by the County. The HCSA and the CAO anticipate that the annual trauma losses associated with trauma specific costs for Childrens and Highland Hospitals may exceed $ 4 million. Based on the recommended criteria limiting trauma subsidy to actual demonstrated loss, it is not expected that Eden Hospital would qualify for trauma subsidy; however, Eden would be eligible for a subsidy if 4 loss were demonstrated. The HCSA is negotiating a trauma subsidy using the following limitations previously recommended to your Board: No subsidy will be provided unless the hospital has a true loss, that is, only if the hospital ' s trauma revenue is less than the hospitals combined variable and trauma specific costs. Trauma specific costs will be determined according to standardized criteria and audit. Trauma System subsidy costs will be borne by the entire County EMS District (CSA EM 1983-1) benefit assessment. No County General Funds will be used for trauma system subsidy. Honorable Board Memb — 3 — June 14, 1989 The proposed increase will not affect current or future supplemental assessments. Attachment II provides a breakdown of existing and proposed benefit assessment rates and revenue generated by city and unincorporated areas. The HCSA is recommending that the SB 12 EMS Funds available for disproportionate uncompensated hospital emergency and trauma care (25% of the fund) and the County' s discretionary portion (17% of the fund) be considered for hospitals in addition to the trauma centers which provide a disproportionate amount of uncompensated emergency care. FINANCING: The proposed recommendations would authorize the use of CSA EM 1983-1 benefit assessment funds for designated trauma center trauma specific costs when such costs are determined to be equal to or exceed the hospital 's actual fiscal loss due to trauma care and increase the benefit assessment for CSA EM 1983-1 . in FY 1989/90 by up to $8.00 to an estimated $15.58 per benefit assessment unit to establish a fund of approximately $4 million for trauma specific losses. Very truly yours, STEVE C ZA' COUNTY ADMINIST OR SCS:DK/ms Attachments cc: County Counsel Auditor—Controller Children' s Hospital Eden Hospital Medical Center Highland Hospital City Managers 9004I <,,, ' ATTACHMENT I C O U T Y C O U N S L / FOURTH Fl:ter'. ADMINISTRATION BUILDING. 1221 CA'!.S7rc_. RICHARD J. MOGRE OAKLAND, CALIFORNIA 94612 TELERHONE 272-67CO ccur+TV COUNSEL '4 IF0Fk ay 12, 1989 r . F.cnorable Don Perata Chairman, Board of Supervisors 1221 Oak Street, Rocm 536 Oakland, California 94512 Re: Paramedic ASsessm ant Dear Chairman Perata: Issue: May the Board of Supervisors allocate J. ds. of - - ty Service P.rea No. F:�? 198c-1 to pay "trG<: specific costs Of des:g-latEd tra=z centers? Answer: Yes. c^ y;ide advisory electicr. aperove by In 1982, t,.-2 Voters In a ���•C"- Bate a county service More than a tNo-thirdS Vote, a ptoposal ( aSl.te C) to C= -^. fLT.d par=--= i C eT'-T-=�C'j ical services. !-I area which would provide a:. - : 1983, the Board adcoted Resolution No. R-83-858 fo�_a11y establisn_.z, with Participating Cities (See rover' enc Code Sec=ion the consent of the pa y °, cx _� -=__-_ „CSA„) _ 1 25210.10x) , County Service Area y 1 .,3 (he-- f:.il^cainz tie advisory election. The CSA covers t; tje entire Cc� y except the Cit or Alameda, and levies annual benefit cacr'-e on prcC�_C7 t0 I1P.ar C°_ paramedic P eda are anr. - emergency medical services. (C-over,ment Code section 25210.77x) A county service area may be established l'D ,cop e a "L''-SC°11Zn`OUS extended ser vice” w;,ich is defined as a goverrrne_ntal service which (1) the county. is authorized by lacy to perform and which (2) t;.e CoLInty does r-ot also perform Co the Sane extent on -Count;.elide basis pOL�• within and FiltriOUt cities. (Government Code section 25210.4) • AS t0 the first L°QU1re.T..e:1t for a "m1SC°11a'erUS eYt�^.Gc"3 service," paramedic service is an authorized service to be pe=for-mod by a ccLmty (Fenitn and Safety Code sections 1797.206 and 1797.218) , ar:d ambulance service is specifically mentioned as a miscellaneous extended service. (Coverr� ent Code section 25210.4x) • The term "miscellaneous extended service" 1S CCe:":-2^.ded There is no question that paramedic service qualifies. The resolution of' the second requirement, t ,e extent to c.,lich the county does not perform the service both within and Without cities, is _a question of fact to be decided by a board of supervisors "end 'n considered evaluation of the circL_-istances of any given case, to t;e end t:1at fairness Paramedic Assessment May 12, 1989 Pate 2 may be achieved among taxpayers by the creation of a service area within the perimeters of the factual setting associated with such circumstances." - (C_itY of Santa Barbara v. County of Santa Barbara- (1979) 94 Ca1.App.3d 277, 286) . The Board has already decideF decided tnac its CSA would not work- an inequity among the taxpayers of the County. Rather, the CSA, 'throu2,out the cities and unincorporated area, spreads the service-benefits and cost-burdens equally and fairly for the basic service, and special zones have been established to pay for higher levels of service. The CSA was, therefore, properly created to provide paramedic service. But may it also pay some of the expenses of the tra!-ma centers? Yes. The ballot argument in favor of Measure C advised the voters that an annual benefit charge would be levied to fund "paramedic and related ser- vices." Firemen first responder service and designated trauma centers are ce{nDOnents of an emergency medical syst-'n, and are, therefore, clearly related to paramedic services. (Health and Safety Code section 1797.182; County of m San Dieso v. Suoerior Courc (1986) 176 Ca1.App.3d IC09, 101-5) . It-is true that the docur:ents relating to the advisory election and to the creation or the CSA do not disclose any intent to fuT•d all in-hospital trauma patient care costs. On the of^me= hand, the D':S staff has distinguished "tral..>Tma specific costs" which represent expenditure_ made so that a hospital has the enhanced life saving capacity necessary to meet the standards ' pre- scribed for Level II trauma center designation. (::ealth and Safety Code section 1798.160) . These costs are o two types: 1. Start-up readiness costs: those expenses incurred to bring the facibity and its personnel into cc-.-pliance with the trauma center standards, including training and certifications for various staff and additional staff hired prior to the and period. 2. On-going t`aura costs: ti-lose additional exoen-ditures -made specifi- cally to maintain the hospital's readiness including increased staffing, payments to on-call physicians, and continuing staff education. The availability of a trauma center greatly enhances Lie value of pre-hospital paramedic service in that the .life-saving efforts of the paramedics will be ensured of fulfillment by the traL= center. The Board has discretion to 'L-ake funding choices concerning the objects of expenditure of CSA funds, because it has been statutorily empowered to determine the nature, extent, and cost of the service to be provided at the - expense of CSA funds. (Government Cede section 25210.72a) . The use of CSA funds to pay trauma specific costs would not constitute an abuse of discretion. Para*redic Assessment yay 12, 1989 Paae 3 Issue: Is the paramedic charge a special tax requiring a two-thirds vote or the voters for its establishment or its inr_=ase? _ Answer: No. ' The Board of Supervisors is authorized, pursuant to section 25210.77a of the Government Code, to fu-mose a benefit charge upon real property within the CSA to finance miscellaneous extended services, such as paramedic ser- vice. No provision in the County Service Area Law requires Coat an election first be held in order for the voters to approve such a charge. Fowever, section 4 of Article XIIIA of the California Constitution (Proposition 13) requires prior t:4o-thirds voter a-croval for the ian osition of a special tax. A special tax is a tax collected and earmarked for a special purpose. (City and County of San Francisco v. Farrell (1982) 32 Ca1.3d 47, 53) . Special charges or assessments, on the other hand, are not taxes at all, and are not Subject to the voter approval re'JUire.ment of %rticle XIIIA. (Hec?cendorn v. City or San •12r o (1986) �42 Cal.3d 481, 488; County or ;�; u_ Ca i.:_Dp.�'a 974, 983) . Charges for gover-,imenc—C Fresno v. �'2Lmsttcm (_ i.) - . . . L�DLOV�;:entS Ot S2=Vic°S it-DOSed in a county service area purSL'ant t0 S2:'ti0h 25210.7 ia, if properly levied as_ a special asses✓ =nt on parcels benefited by the provision of such services, a=-, not special taxes. (62 Ops.Cal.Atty.Gen. 831, 830 (1979) . There must be a correction or -, .s" between the purpose or the assessment and the property Oen_e_ited. The cases use such vayLe tom_<5 a5 � "direct � n benefit OL proCOttiOnal" benefit. (SolVai;= i:un. II'i1LrOVem°.^.t Dis=. V. Board of Supervisors (1980) 1122 Cai.ADD_ .3d 54D) . It is more ne_,pLU! to examine exactly what relationships between services and properties have been approved, and why. For exa=le, in J.W. Jones Ccmoanies v. Cit'a of San Diego (1984) 157 Cal.ADD_ .3d 745, 749, 754, the court held-.that a facilities benefit assessment, levied againSt real property after notice and hea_i-c afforded to the property owners and calculated by the apportionment of the test of t:he facilities amc g the parcels within the area of be_:e=it in proportion to esCi ate- benefit, was a special assessment and not a special tax. The public facilities allowed were: watermains, utilities, servers, Streets and s;.-walks, parks, transit and transportation, libraries, fire stations, schcol buildings and police stations. "The list is not exclusive," 157 Cal.App. 3d. at 749. The trial court's determination that this was a special tax was reversed by the Court of Appeal. The court discussed cases previously re=-,r=ed to in this memorand=, as well as Trent Meredith, Inc. v. City of Oxnard (1981) 114 Cal.App.3d 317, which upheld a facilities fee for schools based cn the nL=ber of students to be generated by the development. The court held t::at the city`s determination of benefit was both reasonable and conclusive. Para.TOdic Assessment ,may 12, 1989 Paze 4 The paramedic charge is similarly determined annually by apportioning the costs of the service according to service benefits to the parcels within the CSA after notice and hearing to the property cwners. (cover=.ent Code section 25210.77a) . If anything, a proposal to .ladd tne• costs of. physical facilities, such as a trauma center, makes our case Fore like Jones with its various public buildings than a service program stardinz alone. City of San Diego v. Holodnak (1984) 157 Cal-App.3d 759, 763, decided the same day by the same court, also held that a facilities benefit assessment against real property was not a special tax but a special assessment, because certain facilities financed by the assessment--parrs, library, fire station-- conferred a direct benefit on the property ,.'assessed whose' residents in the vicinity of the improvements would regularly use the facilities while the ccmunity at large would only benefit generally by the availability �of additional facilities. Similarly, the occupants of parcels charged for paramedic service benefit directly frcm paramedic services which are within an eight-minute response time from the parcel, wnile the whole county only benefits generally by the availability of a g--e-ater nurber of paramedic ambulances. It is hard to see any difference between a park, a fire station, a library, and a school, on the one hard, and a tra= center on the other. The Supreme Court has held that, as a g=_neral proposition., the te-i Special tar{ must be strictly Construed and am Ou�t_es resolved SO as to 1-alt the situations to which the two-thirds requirement applies, because of the inherently undemocratic requirement that a special tax trust be approved by a supermajority of the electorate. (Farrell,. supra, ^33 Cal.3d at p. 52) . Moreover, the ceuzis will give very persuasve si`nificarce to the Legi=la- ture's determination that the Cost or paramedic a bL1;c� SerV1Ce, tvillCh 15 a miscellaneous extended service (Gower orient Code sections 25210.4 and 25210.4(x)) , may be apportioned against real property as a benefit assess- ment. (Heckendorn; supra, 42 Cal.3d afi p 488; dills v. . County of Trinity (1980) 168 Ca .App.3d b , 662) . The most recent Supreme Court case dealing with these questicns is Fuss Bldg. Partnership v. City and County of San Francisco (1988) 44 Cal.3d 839, in which San Francisco's transit evelopm:ent tee was approved. Pay-ent of the fee was a condition to receipt of an occupancy perm-i-C The amount of the fee was based upon the square footage of new office space. The court dared the fee to assessment districts, and held that' The funds it generates are earmarked to offset demands created by the affected properties, it benefits those om whcm the fee is collected (by facilitating public transportation- to [heir office projects) , and it is the product of the democratic process, having been adopted by the board of supervisors after public hearing. (44 Cal.3d at 849) Paramedic Assessment ZAay 12, 1989 Pate 5 . The plaintiffs challenged the "directness" of the assessment in relaticn to the benefit received, as well as the alleged excessive i�act. The Court rejected all challenges. The Court said the benefit is the increased transit r service; paramedic services are no core rec',ote. The Supreme Court closed by ordering published' (and hence approving) the prior opinion of the Court of Appeal. That opspecifically p a decidest hate he 1495) upholds the transit developu:ent- fe_, and fee is not an invalid special tax. (199 Ca1.App. 3d at 1504) . Issue: May the Board of Supervisors increase the benefit assessment to more than X10.00 withoup an election? Answer: Yes. To begin with, as previously indicated, no election is required to i:�ose a benefit assessment for paramedic and traL� specific costs, Gover��ent Code section 25210.77a, and no election was required to impose the assessment originally. measure C, as submitted to the voters, provider hat the DDS program "will not be financed by a benefit asses sent on the real property within the the county to exceed X10.00 annually for e. cI- benefit unit . . resolution provided that "the dollar value of each benefit unnit shall not exceed te-n (10) dollars annually without further voter ar) oval. These state-Tents are of no legal effect. The me.=su-e itself provided that it was an "advisory vote only, " and the County Cou^isel's analysis Warned that "under_ State law, the vote on this measure is advisory only, and a 'yes' vote can neither create the service area nor levy any assessment. Rather, it will only indicate to the Board that the voters favor the implementation of a paramedic program. Similarly, a 'no' vote does not of itself defeat any such program." The County Counsel concluded by stating that both "yes" and "no" votes were "advisory" only. Such advisory votes are expressly made not birYdirr on the local goverr, uunt. Elections Code section 5353 provides that each county may hold, at its discretion, an advisory election for the purpose of allowing voters to voice their opinion on substantive issues or to.Znaicate to the local legislative body approval or disapproval of the ballot proposal. Such advisory votes are to be indicated as "advisory vote only." Section 5353 continues by providing that As used in this section, 'advisory vote' means an indication of general voter opinion regarding the ballot proposal. The results of the advisory vote will in no manner be controlling on the sponsoring legislative body. Paramedic Assessment Hay 12, 1989 Pn 6' Such e is.self-er lanato and is the law. „uch language Explanatory, _ It is true that in certain bond election cases, the courts- have' stated that after a successful election there is swieth-Ing; analogous to a contract between the electors and the public body, pursuant to which the provision of the ballot proposal may not be altered. (Coun't j of San Diego V. Perrigo (1957) 155 Cal.App.2d 644, E.B.M.U.D. v.- Sin elar Cal-App. 910) . However, that legal principle is applicable on-ly when sorre constitutional provision required voter aporoval of the measLZ e in the first place. then there is no constitutional requirem-ent for an election, there are no vested rights in the electorate and the public body is free to act without regard to limitations approved in the ballot proposal. to(Eastern Municipal Water District V. Scott (1969) 1 Cal.App.3d 129, City of Santa Clara v. Von Raesfeld Ca . 39) . In the present case, where tnere is neither a conscitu ticnal nor a statutory election requirement to the i=osition of the benefit assessment, the Board of Supervisors may increase the benefit assessment without regard to the $10.00 limitation set forth in Measure C. ' The p_ece- d�res to be followed are set forth in Governcent Code section 25210.77a and Ordinance Code sections 5-700.0, and following. We apologize for the length of this opinion but it is the only way we , could respond to your request fora „thorough legal analysis." Very t_uly yours, RSC. RD J./y) RE, County Counsel 915J:RJL/BZ/1 b 9 �( /P cc: Each�uard Memher County Administrator Director, Health Care Services Agency _ ATTACHMENT II HEALTH CARE SERVICES AGENCY EMERGENCY MEDICAL SERVICE DISTRICT Current and Proposed Benefit Assessments and Revenue by Cities and Unicorporated Areas Base Assessment . Supplemental as Applicable Benefit Current FY Proposed FY 89/90 Current Proposed Proposed Assessment Base Total Base Plus $8.00 Total FY 88/89 FY 89/90 Total Area Units Rate Amount No Trauma for Trauma Amount er . 5_Upplemental* $ Amount Albany 7,035 $6.54 $ 46,009 $7.58 $15.58 $ 109,605 $2.78 $ 4.02 (1 ) $ 137,886 Berkeley 50,723 $6.54 331 ,728 $7.58 $15.58 $ 790,264 $2.78 $18.24 (2) $1 ,715,452 Dublin 6,454 $6.54 42,209 $7.58 $15.58 $ 100,553 n/a n/a $ 100 Emeryville 4,482 $6.54 29,312 $7.58 $15.58 $ 69,830 n/a n/a $ 69,830 Fremont 62,136 $6.54 406,370 $7.58 $15.58 $ 968,079 $3.46 $ 3.46(3) $1 ,183,070 Hayward 42,398 $6.54 277,283 $7.58 $15.58 $ 660,561 $2.78 $ 4.02** $ 831 ,001 Livermore 20,332 $6.54 132,•971 $7.58 $15.58 $ 316,773 n/a n/a $ 316,773 Newark 12,723 $6.54 83,208 $7.58 $15.58 $ 198,224 $2.78 $ 4.02** $ 249,371 Oakland 168,127 $6.54 1 ,009,551 $7.58 $15.58 $2,619,419 $2.78 n/a(4) $2,619,418 Piedmont 3,914 $6.54 25,598 $7.58 $15.58 $ 60,980 $2.78 $ 4.02** $ 76,714 Pleasanton 16,376 $6.54 107,099 $7.58 $15.58 $ 255,138 n/a n/a $ 255,138 San Leandro 32,161 $6.54 210,333 $7.58 $15.58 $ 501 ,068 $2.78 $ 4.02** $ 630,356 Union City 15,708 $6.54 102,730 $7.58 $15.58 $ 244,731 2.78 $ 4.02** $ 307,877 C.V. FD 17,646 $6.54 115,405 $7.58 $15.58 $ 274,925 $2.78 $ 4:02** $ 345, Eden FD 23,499 $6.54 153,683 $7.58 $15.58 $ 366,114 $2.78 $ 4.02** $ 460,580 Fair. FD 3,078 $6.54 20,130 $7.58 $15.58 $ 47,955 $2.78 $ 4.02** $ 60,329 Othr Uninc. 3,249 $6.54 21 ,248 $7.58 $15.58 $ 50,619 n/a n/a $ 50,619 Total 490,041 $3,204,868 $7,634,838 $9,410,828 NOTES * Supplemental calculated on 3rd person cost unless otherwise noted. ** Third person including increase occuring in FY 1988/89 not budgeted. (1 ) Albany may request a change in their supplemental assessment. (2) Berkeley City Council approved request to increase 6/13/89 (3) Maintains existing supplemental for Fremont. (4) Oakland may propose supplemental assessment for Fire Department Emergency Medical Dispatch R111,1/nF/1n /n00479;7 I� l..i EMERGENCY MEDICAL SERVICE DISTRICT I� ' C L: r l_ J n Alameda Couty Health Care Services Agency 1 1•• ALAMEDA COUNTY HEALTH CARE SERVICES �� 4! 1►= AGENCY DAVID J. KEARS,Agency Director �44 EPAERGENCY MEDICAL SERVICE DISTRICT 55 Santa Clara Avenue,Suite 2G0 June 6, 1989 Oakland,California 94610 (415)874-6828 FAX(415)763-2323 TO: Emergency Medical Oversight Committee Emergency Medical Care Committee D Trauma Audit Committee Trauma Directors ����� Trauma Coordinators Base Hospitals Receiving Hospitals California EMS Authority Bay Area Regional EMS Council Paramedic Provider Services Fire Chiefs Police Chiefs Requesting Individuals FROM: Ben H. Mathews, Director, Emergency Medical Services District SUBJECT: Alameda County Trauma Report On behalf of Alameda County' s Trauma Centers and the Health Care Services Agency Emergency Medical Services District, I am pleased to provide you a copy of the Alameda County Trauma Report for 1987 and 1988. The achievements and successes reported represent the concerted and coordinated efforts of all the participants in the County' s EMS System. During the presentation of this report to the Board of Supervisors today, three trauma patients gave public testimony of their successful outcomes and their support of the system. Should you have any questions regarding this report or the Trauma System please contact Gretchen Parker, Trauma Program Coordinator in this office. BHM/ms Attachment 2415z r- f �. ALAMEDA COUNTY TRAUMA REPORT 1987 — 1988 i Prepared by Alameda County Health Services Agency Emergency Medical Services District May 1 , ,1989 i i Data Source: All information contained in this report was obtained from the Bay Area Trauma Registry, Base Hospital Trauma Logs, Trauma Audit Committee Minutes , and reports generated by the Alameda County Emergency Medical Services District-. f— ALAMEDA COU14TY TRAUMA REPORT i 1987 — 1988 TABLE OF CONTENTS SUBJECT PAGE EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . 1 Background . . . . . . . . . . . . . . . . . . . . . . . . 3 SYSTEM OVERVIEW 4 Methods of Identifying Patients . . . . . . . . . . . . . 4 Patients taken to Trauma Centers . . . . . . . . . . . . . 4 Table I Destination Of System Trauma Patients (1987 — 1988) 5 Patient Demographics . . . . . . . . . . . . . . . . . . . 6 Table II Age Comparison Of Trauma Victims (All Trauma Centers) 6 Blunt versus Penetrating Trauma . . . . . . . . . . . . . 7 Table III Blunt vs. Penetrating Trauma (All 'Trauma Centers) 8 Scene Times . . . . . . . . . . . . . . . . . . . . . 9 Mode of Arrival . . . . . . . . . . . . . . . . . . . . . 9 Field Triage Accuracy . . . . . . . . . . . . . . . . . . 10 Table IV Annual Undertriage And Overtriage Rates 11 Trauma Center Bypass . . . . . . . . • • • • • • • 12 TRAUMA CENTERS . . . . . . . . . . . . . . . . . . . . . . . . 13 Children' s . . . . . . . . . . . . . . . . . . . . . . . . 13 Table V Demographic Summary (Children's Hospital) . . . . . . 13 Table VI Patient Dispositions (Children's Hospital) . . . . . 14 Eden Hospital 15 Table VII Demographic Summary (Eden Hospital) . . . . . . . . . 15 Table VIII Patient Dispositions (Eden Hospital) 16 Highland . . . . . . . . . . . . . . . . . . . . . . . . . 17 Table IX Demographic Summary (Highland Hospital) . . . . . . . 17 Table X Patient Dispositions (Highland Hospital) . . . . . . 18 SYSTEM BENEFITS . . . . . . . . . . . . . . . . . . . . . . . 19 Table XI Expected And Actual Survival Rates . . . . . . . . . . . . 19 _ Table XII Reduction in Deaths Attributable to Trauma System . . . . 20 QUALITY ASSURANCE MONITORING . . . . . . . . . . . . . . . . . 21 ECONOMICS OF THE TRAUMA SYSTEM . . . . . . . . . . . . . . . . 23 Trauma Center Actual Loss . . . . . . . . . . . . . . . . 24 Trauma System Costs . . . . . . . . . . . . . . . 25 Trauma System Survivability . . . . . . . . . . . . . . . 26 Trauma System Funding . . . . . . . . . . . . . . . . . . 26 Trauma System Dependence on All Trauma Centers . . . . . . 27 EXECUTIVE SUMMARY In the two years since it began service, the Alameda County Trauma System has made a significant difference in the treatment of trauma. The system has reduced the number of trauma deaths in this county and shortened the recovery period for trauma victims by treatment in the first hour of injury, thus improving the quality of individual lives and creating a financial savings to victims and taxpayers. The County Trauma System began service on January 15, 1987, with two adult trauma centers and a pediatric trauma center. The pediatric center in Alameda County is the only designated trauma center for children in Northern California. The uncertainties surrounding health care funding that have arisen in this decade and hospitals' concern about financial solvency have raised questions about the future of trauma care. But these issues have not prevented the Alameda County Trauma System from successfully accomplishing its goal of saving lives and reducing the number of deaths caused by trauma. o The three Alameda County Trauma Centers treated 8,308 trauma victims during the first two years of service. o The number of actual Major Trauma Victims (MTVs) in 1987 considerably exceeded the number anticipated prior to system implementation. National calculations of 1 MTV per 1 ,000 population predicted 1 ,300 victims. Alameda County treated -1 ,732 MTVs in 1987, a 33 percent increase over the number anticipated. (Data from the Trauma Registry audit is not yet available for 1988.) o The Alameda County Trauma System saved 252 lives, when compared with the Trunkey Study of Bay Area Trauma Deaths in 1982. The Trunkey Study found 34 percent of trauma deaths in Alameda County were preventable or possibly preventable. Alameda County can now document a preventable or possibly preventable trauma death rate of 4.6 percent in 1987 and 3.9 percent in 1988. o The success of the trauma system can be confirmed by comparing the expected survival rates versus actual survival rates from Alameda County with those of more than 100 other trauma centers participating in the national Major Trauma Outcome Study. - 2 - o Although 1988 figures are not yet available, 1987 undertriage rate of transporting critical trauma patients to non-trauma centers is very low at 2.1 percent. Overtriage of patients taken to trauma centers and retrospectively evaluated as not having a need for specialized trauma care fell below expectation at 40.9 percent. Trauma triage criteria were adjusted in March 1988 to improve both over and undertriage. o The trauma centers had a 2 percent closure for bypass in 1987. Bypass time more than doubled in 1988 to 4.8 percent. Thp system has set a goal of maintaining a rate of 5 percent or less for bypass time. A significant portion of the bypass time occurred when CT scanners (computerized tomography) were inoperable, requiring rerouting of only those patients with suspected head injuries. o The Arthur Young Trauma Fiscal Study showed that none of the three : hospitals profited financially from- the trauma center designation. Health care economics will continue' as a major issue in determining trauma system survivability. The statistics contained in this report reflect the number of lives saved, based upon measurable criteria. However, an even greater benefit may be the reduction of morbidity among victims and shortened recovery periods because a trauma system exists in Alameda County. A method is not yet available to measure the effect of an organized trauma system on morbidity and the magnitude of this benefit. r-' — 3 — iBackground In the United States, organized trauma care developed as a specialty subsystem r- of Emergency Medical Services (EMS) in concept in the late 1970s and in practice in the early 1980s. Deficiencies in trauma care in the San Francisco Bay Area were reported in 1982 by Donald Trunkey, M.D. , Chief of Trauma at San - Francisco General Hospital . Dr. Trunkey's report that 40 percent of the trauma deaths from motor vehicle accidents could have been prevented with modern trauma care received widespread media attention. Dr. Trunkey estimated preventable deaths in Alameda County at 34 percent, less than the Bay Area average. I Although Dr. Trunkey based his conclusions -on a study of coroners' reports, these conclusions serve as a baseline for a simple comparison with trauma care now provided in Alameda County. This report addresses the determination of preventability of trauma deaths and provides a more accurate assessment than the single method available to Dr. Trunkey in 1982. The attention focused on trauma care deficiencies in 1982 also highlighted the lack of paramedic level emergency ambulance service in Alameda County. This attention sparked the 1982 ballot measure to establish the EMS Benefit Assessment District and fund emergency medical services including paramedic ambulance services. Concurrent with directing the implementation of the ballot measure for the EMS District and paramedic services , the Alameda County Board of Supervisors directed the Health Care Services Agency to implement a planning process to improve trauma care in the county. The Board approved the County Trauma System Plan in 1985, designating one pediatric and two adult trauma centers. The process to designate trauma centers was initiated with a Request for Proposals and site surveys by a team of trauma experts brought in from outside California. In November 1986 the Board of Supervisors designated Children's Hospital Oakland a pediatric trauma center and Eden Hospital Medical Center and Highland General Hospital as adult trauma centers. Trauma system operations began January 15, 1987. - 4 - SYSTEM OVERVIEW Methods of Identifying Patients Eighty—two percent of all trauma patients enter the trauma system as a result of a response by EMS to a 911 call or to a report by public safety personnel . The majority of the remaining eighteen percent are patients transferred from other hospitals. Upon arrival at the scene, paramedics and EMT—Is evaluate the victim' s injuries. They use pre—established triage criteria to identify patients who require treatment and transport to a trauma center. Triage criteria differ for pediatric patients (children 14 years and younger) and adult patients. Triage criteria include physiological information, (i .e. , vital signs) mechanism of injury and anatomical factors. Current triage guidelines used in Alameda County follow the recommendations of the American College of Surgeons. Not all patients who meet triage criteria require transport to a trauma center. When a patient meets trauma criteria and has not sustained a severe or possibly life threatening injury, paramedics contact the base hospital/trauma center by radio. The base hospital/trauma center personnel have the ultimate responsibility to determine whether a patient is transported to a trauma center or a receiving hospital . In March, 1988, changes in trauma protocols were implemented, based on the first year' s operation of the system. The changes accomplished the following: (1 ) restrict base hospital direction for trauma patients and destination to the two hospitals with both ALS base and trauma center . designation; and (2) allow paramedics to independently exercise their judgment in determining trauma patient destination in most situations. The changes have decreased the number of base hospital contacts for trauma destination and have decreased slightly the overtriage rate. This signifies the competence of the paramedics in independently triaging trauma patients and further minimizes any delay that might occur from determining a patient's hospital destination. Patients Taken to Trauma Centers _ In the first two years of the Trauma System operation, the total number of patients transported to one of the three trauma centers was 8,304. This was an average of 12 patients per day triaged to trauma centers by prehospital care personnel or by the trauma center base personnel . Approximately 170 - 5 — patients were triaged to the closest Basic Emergency Department because the paramedic was unable to establish an airway for the patient or the patient was lacking vital signs resulting from a blunt trauma injury. 1 Although the EMS system demonstrated a 4 percent increase in total patients from 1987 to 1988, the number of patients transported to trauma centers decreased 1 percent.l TABLE I DESTINATION OF SYSTEM TRAUMA PATIENTS L 1987 — 1988 19871 1988 Total Children' s 793 (19.4X) 736 (17.4X) 1 ,529 (18.4X) Eden 1 ,193 (29.2X) 1 ,273 (30.2X) 2,466 (29.7X) Highland 2,102 (51 .4X) 2,211 (52.4X) 4,313 (52.0X) Total 4,088 ( 100%) 4,220 ( 100%) 8,308 ( 100%) i L r- i 1 Data for 1987 collected from January 15 to December 31 . For annual comparisons, average number of patients per day was calculated. - 6 — Patient Demographics Alameda County trauma patient demographics are consistent with nationally published figures. The groupings most likely to experience trauma are males between the ages of 15 and 29. In both years of the trauma system operation male trauma victims constituted more than 70 percent of all trauma patients. TABLE II AGE COMPARISON OF TRAUMA VICTIMS All Trauma Centers 1987 1988 Total 0 — 14 years 777 (19.0X) 723., (17.1X) 1 ,500 (18.1X) 15 — 29 years 1 ,739 (42.5X) 1 ,789 (42.4X) 3,528 (42.5X) 30 — 54 years 1 ,296 (31 .7X) 1 ,388 (32.9X) 2,684 (32.3X) 55 years and over 276 ( 6.8%) 316 ( 7.4%) 592 ( 7.1%) Unknown 0 ( 0.0%) 4 ( 0.0%) 4 ( 0.0%) - 7 — I` Blunt versus Penetrating Trauma �^ Trauma is commonly classified as blunt or penetrating. Blunt trauma typically results from motor vehicle accidents , falls, and assault by bludgeoning. Penetrating trauma typically results from gunshot and stab wounds. These categorizations have different morbidity expectations and mortality rates. r Patients with blunt injuries and without signs of life can rarely be i resuscitated. Penetrating trauma victims who appear lifeless hwe a better chance of survival than those with blunt trauma. Predictably, rural and suburban areas with less population density generate a greater percentage of blunt trauma for the system. Metropolitan inner city areas with higher densities generate more penetrating trauma. Blunt trauma accounts for �- of all trauma in'u'ries in Alaneda County. approximately 80 percent J I L_ f" I ' f i L - 8 - TABLE III BLUNT VS. PENETRATING TRAUMA 1987 - 1988 TYPE OF INJURY SUMMARY 1987 VS. 1988 ALL TRFUP�r� CENTER 4;00 HUMBER OF CASES 3285 3086 3ii00 f �.. _f 2000 ITT v M3 1988 0 ® 1987 BLUNT PEKE T Rf'iT I NG BLUNT VS. PENETRATING•. I : Scene Times I . Trauma systems attribute their success to the premise--of "the golden hour." _ Patients who receive definitive care (surgery, etc.) within the first hour after injury have a much greater probability of survival . Prior to a trauma system in Alameda County, there was no significant difference in the time paramedics/EMT-Is spent at the scene for medical patients compared with trauma patents. Since the trauma s Y stem be 9 an, scene times for trauma patients have �— decreased, a result of training and education. The national standard of 20 minutes or lesson-scene time was adopted by Alameda County. The trauma review process , discussed later in this report, evaluates scene times for adherence to this standard. Alameda County, prehospital care personnel routinely spend less than 20 minutes on the scene. Mode of Arrival Eighty two percent (82%) of the County's trauma patients arrived at the trauma centers in Alameda County by ambulance. Of these trauma patients, 94 percent received an ALS paramedic ambulance response and transport, with the remainder (6%) being transported by an EMT-IA BLS ambulance unit. Certain areas of Alameda County still routinely receive BLS ambulance service. Albany, Alameda, and.Lawrence Berkeley Laboratory Fire Departments provide only Basic Life Support ambulance service. Other ambulance providers in the county use BLS units only when ALS units are not available. L All three trauma centers in Alameda County lack an on-site helipad. The need for medical helicopter transport of trauma patients arises primarily from rural areas of the County which have greater distances to travel to reach the trauma centers. Trauma occurring in these areas may receive a medical Lhelicopter response to insure a transport time within the golden hour. The EMS District has arranged for air transporting of patients directly to trauma centers with helipads in Contra Costa and Santa Clara Counties from Alameda County. In 1987, three patients were flown to Stanford University Hospital ; one patient was flown to San Jose Hospital , and twelve to John Muir Hospital . In 1988, eight patients were flown to John Muir Hospital ; five were flown to Stanford University Hospital , and seven to San Jose Hospital . - 10 - A helicopter landing field at Oakland Army Base allows helicopter transport to Children' s Hospital . A patient taken to the Army Base by helicopter is transferred to a waiting ambulance and then transported to Children's Hospital about six minutes away. In 1987, fifteen patients were transported to Children' s Hospital by helicopter. In 1988, Children's Hospital received seventeen patients through helicopter transport. Highland Hospital established an agreement with the U.S. Coast Guard in October, 1988 for use of the helipad on Government Island by medical helicopter services. This arrangement now permits air transport of a trauma patient to Highland Hospital via Government Island with an approximate six-minute ground transport to the trauma center. Two patients were transported via helicopter to Highland Hospital in late 1988. At present, ALS helicopter personnel transport adult patients to the closest trauma center having an approved helipad or alternate landing facility. Pediatric patients transported by helicopter arrive at Children's Hospital via the Oakland Army Base and ground transport. Field Triage Accuracy The determination of serious trauma at the scene can sometimes be difficult. A patient may appear stable, but then deteriorate rapidly. Although several methods exist to evaluate patients who have traumatic injuries, no system exists that identifies all Major Trauma Victims (MTVs) without including some patients who retrospectively are found to have no severe injuries. Paramedics evaluate patients in the field using established criteria to determine those needing transport to a trauma center. (See "Methods of Identifying Patients.") Patients meeting the field criteria for transport to a trauma center are known as "Critical Trauma Patients" or "CTPs". At the time of discharge or death, the patient is evaluated to determine the severity of the injuries. Those meeting the retrospective evaluation criteria are classed as "MTVs" . The Alameda County Trauma System uses the guidelines from the American College of Surgeons to define MTVs. The guidelines provide an objective evaluation using codes derived from the discharge diagnosis or autopsy findings. The goal of triage with trauma patients is transport of all MTV patients to a trauma center. When a patient evaluated by the paramedic as having minor Iinjuries is later determined to meet the MTV classification and is sent to a non—trauma hospital , the patient is classed as "undertriage". Patients (— identified as "CTP" by the paramedic and retrospectively found not to be a MTV are classed as' "overtriage" . The goal of triage may also be stated as minimizing both the under and overtriage. Table IV documents the overtriage and undertriage rates. The incidence of under and overtriage intAlameda County are well within nationally accepted standards. In developing the Alameda County Trauma Plan the 1984/85 national statistics were used to estimate the expected annual number of MTVs for Alameda County. Using the estimate of one MTV per 1 ,000 population, the estimate for Alameda County was 1 ,100 MTVs per year. In 1987 the population for Alameda County was estimated at 1 .3 million people, resulting in an estimated 1 ,300 MTVs. The actual number of MTVs in 1987 was 1 ,732 or 33 percent greater than the estimate based on the national average. Data for 1988 is still being tabulated. TABLE IV i 1987 ANNUAL UNDERTRIAGE AND OVERTRIAGE RATES2 ( Patients triaged to Trauma Centers 3802 Patients triaged to Receiving Hospitals* 1020 Total patients meeting triage criteria 4822 Number of MTVs at Trauma Centers 1732 Overtriage Rate 40.9% Number of non—MTVs at TC = 1972 Total Number Triaged = 4822 MTVs at Receiving Hospitals+ 102 Undertriage rate 2.1% Number of MTVs at Receiving = 102 - Total Number Triaged = 4822 * via EMS + excludes blunt field arrests I - 2 1988 Registry Data..incomplete; awaiting audit results. — 12 — Trauma Center Bypass ' The trauma system standards permit a trauma center to go on "bypass", meaning that a trauma patient will be directed to the next closest available trauma center, only for specified reasons. Trauma center closure is authorized by the trauma medical director at times when the hospital is unable to provide quality care to additional trauma victims. These reasons include when the emergency department or operating rooms are filled with other trauma patients, the trauma center has no critical care beds available, or the hospitals CT scanner is not working. The latter condition would result in redirecting only trauma patients with possible head injuries. The EMS District requires trauma centers to report all episodes of bypass with the reason or reasons and the duration of bypass stated. The recent mid—winter increased morbidity experience indicates that trauma bypass was being initiated more frequently due to insufficient intensive care bed capacity. Hence, factors other than trauma cases may result in a trauma center initiating "bypass." A mutually beneficial agreement between the trauma systems in Alameda and Contra Costa Counties permits routing of trauma patients across county lines when a trauma center is on bypass. To date, there has never been a time when all three adult trauma centers have been on simultaneous bypass. The trauma centers had a 2 percent closure for bypass in 1987. Bypass time more than doubled in 1988 to 4.8 percent. The system has set a goal of maintaining a rate of 5 percent of less for bypass time. A significant portion of the bypass time occurred when CT scanners (computerized tomography) were inoperable, requiring rerouting of only those patients with suspected head injuries. - 13 - ( ? TRAUMA CENTERS r' Children's Hospital Oakland (- When Alameda County designated Children's Hospital as a Trauma Center, it was I , expected that other counties in Northern California would recognize this designation. There are only two other pediatric trauma centers in the state, I one in Los Angeles and one in San Diego. Patients age 14 and under are transported directly to Children' s from the scene in any area of Alameda and (� Contra Costa Counties. Pediatric trauma patients in other Northern California t .: counties are stabilized at a local hospital for subsequent transfer to Children' s Hospital . Approximately twenty percent of Children's trauma L' patients are transferred from hospitals out of Alameda County. LPatients older than 14 are sometimes transported to Children's Trauma Center as the closest facility for a patient with an unmanageable airway. Occasionally a parent with minor injuries may be transported to Children's with a more critically injured child to prevent separation of the parent and child. TABLE V `.— DEMOGRAPHIC SUMMARY Children's Hospital I- 1987 1988 Total f� 0-14 years 708 (89.3X) 672 (91 .8X) 1 ,380 (90.5X) 15-29 years 77 ( 9.710 54 ( 7.4%) 131 ( 8.6%) 30-54 years 8 ( 1 .0%) 1 ( 0.0%) 9 ( 0.6%) over 55 years 0 ( 0.0%) 1 ( 0.0%) 1 ( 0.0%) L I Male 500 (63.1X) 470 (64.2X) 970 (63.6X) Female 290 (36.5X) 261 (35.7X) 551 (36.1X) Not Specified 3 ( 0.4%) 1 ( 0.1%) 4 ( 2.6%) — 14 — Since children are more difficult to assess in traumatic situations, the triage criteria used for children are different than those used for adults. Paramedics and base personnel tend to take a cautious approach when dealing with pediatric patients 'to prevent errors when triaging. Almost 50 percent of all children transported to the trauma center are released from the emergency department. By comparison, less than 20 percent of the patients transported to the adult trauma centers are released from the emergency department. Pediatric patients are also much less likely to undergo surgery after trauma as shown in Appendix A. TABLE VI PATIENT DISPOSITIONS FROMTRAUMA CENTER Children's Hospital 1987 1988 Total Released from ED 368 (46.4X) 354 (48.4X) 722 (47.3X) Transferred from ED 20 ( 2.5%) 15 ( 2.0%) 35 ( 2.3%) Admitted/transferred 13 ( 1 .6%) 19 ( 2.6%) 32 ( 2.1%) Admitted/discharged 376 (47.4X) 310 (42.3X) 686 (45.0X) Died - 14 ( 1 .8%) 14 ( 1 .9X) 28 ( 1 .8%) AMA/AWOL 1 ( 0.1%) 4 ( 0.5%) 5 ( 0.3%) Foster Care/Police 0 ( 0.0%) 15 ( 2.0%) 15 (-1 .0X) Unknown 1 ( 0.1%) 1 ( 0.1%) 2 ( 0.1X) Bypass: Children' s Trauma Center was on bypass only 19.5 hours (0.2X) during 1987. The entire bypass resulted from the hospital 's CT scanner (computerized tomography) being out of service. Bypass resulting from an inoperable CT scanner requires rerouting only those patients who need an immediate CT scan (e.g. , head injuries) . In 1988, Children's Hospital Trauma Center was on bypass 151 .5 hours or 1 .7 percent of the time. Ninety—two percent of bypass occurred when the CT scanner was out of service, requiring only the rerouting of those patients in need of a CT scan. . During bypass situations, pediatric patients requiring trauma center resources are routed to the appropriate adult - trauma center. — 15 — Eden Hospital Approximately 30 percent of all trauma patients in Alameda County went to Eden Hospital . Patients transported to Eden are more likely to be males between the ages of 15 and 29 with blunt (fall or auto accident) injuries. F TABLE VII DEMOGRAPHIC SUMMARY Eden Hospital i ^ 1987 1988 Total 0-14 years 34 ( 3.6%) 32 ( 2.5%) 66 ( 3.0%) 15-29 years 635 (53.2X) 674 (52.9X) 1 ,309 (53.1X) I - 30-54 years 405 (33.9X) 439 (34.5X) 844 (34.2X) i over 55 years 110 ( 9.2%) 128 (10.1X) 238 ( 9.7%) i. . Unknown 9 ( 0.8%) 0 ( 0.0%) 9 ( 0.4%) Male 812 (68.1X) 927 (72.8X) 3,330 (70.5X) Female 377 (31 .6X) 344 (27.1X) 721 (29.2X) Not Specified 4 ( 0.3%) 2 ( 0.2%) 6 ( 0.2%) Patient Disposition: Less than 18 percent of the patients sent to Eden Hospital for critical traumatic injuries were discharged from the emergency department. The remaining 80 percent were admitted, transferred or died. i I I - I L. — 16 — TABLE VIII PATIENT DISPOSITIONS FROM TRAUMA CENTER Eden Hospital 1987 1988 Total Released from ED 231 (19.4X) 205 (16.1X) 436 (17.7X) Transferred from ED 105 ( 8.8%) 149 (11 .7X) 254 (10.3X) Admitted/transferred 142 (11 .9X) 112 ( 8.8X) 254 (10.3X) Admitted/discharged 630 (52.8X) 698 (54.9X) 1 ,328 (64.2X) Died 61 ( 5.1%) 66 ( 5.2%) 127 ( 5.2%) AMA/AWOL 17 ( 1 .4%) 18 ( 1 .4%) 35 ( 1 .4%) Foster Care/Police 0 ( 0.0%) 24 ( 1 .9t) 24 ( 1 .0%) Unknown 7 ( 0.6%) 1 ( 0.0%) 8 ( 0.3%) Bypass: Eden Hospital was on bypass a total of 121 .5 hours, or 1 .4 percent in 1987. Sixty—four percent of the bypass resulted from the CT scanner being inoperable, requiring only those patients with suspected head injuries be diverted. In 1988, Eden was on bypass for 351 hours or 4 percent of the time. Almost 50 percent of the bypass resulted from ICU having reached maximum capacity; 29 percent of the bypass resulted from the CT scanner being out of service and applied only to suspected head injuries. — 17 — Highland Highland Hospital receives approximately 52 percent of all trauma patients in Alameda County. Consistent with Eden Hospital and the national statistics for trauma patients , Highland Hospital ' s trauma patients are predominantly males between the ages of 15 and 29. Penetrating trauma frcm stab or gunshot wounds accounts for 37 percent of Highland' s trauma, a figure consistent with national statistics of hospitals serving urban populations. (SFe Appendix B.) TABLE IX DEMOGRAPHIC SUMMARY Highland Hospital 1987 1988 Total 0-14 years 26 ( 1 .2%) 16 ( 0.7%) 42 ( 1 .0%) 15-29 years 1 ,027 (48.9x) 1 ,061 (48.0X) 2,088 (48.4X) 30-54 years 883 (42.0x) 946 (42.8X) 1 ,829 (42.4X) over 55 years 166 ( 7.9%) 188 ( 8.5%) 354 ( 8.2%) Male 1 ,604 (76.3x) 1 ,726 (78.1X) 1 ,739 (77.2x) Female 497 (23.6X) 485 (21 .9X) 982 (22.8x) Not Specified 1 ( 0.0%) 0 ( 0.0%) 1 ( 0.0%) Patient Disposition: Seventy—five percent of the trauma patients transported to Highland Hospital Trauma Center were admitted, transferred or died. Only 20 percent were released directly from the Emergency Department. TABLE X PATIENT DISPOSITIONS FROM TRAUMA CENTER Highland Hospital 987 1988 Released from ED 444 (21 .1X) 432 (19.5X) 876 (20.37.) Transferred from ED 77 ( 3.7%) 42 ( 1 .9%) 119 ( 2.8%) Admitted/transferred 176 ( 8.4%) 212 ( 9.6%) 388 ( 9.0%) Admitted/discharged 1 ,186 (56.4X) 1 ,321 (59.7X) 2,507 (58.1X) Died 139 ( 6.6%) 135 ( 6.1%) 274 ( 6.4%) AMA/AWOL 80 ( 3.8%) 68 ( 3.1%) 148 ( 3.4%) Foster Care/Police 0 ( 0.0%) 1 ( 0.0%) 1 ( 0.0%) Bypass: Highland Trauma Center required activation of bypass 5.4 percent (477.25 hours) in 1987. Fifty-two per cent of the bypass resulted from an ICU overload. Almost 36 percent of the bypass was due to the CT scanner being inoperable. In 1988, Highland Trauma Center diverted patients 6.5 percent of percent of the time was caused by the CT the time (565.5 hours) . Fifty scanner being down requiring only the rerouting of patients with suspected head injuries. Forty three percent of Highland's bypass hours were the result of the ICU being overloaded. - 19 - SYSTEM BENEFITS I . An in-depth study measuring trauma care prior to the implementation of the trauma system does not exist. Therefore, it is difficult for the county to measure the absolute impact of trauma care on the populace since the system began. However, the national Major Trauma Outcome Study (MTOS), developed by Howard Champion, M.D. , allows trauma systems to be evaluated in relation to � ., each other. Table XI shows that Alameda County Trauma Center survival rates compare favorably to other trauma centers participating in the study. jL TABLE XI EXPECTED AND ACTUAL SURVIVAL RATES 1987 1988 i Expected 94.9% 94.9% Actual 94.8% 95.0% In 1982, Donald Trunkey, M.D. , a well-known trauma specialist, published a study of motor vehicle trauma deaths occurring in the nine San Francisco Bay Area counties. Dr. Trunkey concluded that 34 percent of trauma deaths in Alameda County were "preventable" , "probably preventable", or "possibly preventable." Since the implementation of the Alameda County Trauma System, the retrospective trauma audit process has determined the preventable and possibly preventable deaths. A comparison of the actual preventable deaths in 1987 and 1988 with Dr. Trunkey' s 1982 finding shows a significant reduction. Compared - with Dr. Trunkey' s estimate of 34 percent preventable and possibly preventable deaths , the trauma audit process found 4.6 percent preventable or possibly i preventable deaths in 1987 and 3.9 percent in 1988. A .34 percent preventable or possibly preventable death rate in Alameda County would have meant an additional 125 deaths in 1987 and an additional 127 in 1988. 20 TABLE XII REDUCTION IN DEATHS ATTRIBUTABLE TO TRAUMA SYSTEM 1987 ACTUAL TRAUMA SYSTEM EXPERIENCE: Trauma Deaths 281 (100X) 279 (160X) Not Preventable 268 (95.4X) 268 (96.1X) Preventable/Possibly Preventable 13 (4.6X) 11 ( 3.9%) EXPECTED DEATHS WITHOUT TRAUMA SYSTEM: Expected Hospital Trauma Deaths 406 (100X) 406 (100X) Not Preventable (actual ) 268 (66X) 268 (66X) Preventable/Possibly Preventable 138 (34X) 138 (34X) Reduction of Deaths by Trauma System 125 127 - 21 - QUALITY ASSURANCE MONITORING F A review of trauma activity occurs monthly through confidential committees known as the Trauma Audit Committee (TAC) and Zone Trauma Audit Committees (ZTAC) for the North and South County trauma zones. A preliminary review of (- trauma cases occurs at ZTAC. Two ZTAC meetings (North and South County) are held each month preceding the monthly TAC. TAC is a combined rAiew by Alameda County and Contra Costa County Trauma Systems. The ZTAC review is chaired by a trauma director on a rotational assignment from another trauma zone. ZTAC membership includes the trauma medical directors, trauma nurse l� coordinators ; receiving facility physicians', tra!►ma center ALS base physicians, a paramedic representative, the EMS medical director, and trauma r nurse coordinator. All trauma cases (deaths and MTV admissions) transported i to a non-trauma center receiving facility are reviewed for mistriage, f Emergency Department (ED) management, hospital complications and patient outcome. Also reviewed are similar trauma center cases and prehospital care including triage and patient management decisions. All questionable cases and �... negative outcomes (e.g. , possibly preventable deaths; complications) are referred to TAC. L TAC meets each month to review the cases selected from the case reviews i conducted by the ZTAC meetings. This two county committee has 26 L representatives including trauma directors, trauma nurse coordinators, EMS �- medical directors , EMS- trauma coordinators, ZTAC receiving facility emergency �..� physicians, a surgeon representing the local surgical society, trauma center emergency department physicians , neurosurgeons, an orthopedist, an anesthesiologist, and the coroner' s pathologist for each county. Cases referred from ZTAC are reviewed for appropriateness of care. The audit process determines the effect the care given had on the patient outcome. All deaths and complications are categorized as: preventable, possibly preventable, or non-preventable. Frank Lewis , M.D. , Director of Trauma at San Francisco General Hospital , participated as consultant to the EMS Medical Director to assist the audit l _ process during the early meetings of the. TAC. L - 22 — The trauma audit provides a comprehensive, objective evaluation of trauma care provided within the County. This review process is unique in that the trauma audit also includes trauma care provided by receiving hospitals that are not designated as trauma centers. This is noteworthy in that all trauma deaths and MTVs occurring in the County are reviewed by the audit process, not just the cases receiving care at the trauma centers. - 23 - ECONOMICS OF THE TRAUMA SYSTEM The high cost of treating major trauma victims impacts a hospital favorably or unfavorably according to the revenue generated from trauma care. Early - experiences of trauma systems elsewhere in California and in other states led to the expectation that trauma center designation would be financially - beneficial , resulting from additional revenues from-trauma care. Trauma centers were also viewed by many hospitals, particularly those competing for trauma center designation, as a threat to the hospital income. Hospitals not I designated as trauma centers expected a loss of revenue with critical trauma patients being treated at trauma centers. This initial view of trauma center economics has changed dramatically in the past few years as evidenced during C- this County s competitive process for trauma center designation. In applying for trauma center designation, certain hospitals included a provision for L financial support from the County should the hospital demonstrate a financial loss resulting from the trauma center. Major cutbacks in health care financing, an increasing population with i - inadequate or no medical insurance, and the increased trauma resulting from assault weapons and drug wars have reversed the proposed benefits of trauma center designation for inner-city trauma centers to a fiscal liability. Eden Hospital Medical Center and Children's Hospital required as a condition of their respective designation agreements with the County that provision be -- made for the hospital (s) to receive County subsidy should they experience financial loss as a result of trauma. A fiscal study of trauma center impact to each of the three trauma centers was conducted by Arthur Young Health Care Services comparing the six-month period prior to the trauma system beginning operation with the first six months of - experience after beginning. This study was completed in late 1988 with conclusions subject to interpretation depending upon whether or not fixed costs are considered as a valid cost when determining the impact of designation. There are no general conclusions which can be drawn from the Arthur Young 1 Trauma Fiscal Study that are applicable to all three trauma centers in the Alameda County Trauma System; however, it is evident that Children's Hospital 24 and Highland Hospital lost money on trauma care during both study periods, pre- and post-designation. The findings for each of the three hospitals may raise additional questions; however the methodology used provides the County with a way to assess the fiscal impact of trauma care to each hospital as a means to consider a need and basis on which a County subsidy could be allocated. I On September 27, 1989, the Board of Supervisors approved a recommendation authorizing the Health Care Services Agency to negotiate modifications to the. agreements with the trauma centers to include provision for subsidy. A subsidy based on a demonstrated financial loss and limited to a fixed dollar amount to be determined in advance by the Board. The recommended limit was a capped fund not to exceed $1 million, with a capped amount of $400,000 per hospital . Trauma Center Actual Loss The Arthur Young Fiscal Study identified three categories of cost to a hospital in providing trauma care as a trauma center. 1) Trauma specific costs are those costs which the hospital incurs directly from being designated as a trauma center such as additional staffing and equipment. These costs exist regardless of patient volume. 2) Variable costs are related to providing care to trauma patients. These costs may be influenced by the patient volume and relate to services and supplies provided by the hospital which may add to the hospital utilization of resources. 3) A hospital 's fixed costs are those allocated to trauma care from costs to the hospital that remain the same regardless of patient volume and utilization. The hospital would have the fixed costs whether or not the hospital is a designated trauma center. Examples of fixed costs are administrative, building, maintenance, and utility expenditures. For Children' s and Highland, a financial loss due to trauma was indicated in both Arthur Young Study periods whether the fixed costs were included. Eden Hospital , however, experienced a trauma gain in the post-designation period if the fixed costs were not included and during the pre-designation period when fixed costs were included. Additionally it can be shown Eden would have experienced a real loss in revenue had another hospital been designated to receive all trauma formerly received by Eden. Although a hospital 's fixed I - 25 - costs are spread or apportioned to all hospital departments, the County should consider subsidy only if a trauma center hospital has demonstrated a loss �^ without including the hospitals fixed costs. Using this interpretation, each of the three trauma centers experienced the following for the first six months of operation: - Eden Children's Highland Estimated Revenue $ 2,503,188 $ 992,716 $ 3,158,093 Trauma Specific (1 ,133,979) (1 ,284,010) (1 ,254,687) Trauma Variable ( 917,4981 ( 616.2281 _ (2,870,889) Net $ 451 ,711 ($907,523) ($967,483) If the first six months experience continues, it could be expected that Eden would not require subsidy. Children's and Highland would each be eligible for the maximum capped amount. However, the Arthur Young study agreed with Children' s that pediatric trauma occurs significantly more during the second six months than during the first six months, hence, Children's annual fiscal impact would be expected to differ from the first six months to show an increase in overall revenue from trauma. The finding of a seasonal fluctuation is corroborated by data collected in the County's trauma registry which indicates an approximate 50 percent increase in trauma patients during the second six months of the year (1987 data). Additionally, the pediatric �- trauma experience at Children's may not warrant the same level of staffing - �. commitment as is required for the adult trauma centers. Further analysis of the first two years of experience with Children' s and the standards set for _ the pediatric trauma center are needed before a final determination for subsidizing Children's Hospital is made. Trauma System Costs `— This report demonstrates the success of the trauma system for 1987 and 1988 in terms of lives saved or unnecessary deaths prevented. Except for Eden, the Arthur Young Trauma Fiscal Study indicates that traumna centers costs exceed their revenue, with or without including the hospitals fixed costs. The missing factor in the overall equation is the savings to the remainder of the hospitals in the County which are not trauma centers and no longer incur the I - r 26 same fiscal liability for uninsured trauma patients. Additionally, these hospitals may have reduced other costs as a result, which ifk owncould be es identified as savings in the overall system. If the combine d which reversed trauma from profit to loss are also appliedeceiving the major hospitals, then it may be assumed that the hospitals not trauma patients are better off financially than they would be if there were no trauma system. { In addition to the costs identified in the Arthur Young Study for teach of the trauma centers, there are also the County's costs e overall trauma resulting . District responsibilities to coordinate and monitor system. The state legislation which enables the establishment of trauma systems allows counties to establish trauma center designation fees as a source of revenue to offset the county' s costs. Alameda County is covering its costs with EMS District Assessment funds rather than through designation fees paid by each trauma center. Trauma S stem Survivability The County' s experience with trauma system costs parallels that of trauma systems elsewhere in California and the nation. Although overall demands on hospital services and particularly intensive care beds have trauma centers, the bypass experience of each hospital has been within acceptable and predicted limits. The recent mid-winter increase of morbidity indicates that trauma bypass was being initiated more frequently due to intensive care bed capacity. Hence, factors other than trauma cases may result in a trauma center initiating bypass. A mutually beneficial agreement between the trauma systems in Alameda and Contra Costa Counties permits routing of trauma patients across county lines when all center tson bypass. To date, there has never been a time when a lthree centers have been on bypass at the same time. The retrospective medical audits have indicated no compromise in patient care or outcomes due to the routing during a period of a trauma center being on bypass. Trauma System Funding T The County has previously identified two sources of funding to assist the es tance trauma centers other than from the County's general fund. Any such ass ( _ 27 _ is viewed only as a temporary solution to maintain the system until Federal and/or State assistance is forthcoming. These sources are the County's discretionary funds collected from the Senate Bill 12 assessment on fines and forfeitures and use of the EMS District Assessment. County Counsel has provided the opinion that the Board of Supervisors can use funds derived from the EMS assessment within the context of the 1982 advisory ballot measure. This allows the offset of trauma costs that are der:cnstrated to be system costs . Trauma specific costs are system costs, i .e. , the costs 'of maintaining ff the availability of the desired level of trauma care. Funds generated from f ^ the SB 12 assessments are not restricted and can be used to cover direct ( patient care costs. I_ The SB 12 fund as amended by S6 612 provides that 25 percent of the fund shall be used to offset uncompensated trauma or emergency care at hospitals providing a disproportionate amount of uncompensated emergency care. Although Board Policy has yet to be determined for this part of the SB 12 Fund, the Health Care Services Agency recommends that all of the 25 percent for disproportionate trauma and emergency care and the 17 percent discretionary portion be allocated specifically to support the trauma system. The Alameda County Health Care Services Agency (HCSA) recommends the 25 percent (_ disproportional care funds be used exclusively for trauma, directing subsidy only to the trauma centers which can demonstrate a real loss due to trauma care. The premise of this recommendation is that all hospitals, both with and L without trauma centers, benefit from the existence of the trauma centers. The I'- hospitals with licensed basic medical emergency departments which do not have 1 trauma center designation benefit from the limited exposure to provide uncompensated or undercompensated trauma care resulting from triaging trauma patients directly to trauma centers. - This reduced exposure benefits the hospital ' s requirement to have expensive specialty services immediately available or on call 24 hours daily. Additionally, the reduced exposure to critical trauma limits the hospitals potential legal liability. L Trauma System Dependence on All Trauma Centers The two—year experience with the trauma system amply demonstrates the need for i the two adult trauma centers and the benefit of the specialized pediatric trauma center. It is further apparent, when considering the present economics of trauma care, that the Highland Hospital Trauma Center is essential to the 28 survival of the County' s Trauma System. The trauma cases originating from' Highland Hospital ' s trauma zone represent more than 50 percent of all trauma occurring in Alameda County. Without the trauma services provided by Highland the organized trauma system would likely collapse, returning the County's EMS System to protocols directing all critical trauma to the nearest basic emergency department. The financial loss to Highland Hospital (and the County) from trauma care is estimated from the Arthur Young Fiscal, Study at approximately $2 million dollars annually. The Arthur Young Fiscal Study identified more than two million dollars of trauma specific costs at Highland, (costs resulting from meeting the trauma center designation requirements). Because Highland would continue to receive the majority of trauma patients with or without trauma designation it is unlikely that these costs could be eliminated or reduced significantly without lowering the quality of trauma care. Although some costs at Highland were identified as trauma specific, most of these costs were necessary to provide an acceptable level of patient care and the resulting improvements benefited other hospital departments in addition to trauma. A loss of the trauma system would reduce the quality of trauma care throughout the County and increase preventable deaths due to trauma. 0538T r-- I _ I , APPENDIX A Percentage to Surgery by. Quarter by Hospital, 1987 (( 40 Percentage 30 urrryrrrrrrryurr`r+`'�•\�� nu n r Vl,�yuu ,p, m r` r h„ •�--\-■ nnr✓rrr ,/ unhm°mum 20 rnnrnru,nrr...... I._ 10 �rrrrrrrr 846 Highland Samos 805 Eden 0 Children's Q1 Q? 03 Q4 Quarter i I I r l_ APPENDIX B TYPE OF INJURY SUMMFRY 1987 ALL TRAU��A CENTERS 1800 �';Ul'EER OF CASES r 1500 1439 1.200 _ 7c: 900 L 656 600 f f 300 f 22 11�� ===L= CHMC EDEN HGH BLUNT VS. PENETRATING TYPE OF INJURY cUlmmc,RY 1988 ALL TP•.A!NA CENTS S I 1800 NLli'I ER. OF CASES 1500 -<q� 1200 1 ,S _ 900 CCSC 5 5 ti 600 300 . 1 J , i Qb 0 ��1��� CHMC EDEN HGH i .. ® PENETRATING BLUNT VS. PENETRATING The Honorable Board of Supervisors County of Alameda 1221 Oak Street Oakland, CA 94612 Dear Members of the Board: It is our understanding that the Board will consider an increase in the CSA EM 1983-1 benefit assessment at their August 8, 1989 meeting. Further, we understand that an additional $8. 00 per benefit assessment unit, for the purpose of funding the County Trauma Centers, will also be considered. The addition of this supplemental $8 . 00 assessment will bring the City of Dublin's unit assessment to $15.58, well in excess of the $10. 00 cap voted on in 1982 . Your County Counsel has informed you that the supplemental assessment is legal since the 1982 vote was advisory only. While this may be true, we feel the issue should be brought before the voters. The City of Dublin supports the efforts of the County in looking for alternative methods of funding the Trauma Centers. We also support the Trauma Center concept and feel it is a valuable asset to our citizens. However, following the spirit of the 1982 ballot measure, the Dublin City Council and I urge that you place this supplemental assessment before the voters of Alameda County. Respectfully, PAUL MOFFATT, Mayor PM/liw