Report of the Ambulance Study Task Force - January 15 1980R 362.18 REP Iowa Books
Report of the ambulance
study task force
IF'III IIIIIIII
3182500118470
Carnegie -Stout Public Library
CITY OF DUBUQUE
REPORT OF THE AMBULANCE STUDY TASK FORCE
JANUARY 15, 1980
II
REPORT OF THE AMBULANCE STUDY TASK FORCE
Table of Contents
Page
INTRODUCTION 1
AMBULANCE STUDY TASK FORCE ESTABLISHED 1
SUMMARY OF TASK FORCE RECOMMENDATION 3
BACKGROUND 4
Current Level of Ambulance Service 4
Impact of State Legislation Pertaining to Advanced Emergency
Medical Care 6
RECOMMENDATIONS 9
Level of Service Recommendation 9
Scope of Service Recommendation 10
Who Should Provide the Service? . . . . . . . . . . . . . . . 10
Mercy Option Two Further Explained 16
How Should the Ambulance Service be Financed? 18
TIMETABLE FOR IMPLEMENTATION 20
CONCLUSION 20
ATTACHMENTS
Memorandum dated May 8, 1979 from Ken Gearhart entitled "Outline of
Study of Ambulance Service"
Minutes of Task Force Meetings
Joint Rules of State Department of Health and Board of Medical Examiners
pertaining to the training, certification and services performed by ad-
vanced emergency medical technicians and paramedics
Hospital Proposals for Providing Ambulance Service
Comments by Ambulance Study Task Force Members
CITY OF DUBUQUE, IOWA
MEMORANDUM
January 15. 1980
DATE
TO: Honorable Mayor and Members of City Council
FROM: W. Kenneth Gearhart, Chairperson, Ambulance Study Task Force
SUBJECT: Report of Ambulance Study Task Force
INTRODUCTION
The purpose of this report is to present the findings and recommendations of the
Ambulance Study Task Force.
AMBULANCE STUDY TASK FORCE ESTABLISHED
An eleven member Ambulance Study Task Force was established by the Dubuque City
Council on May 21, 1979.
The purpose of the Ambulance Study Task Force was to review and evaluate ambu-
lance services provided the citizens and visitors of the City of Dubuque and make
appropriate recommendations. The overall objective was to provide the community
with the highest possible level of ambulance service (level of care) consistent with
a reasonable level of risk and the ability of the community and/or user to pay for
it. As you review the report, keep in mind these three key evaluation criteria:
1) level of care, 2) risk and 3) cost. Whatever the ultimate decision, these three
critical criterion must be evaluated and placed in balance.
Specific areas to be studied were spelled out in a memo entitled "Outline of
Study of Ambulance Service" dated April 23, 1979 from W. Kenneth Gearhart to Gilbert
D. Chavenelle. Briefly, the areas to be studied were as follows:
1. What level of service should the ambulance service provide? For example,
basic first aid or advanced life support.
2. What should the scope of service be? This study area includes two important
facets of providing ambulance service: a) should the scope of service in-
clude emergency ambulance service only or should local transfer service
continue to be provided as part of the service; and b) should the ambulance
PAGE I OF 21 PAGES
Honorable Mayor and Members of City Council
January 15, 1980
service be limited to the City limits or should service into East Dubuque
be continued.
3 Who should provide the service? This study area pertains to what group
or organization should provide the ambulance service (i.e., City, hospital
based, etc.).
4. How should the ambulance service be financed? This study area is concerned
with who pays (user, City, County) and how much. Another important aspect
of this study area is whether the ambulance service should be self
supporting.
5 Ambulance personnel issues. This study area involved certain personnel
management issues resulting from a very small number of highly trained
technicians providing a highly visible and important service. It became
clear prior to the deliberation of the Task Force that certain of these
issues involved collective bargaining matters between the Dubuque Fire
Fighters' Association and the City and could not be fully discussed by
the Task Force, and that other issues were intrical parts of the various
proposals and alternatives, and, as such, need not be addressed individually.
The eleven member Ambulance Study Task Force was subsequently appointed by the
City Council as follows:
3 members representing the area hospitals:
Ken Sargent, Executive Vice -President, Mercy Health Center
Phyllis Anger, R.N., Nurse Supervisor, Emergency Room, Finley Hospital
Gary Rieniets, Assistant Hospital Administrator, Xavier Hospital
3 members from City of Dubuque:
Robert Dunphy, Fire Chief
Art Roth, Health Director
Richard Kreiman, Ambulance Driver/Attendant
1 member representing Dubuque County Medical Society:
Dr. Craig Rose, Emergency Room Physician, Mercy Health Center
1 member representing Dubuque Nursing Homes:
Patricia Gabriel son, Bethany Home
3 citizen members:
Don Allendorf
R.C. "Jack" Schaefer
Ann Sweeney
Page 2 of 21 pages
Honorable Mayor and Members of City Council
January 15, 1980
SUMMARY OF TASK FORCE RECOMMENDATIONS
The purpose of this section is to summarize the several recommendations of the
Ambulance Study Task Force. Please refer to the pages indicated for a full explana-
tion of the recommendation. The recommendations are as follows:
1. The level of service to be provided by the ambulance service should be at
least Emergency Medical Technician II (EMT -II) level with a goal after one
year to upgrade the level of care to EMT -Paramedic level (see page 9).
2. At least two advance life support (ALS) ambulances should be available at
all times (see page 10)•
3. Transfer service represents a significant portion of the workload (and
therefore income) of the ambulance service and must be continued (see
page 10)
4. The service area should continue to include East Dubuque, Illinois and the
parts of Dubuque County, Iowa presently covered (see page 10).
5 Ambulance service should continue to be owned by the City, but should be
operated by Mercy Hospital and the level of service should be two full-
time ALS ambulances and one eight -hour ALS transfer vehicle (see page 14).
6. The recommended rate structure for the Mercy Hospital based ambulance
service should be as follows (see page 18):
Transfer Rate $ 63
Basic Service Rate $110
Advanced Care Rate $170
7. The Ambulance Study Task Force strongly recommends that a City subsidy be
considered to lower the proposed rate structure (see page 18).
8. A 13-member Ambulance Commission should be established to set rates, provide
policy guidance and handle service complaints (see page 19).
9. The patient's right to go to the hospital of his/her choice must be protected
(see page 19).
10. The City should continue to receive calls from the general public for emer-
gency ambulance service and relay such requests to the hospital based ambu-
lance service for prompt dispatch. Requests for transfer service should be
handled directly by the hospital based ambulance service (see page 19).
11. The City of Dubuque should also continue to dispatch the nearest engine
company to all cardiac and life threatening calls (see page 20).
Page 3 of 21 pages
Honorable Mayor and Members of City Council
January 15, 1980
12. The Mercy Hospital based ambulance should begin operation 120 days from the
time of City Council approval (see page 20).
BACKGROUND
The Ambulance Study Task Force held its first meeting on July 5, 1979 and met a
total of twenty-one times through January 15. The minutes of these meetings are
attached and made a part of this report. At the first meeting, Ken Gearhart, at that
time Systems Analyst in the City Manager's Office, was designated Task Force Chair-
person by Mayor Wertzberger.
Current Level of Ambulance Service
The first major assignment for the Task Force was to review the current level of
ambulance service provided citizens and visitors to Dubuque and surrounding areas by
the Dubuque Fire Department.
The Dubuque Fire Department maintains two fully equipped first -line ambulances
and one reserve vehicle which can be converted into an ambulance as needed.
Ambulance #1 (Medic 11), which is the primary or first ambulance to be used, is
centrally located at Fire Station No. 4 at 1697 University Avenue. This ambulance is
operated by six Ambulance Driver/Attendants on a three platoon system (two each 24-
hour period) which is the same as worked by firefighting personnel of the department
and averages 56 hours per week. In order to qualify for appointment as an Ambulance
Driver/Attendant, an applicant must have been certified as an EMT/A (Emergency
Medical Technician/Attendant) and pass a promotional Civil Service Examination or an
entry level Civil Service Examination.
Ambulance #2 (Medic 12) and the reserve vehicle are housed at the Fire Department
Headquarters at Ninth and Central and are manned as required by on -duty firefighters
at the headquarters station. Medic 12 is used for emergency calls when Medic 11 is
on another call. Likewise, the reserve vehicle would respond to emergency calls
when Medic 12 is not available. There are currently no minimum training require-
ments for personnel assigned to Medic 12, however, to the extent possible, personnel
with cardiac care training are assigned.
Page 4 of 21 pages
Honorable Mayor and Members of City Council
January 15, 1980
In addition to responding to emergency calls in the City of Dubuque, the ambu-
lance service will answer non -emergency calls (primarily transporting requests) in
the City and will respond to authorized calls in Dubuque County, East Dubuque,
Illinois and five miles into JoDaviess County, Illinois. Calls into East Dubuque
and JoDaviess County must be authorized by the East Dubuque Police Department, and
calls into Dubuque County by the Dubuque County Sheriff's Department or payment
made in advance by the user. These out -of -city calls are made under written agree-
ment as authorized by City Ordinance No. 10-74 (as included in the Municipal Code
as Section 18-56).
Rates and service area are established by the Municipal Code in Sections 18-52
through 18-55. The current charge for emergency and non -emergency ambulance service
in the city limits is $35.00 per person for transportation to or from any hospital,
doctor's office, nursing home, home for the aged, convalescent home or other point
within the city. For transporting any person from a point outside the city to any
hospital or doctor's office within the city or transporting a person from any hospital
or doctor's office within the city to any point outside the city, the charge is $40.00
per person plus $.50 per mile per trip. In addition, a further charge of $10.00 per
hour may be charged for delays in excess of ten minutes not caused by the ambulance
driver. These rates were established on February 4, 1974.
In FY 1978-79 (ending June 30, 1979) the latest year for which complete statistics
are available, the ambulance service responded to a total of 3,244 calls. This was
divided between 1,411 (43.5%) emergency calls and 1,833 (56.5%) non -emergency calls.
Medic 11 responded to 1,233 (87.4%) emergency calls and Medic 12 responded to 178
(12.6%) emergency calls. Ninety-nine point four percent (99.4%) of the non -emergency
calls were performed by Medic 11. In comparison with FY 1977-78, emergency calls
were down 51 (-3.5%) from 1,462 to 1,411 and non -emergency calls were down 36 (-1.9%)
from 1,869 to 1,833.
FY 1978-79 expenditures for the ambulance operations activity totaled $169,972.77.
The $169,972.77 amount includes a nonrecurring amount of $25,393.09 representing an
ambulance purshase, but does not include any of the cost for staffing the second
ambulance; filling in during periods of vacation, sick leave or casual leave; or the
cost of dispatching or billing services. These costs representing approximately $60,000
are assigned to other activities.
Page 5 of 21 pages
Honorable Mayor and Members of City Council
January 15, 1980
FY 1978-79 income from users of the ambulance service totaled $98,441.62 or
57.9% of the direct cost of ambulance service of $169,972.77. The percentage in-
creases to 68.1% if you take out the $25,393 ambulance purchase. The direct City
subsidy for ambulance service in FY 1978-79, therefore, was $71,531.15 (169,972.77 -
93,441.62) representing 42.1% of direct cost or a subsidy of $46,138 (31.9% of direct
cost) if you adjust for the ambulance purchase. The adopted FY 1979-80 budget
anticipates the subsidy being $60,920.00 in the current fiscal year.
Impact of State Legislation Pertaining to Advanced Emergency Medical Care
The 67th General Assembly added a new Chapter 147A to the Code of Iowa entitled
"Advanced Emergency Care - Paramedic." The legislation provided for the establish-
ment of rules pertaining to a) the operation of ambulance services and b) the
certification of advanced emergency medical technicians (EMT's) and paramedics.
During late May, 1979, the State Department of Health and the State Board of
Medical Examiners issued a set of joint rules pertaining to the training, certification
and services performed by advanced emergency medical technicians and paramedics.
Such rules were effective July 5, 1979. A copy of the joint rules are attached to
and made a part of this report.
The rules establish four levels of service or training. They can be summarized
as follows:
1. Basic Emergency Medical Technicians (Basic EMT)
Training Requirement
Completion of the U.S. Department of Transportation prescribed course
for basic EMT. Involves 80-120 hours.
Continuing Education Requirement (not affected by recent legislation)
Summary of Expertise
1) Legal responsibility
2) Anatomy
3) Vital signs
4) Basic Life Support - Cardio Pulmonary Resuscitation (CPR)
5) Hemorrhage control
7) Seizure control
8) Patient handling and extrication
9) Communication
10) Emergency driving and traffic control
Page 6 of 21 pages
Honorable Mayor and Members of City Council
January 15, 1980
2. Emergency Medical Technician I (EMT -I)
Training Requirements
Certification as basic EMT and completion of modules 1, 2, 3 and 5 of
the Department of Transportation's paramedic guide:
#1 Role and responsibilities
#2 Patient assessment
#3 Shock and fluid therapy
#5 The respiratory system
Continuing Education Requirements
Renewal of certificate is required every two years. In order to be
eligible the advanced EMT must have completed at least 30 hours of continuing
education per year.
1) 6 hours of formal classroom
2) 6 hours of ambulance run evaluation
3) 6 hours of clinical experience in the hospital
4) 12 hours to be determined by the medical director
Summary of Expertise
All those listed above for Basic EMT in addition to:
1) Obtaining patient history and able to assess accurately a change in the
patient's condition.
2) Administration of intravenous solutions including IV cannulation.
3) Able to use adjunctive equipment for airway maintenance
a) Robert -Shaw
b) Oropharyngeal airway
c) Esophageal Gastric Tube Airway (EGTA)
Does not include endotracheal intubation.
4) Military Anti -Shock Trousers (MAST) garment application (Anti -Shock Trousers).
3. EMT -II
Training Requirements
Certification as basic EMT and completion of modules 1, 2, 3, 4, 5, 6
and 15 of the D.O.T.'s paramedic guide and certification in Advanced Cardiac
Life Support. Includes those modules required for EMT -I plus modules 4, 6
and 15.
Page 7 of 21 pages
Honorable Mayor and Members of City Council
January 15, 1980
#4 General pharmacology
#6 Cardiovascular system
#15 Telemetry and communication
Continuing Education Requirements
Same as for EMT -I.
Summary of Expertise
All those listed above for EMT -I in addition to:
1) Endotracheal intubation
2) Cardiac monitoring including arrhythmia recognition, defibrillation and/or
cardioversion
3) Knowledge of basic pharmacology and administration of cardiac drugs.
4. EMT -Paramedic
Training Requirements
Certification as basic EMT and completion of all 15 modules of the D.O.T.'s
paramedic guide, as well as certification in Advanced Cardiac Life Support.
Includes those modules required for EMT -II plus modules 7 through 14 inclusive.
#7 Central nervous system
#8 Soft tissues injuries
#9 Muscoloskeletal system
#10 Medical emergencies
#11 OB/Gyn emergencies
#12 Pediatrics and neonatal emergencies
#13 Emergency care of the emotionally disturbed
#14 Extrication rescue techniques
Continuing Education Requirements
Same as for EMT -I
Summary of Expertise
All of those listed above for EMT -II in addition to:
1) Overall increase in knowledge of emergent pre -hospital conditions
2) Advanced care of the newborn
3) Difficult deliveries
4) Transtracheal cannulation (trach)
Page 8 of 21 pages
Honorable Mayor and Members of City Council
January 15, 1980
5) Needle thoracotomy (Emergency treatment for collapsed lung)
6) Advanced physical assessment techniques
7) Central intravenous cannulation techniques (jugular, subclavic or
femoral sticks)
8) Familiar with the techniques for venous cutdown
The rules included provisions for current EMT's to "challenge" the EMT -I and
EMT -II certification test. Under such provisions, current EMT's could take an exam-
ination and, if pass, be certified as EMT -I or EMT -II without having to go through
the formal training requirements. The challenging process must be completed by
January 5, 1980. Failure to be certified at an advanced level means that if you are
providing advanced life support services, you can no longer do so until the appropriate
certification had been obtained.
A review of the four service levels indicates that Ambulance Driver/Attendants
assigned to Medic 11 provide an EMT -II level of care except they are not authorized
to perform endotracheal intubations. The level of care provided by Medic 12 varies
from Basic to nearly EMT -II depending on the training of the personnel available to
respond with the ambulance.
The significance to the Task Force of the state legislation and subsequent rules
was to establish conditions to which any Task Force recommendations would have to
comply and to provide a framework for discussing service levels. It was also apparent
that if our personnel didn't successfully challenge the EMT -II test that the current
level of care could not be continued.i/
RECOMMENDATIONS
Level of Service Recommendation
The Task Force dealt with the level of service question in two ways. First,
level of service in terms of level of care provided patients. It was determined
fairly early by the Task Force that it wanted to retain and, in fact, improve the high
1/As of January 15, three of the Ambulance Driver/Attendants have successfully passed
the EMT -II certification process. With three EMT-II's, it is possible to maintain the
current level of service on Medic 11. It is hoped that additional Fire Department
personnel will pass the necessary testing by the end of February.
Page 9 of 21 pages
Honorable Mayor and Members of City Council
January 15, 1980
level of care currently provided by the Dubuque Ambulance Service. This translates
into a recommendation that the level of service be at least the EMT -II level with a
goal after one year to upgrade the level of care to EMT -Paramedic level.
Second, it was determined that a city the size of Dubuque warrants more than one
advanced life support (ALS) ambulance. This is particularly true when a single ALS
ambulance is used for both transfers and emergency calls and, therefore, may not be
available when an emergency call comes in. This translates to a recommendation that
the ambulance service provide at least two ALS ambulances at all times.
Scope of Service Recommendation
Scope of service was also viewed by the Task Force in two ways. First, should
the scope of service include emergency ambulance service only, or should local transfer
service continue to be provided? The Task Force, after discussion, concluded that
transfer service, because it represents a significant portion of the workload and there-
fore income of the ambulance service, must be continued. Non -emergency calls (primarily
transfers) represented 56.6% of the calls received in FY 1978-79.
Second, should ambulance service be limited to the city limits or should service
to East Dubuque, Illinois and parts of Dubuque County, Iowa be continued. The Task
Force, after discussion, concluded that as long as two ALS ambulances were available
that the current service outside the city limits should be continued. However, it
was apparent from the discussion, that should only one ALS ambulance be provided,
there would be considerable support to limiting the service area to the Dubuque city
limits.
Who Should Provide the Service?
It turns out that the bulk of the Task Force's time and energy was spent on de-
termining who should provide the ambulance service.
The Task Force looked at having the ambulance service provided by a private
agency and, for many different reasons, decided not to give further consideration to
that option. The primary reason was that the private agencies contacted were not
interested in providing the service at the level of care that the Task Force deter-
mined necessary. There also appeared to be no interest by Dubuque County to get
into the ambulance business. Therefore, the two most likely providers of ambulance
service became the City of Dubuque and one or more of the local hospitals.
Page 10 of 21 pages
Honorable Mayor and Members of City Council
January 15, 1980
The Task Force reviewed several alternatives for city based ambulance service.
The major options discussed were as follows:
1. No change - provide one ALS ambulance.
Transfers handled by ALS ambulance.
Back-up ambulance and fill-in from on -duty Fire Department personnel
2. Eliminate Transfers (transfer service to be provided by someone else)
Provide one ALS ambulance without transfer service.
Back-up ambulance and fill-in from on -duty Fire Department personnel
3. Provide transfer service with current on -duty personnel.
Provide one ALS ambulance with no transfer duties.
Back-up ambulance and fill-in from on -duty Fire Department personnel
4. Add two civilian, eight -hour, five-day a week personnel to provide transfer
service.
Provide one ALS ambulance with no transfer duties.
Back-up ambulance and fill-in from on -duty Fire Department personnel.
5. Add six ambulance driver/attendant positions.
Provide two full-time ALS ambulances with transfer duties.
Back-up ambulance and fill-in from on -duty Fire Department personnel.
6. In the interest of having the numbers assigned in this report to the various
City options be the same number as used in the minutes to identify the same
options, number 6 will not be used.
7a. Add two civilian positions to provide transfer services and expand number of
ambulance driver/attendant positions.
Provide two ALS ambulances, one full-time ALS ambulance without
transfer duties and one back-up ALS ambulance staffed by on -duty
Fire Department personnel trained to provide advanced care.
Fill-in from on -duty Fire Department personnel.
7b. Expand number of ambulance driver/attendant positions.
Provide two ALS ambulances, one full-time ALS ambulance with
transfer duties and one back-up ALS ambulance staffed by on -duty
Fire Department personnel trained to provide advanced care.
(This is basically what we have now, except steps would be taken
to train the personnel responding with the second ambulance to
the EMT -II level.)
Page 11 of 21 pages
Honorable Mayor and Members of City Council
January 15, 1980
It was also felt that in addition to looking at various City alternatives, an
effort should be made to develop a viable hospital_ based ambulance proposal. Interest
in a hospital based proposal seemed to center on two key factors. First, since they
were already in the health care business, they were in a better position to know what
was required and could provide it more effectively. Basing the ambulance service at
a hospital provides an opportunity for building closer working relationships between
ambulance personnel and emergency room physicians and nurses. Second, it was believed
that significant savings could result from a hospital based service because the ambu-
lance attendants could be performing other duties in the hospital when not on a call.
One of the problems with the Fire Department based service is how to productively
use the time of the ambulance attendants when they are not on a call. In addition,
the added clinical expertise the ambulance personnel would attain from working in the
hospital caring for patients when not on a call would upgrade and help maintain their
advanced skills. Another of the problems of a Fire Department based service is how
to maintain the skills needed to provide advanced medical care.
Initially, the hospitals did not feel that they could submit a proposal (see
minutes of meeting no. 6 held on August 23). However,, after a presentation on the
Cedar Rapids Mercy Hospital hospital based service, it was decided by the Task Force
to have each of the three local hospitals prepare a proposal for providing ambulance
service.
The Task Force provided the following assumptions to the three hospitals for use
in preparing their proposals.
1. The service will be run on a break even basis, i.e., no hospital will sub-
sidize the operation of the ambulance service. However, proposals will in-
clude the projected cost of service. (At this point, it was also assumed
that the City would not be providing any subsidy.)
2. The City will continue to own the service and contract with one of the
hospitals to operate it. It is mutually understood that this is an ex-
clusive contract.
3. All proposals will be based on the following service levels:
a) operation of at least two fully equipped ALS ambulances;
b) staffing level of one EMT -II and one EMT-P within one year of beginning
operations. All staff will be employees of the contracting hospital.
4E. Projected cost of operating the service will include depreciation expense on
all capital equipment involved.
Page 12 of 21 pages
Direct Expense
Salaries
Medical Specialist Fees
Fuel and Oil
Vehicle Maint. & Repair
Equipment Maint. & Repair
Supplies
Miscellaneous
Training
Total, Direct
Indirect Expense
Bldg. Depr. , Int. & Ins.
Equipment Depreciation
Fringe Benefits
Administration & General
Plant Maint. & Operation
Laundry
Nursing Administration
Total, Indirect
TABLE I
COST COMPARISON OF HOSPITAL BASED ALTERNATIVES
TO PROVIDE AMBULANCE SERVICE
1 2 3
Xavier Finley Finley
Option 1 Option 1 Option 2
$229,953 $184,939 $218,653
5,000 5,000
5,000 4,620 4,620
4,000 1,000 1,000
1,400 1,400
- 13,690 13,690
2,000 2,000
33,333
4
Mercy
Option 1
$248,500
4,900
1,800
1,800
900
$272,286 $212,649 $246,363 $257,900
$ 19,899
11,540
32,193
31,030
2,700
15,000
$ 3,640
8,000
24,209
31,403
4,585
3,256
19,672
$ 3,640
8,000
28,622
36,472
4,585
3,256
21,592
$ 5,600
19,700
30,800
43,500
13,300
2,300
$112,362 $ 94,765 $106,167 $115,200
5
Mercy
Option 2
$152,500
4,900
1,800
1,800
900
6
Mercy
Option 3
7
Mercy
Option 4
$184,200 $270,900
4,800 4,800
1,200 1,200
1,200 1;200
900
900
$161,900 $192,300 $279,000
$ 7,300
19,700
18,400
28,200
17,300
2,300
$ 5,600
9,500
22,800
31,900
13,300
2,300
$ 4,300
9,500
33,600
45,200
10,300
2,300
$ 93,200 $ 85,400 $105,200
TOTAL $384,648 $307,414 $352,530 $373,100 $255,100 $277,700 $384,200
Honorable Mayor and t•lembers of City Council
January 15, 1980
5. Review of operations and policy making for the operation of the service
will be accomplished by a committee composed of representatives of each
of the three hospitals and the City.
6. Term of the contract should be three years,with provisions for renewal.
7. The proposal should include the effective date for starting the new ambu-
lance service.
8. The City will continue to provide dispatch service.
The hospital proposals were to be received by noon on Monday, November 5, 1979.
Each hospital was allowed to clarify and refine their proposal one time. The pro-
posals and subsequent refinements are attached to and made a part of this report.
The reader is asked to review the proposals at this time so they will not have to be
extensively repeated in the body of this report. There were seven alternatives sub-
mitted by the three hospitals: one from Xavier Hospital, two from Finley Hospital
and four from Mercy Hospital. The several alternatives can be identified and
labeled as follows:
1. Xavier Option One
Two ALS ambulances; one at Xavier Hospital and one at another unidentified
hospital.
2. Finley Option One
One ALS ambulance; one 12-hour per day transfer vehicle.
3. Finley Option Two
Two ALS ambulances located at Finley Hospital.
4. Mercy Option One
Two ALS ambulances and one eight -hour per day transfer vehicle; one ALS
ambulance and transfer vehicle at Mercy and one ALS ambulance at Xavier.
5 Mercy Option Two
Two ALS ambulances and one eight -hour per day transfer vehicle located at
Mercy.
6. Mercy Option Three
Two ALS ambulances located at Mercy Hospital.
7. Mercy Option Four
Two ALS ambulances; one at Xavier and one at Mercy Hospital
Page 13 of 21 pages
Honorable Mayor and Members of City Council
January 15, 1980
Table I on the following page is a cost comparison of the seven hospital
alternatives.
The Task Force met on Saturday, November 17, to act upon the various proposals.
It was determined by the Task Force that Xavier Option One, Finley Option Two and
Mercy Option Three most nearly met the guidelines set down by the Task Force. However,
further discussion noted that Mercy's Option Two provided a higher level of service
at less cost. Since it clearly met the minimum requirements set by the Task Force
and at less cost, it was decided that Mercy Option Two should compete with Xavier
Option One and Finley Option Two for the Task Force's hospital based choice.
All eleven Task Force members were present for the vote to select which hospital
based option would compete with the City option for recommendation to the City Council.
The vote was as follows:
Mercy Option Two - 6 votes
Finley Option Two- 4 votes
Xavier Option One- 1 vote
11 votes
Some of the reasons stated by the majority for selecting the Mercy option include
the following:
1. Mercy Hospital was prepared to put "up front" approximately $350,000 to cover
the cost of a) training staff before the effective date of providing ambulance
service and therefore before any income would be generated; b) building a
garage and classroom facility; c) purchasing an additional ambulance; and
d) purchasing additional equipment (see pages 2 and 22 of the Mercy proposal).
Neither Xavier Hospital, nor Finley Hospital indicated any willingness or
capability to provide such up front money.
2. Mercy Hospital exhibited the best use of ambulance personnel in the hospital
to get the cost of the ambulance service as low as possible. The time and
expense of ambulance personnel charged to other cost centers within the
hospital, when not assigned to ambulance tasks, was called "off -set" by the
Task Force. The greater the off -set, the more time being charged to other
cost centers and the lower the ambulance service cost. The off -set for Mercy
Option Two was $160,000; for Finley Option Two, it was $85,000; and for
Xavier Option One, it was "0".
3. The cost and the level of service offered by Mercy Option Two was significantly
better than either option from the other hospitals. The level of service
Page 14 of 21 pages
Honorable Mayor and Members of City Council
January 15, 1980
includes an ALS transfer vehicle not offered by the other proposals at a
cost almost $100,000 lower than the nearest comparable proposal (see Table I).
4. The start-up date offered by Mercy Option Two was superior to the other two
proposals. Mercy stated that they could be in operation within 120 days
from acceptance of their proposal. Finley Hospital stated a six-month
start-up requirement, and Xavier indicated they would require six to nine
months to get their service into operation.
The Task Force next turned its attention to which City option to compare with
Mercy Option Two. At the Saturday, November 17, meeting, the Task Force considered
two City options. First, the option known as City Option Five, which would provide
two full-time ALS ambulances with transfer duties. The second, known as City Option
7b would provide one full-time ALS ambulance with transfer duties and one back-up
ALS ambulance staffed by
vanced care. It was the
met the minimum level of
eleven member Task Force
Option 7b.
The majority of the
tion to the City Council
tion to be
presented, the Task Force chairperson stressed
on -duty Fire Department personnel trained to provide ad -
majority opinion of the Task Force that only City Option Fives
service established by the Task Force. The vote of the
was eight votes for City Option 5 and three votes for City
Task Force felt that they should present a single recommenda-
for providing ambulance service. In voting for the recommenda-
that the decision should be
based on a balance between level of service, cost and risk. The vote was as follows:
City Option Five - 4 votes
Mercy Option Two - 7 votes
11 votes
It was therefore the decision of the majority of the Ambulance Study Task Force
members to recommend to the City Council that the ambulance service be provided by
Mercy Hospital, and the level of service be two full-time ALS ambulances and one eight -
hour ALS transfer vehicle.
The primary reason the Mercy Hospital option was selected over the City option
was one of cost and level of service. The Mercy option would provide two full-time
ALS ambulances and one ALS eight -hour transfer vehicle at a cost of approximately
$225,100. The City's option of two full-time ambulances with transfer duties would
cost approximately $370,800. Upgrading the City proposal to be equivalent to the Mercy
proposal would cost approximately $419,000. The difference is the hospital can use
the ambulance personnel for other hospital services and thereby charge some of the cost
Page 15 of 21 pages
Honorable Mayor and Members of City Council
January 15, 1980
of the standby time of ambulance personnel to other cost centers within the hospital.
The City, in Option Five, has no such advantage. _Secondary reasons were those
earlier identified on page 12 pertaining to improving communication between ambulance
and hospital personnel and the benefit to the ambulance personnel in maintaining and
upgrading their skills by working in the hospital when not on a call.
There has been considerable controversy surrounding the selection of the Mercy
option to provide ambulance service to our community.
to leave it with the City, even if it involves increas
to be made here that if you want to increase the level
full-time ALS ambulances (that is, two crews dedicated
the Mercy option is the most cost-effective.
.Some have expressed a desire
ing the rate. The point needs
of service and provide two
to ambulance service) then
For the City to provide such level of
service would be very much more expensive and much less efficient. Table II on the
following page summarizes and compares the cost of the selected Mercy Option Two with
several City options. You will note that to get to a comparable dollar cost for a
City operated service, that you must give up a considerable amount in terms of the
level of service provided. Table II costs out the following options:
1. Mercy Option Two - two ALS ambulances and oneeight-hour per day, five-day
per week transfer vehicle located at Mercy.
2. Comparable City Option - two ALS ambulances and one eight -hour per day,
five-day per week transfer vehicle.
3. City Option Five - two ALS ambulances, one with transfer duties.
4. City Option 7a - one full-time ALS ambulance, one back-up ALS ambulance
staffed by on -duty Fire Department personnel and one eight -hour per day,
five-day per week transfer vehicle.
5. City Option 7b - one full-time ALS ambulance with transfer duties and one
back-up ALS ambulance staffed by on -duty Fire Department personnel.
Mercy Option Two Further Explained
Because Mercy Option Two is the recommendation from the Ambulance Study Task Force
to the City Council for providing ambulance service to the community, it is appropriate
at this point to further explain what that option involves.
As stated above in this report, the recommended Mercy Hospital option would pro-
vide for two full-time ALS ambulances and one eight -hour ALS transfer vehicle five
days per week. All three vehicles would be stationed at Mercy Hospital.
Page 16 of 21 pages
TABLE II
COST COMPARISON OF RECOMMENDED MERCY HOSPITAL OPTION
WITH VARIOUS CITY ALTERNATIVES FOR PROVIDING AMBULANCE SERVICE
Direct Expense
Salaries
Medical Specialist Fees
Fuel & Oil
Vehicle Maint. & Repair
Equipment Maint. & Repair
Supplies
Miscellaneous
Training
Total, Direct
Indirect Expense
Building Depr. , Int. & Ins.
Equipment Depreciation
Fringe Benefits
Administration & General
Plant Maint. & Operation
Laundry
Nursing Administration
Total, Indirect
1
Mercy
Option 2
$152,500
4,900
1,800
1,800
900
2
Comparable
City Option
$259,800
7,500
1,024
5,850
$161,900 $274,174
$ 7,300 $ 4,476
19,700 24,000
18,400 112,100
28,200 4,300
17,300 -
2,300 -
3
City
Option 5
$231,800
6,500
1,204
5,000
$244,324
$ 2,976
16,000
103,200
4,300
4
City
Option 7A
5
City
Option 7B
$149,157 $121,143
7,500
1,024
5,850
6,500
1,024
5,000
$163,531 $133,667
$ 4,476
24,000
62,693
4,300
$ 2,976
16,000
53,793
4,300
$ 93,200 $144,876 $126,476 $ 95,469 $ 77,069
TOTAL $255,100 $419,050 $370,800 $259,000 $210,736
Honorable Mayor and Members of City Council
January 15, 1980
To initiate the hospital based service, Mercy Hospital would hire nine registered
nurses (R.N.'s), nine basic EMT's, one instructor and one ambulance service manager.
The staffing pattern would involve assigning one R.N. and one basic EMT to each unit.
The ALS transfer vehicle would operate from 7:00 a.m. to 4:00 p.m. daily, five days
per week. The advantage of this staffing pattern is that the advanced care provided
by the R.N.'s is guided by the Nurse Practice Act rather than the new advanced care
legislation. This enables Mercy Hospital to provide the advanced level of care with-
out the delays of hiring, training and certifying EMT-II's.
Both the R.N.'s and basic EMT's would be trained and capable of providing ad-
vanced care prior to the initiation of the service. Their duties will be:
R.N. - Advanced Care:
IV insertion
Administer medications
Arrhythmia recognition
Defibrillation
Intubation
Basic EMT - Support or Basic Care:
Attach monitor electrodes
Set up IV's
Basic life support - CPR
Prepare equipment
Bandaging
Splinting
Extrication
The training for the R.N.'s will include:
1. Advanced Cardiac Life Support
2. Ability to provide five minutes of one person uninterrupted CPR
3. Agility testing (i.e., lifting 200 lb. cot up and down two flights of
stairs and into the back of an ambulance, one mile run in eight minutes,
sit-ups and deep knee bends). This agility test is utilized throughout
the state.
4. Defensive and emergency driving
5. Extrication techniques
6. Emergency care and triage
7. Communications
Page 17 of 21 pages
Honorable Mayor and Members of City Council
January 15, 1980
Basic EMT training will initially include everything listed above except ad-
vanced cardiac life support.
Training for all personnel will be on -going. After 12 months, R.N.'s will be
prepared to challenge the paramedic exam, while basic EMT's will be prepared to com-
plete the EMT -II exam. In addition, the hospital based ambulance service has the ad-
vantage of providing continuing training through "down -time" in -hospital experience.
How Should the Ambulance Service be Financed?
Ambulance service can be financed entirely from user fees or from a subsidy from
the City or other governmental unit or a combination. Although a subsidy can be an
important factor in keeping the ambulance user rate down, for purposes of analysis,
each alternative being considered should include an equal subsidy or exclude a sub-
sidy entirely for purposes of comparability. One of the ground rules for the hospital
proposals was that they operate on a break-even basis. So, for purposes of evaluating -
the hospital options, no subsidy was assumed.
At its November 20 and December 4 meetings, the Task Force discussed the rate
schedule for the recommended hospital based ambulance service. The Task Force adopted
a three-tier rate structure as follows:
Transfer Rate $ 63
Basic Service Rate $110
Advanced Care Rate $170
As the rate is evaluated, keep in mind that it provides fora -significant increase
in the level of care and involves no subsidies. In response to significant public
comment that the ambulance service should be subsidized to get the cost down, the Task
Force, at its December 4 meeting, agreed to "strongly suggest to the City Council that
a subsidy be considered in that it would lower the proposed rate structure."
Table III defines each category in the three-tier rate structure and provides
examples of the level of care which would be provided.
Table IV presents ambulance rates and levels of care in other Iowa communities.
Other Recommendations
The Ambulance Study Task Force recommends that a 13-member ambulance commission
be established with the following purposes:
Page 18 of 21 pages
Category Fee
I. Transfer
II. Basic
TABLE III
Definition
$ 63 This category refers to scheduled transportation
of a patient from:
1) an extended -care facility to a hospital;
2) a hospital to an extended -care facility;
3) inter -hospital transfers;
4) from or to a private residence or any combina-
tion thereof.
$110 This category refers to any treatment which may
be performed by a Basic EMT at the scene of an
accident or illness.
III. Advanced $170 This category refers to any treatment which re-
quires the expertise and medical intervention of an
R.N. or Advanced EMT at the scene of an accident
or illness. It includes the level of care rendered
to a critically ill patient in cases of unexpected
cessation of vital signs (i.e. cardiac or res-
piratory arrest) .
Examples of Care/Remarks
This category will affect only those patients
whose condition will not be adversely affected
by a delay in transport and does not require
advanced emergency medical care as defined
by recent legislation. When questions arise,
the coordinator of the service will be consulte(
Again, the condition of this type of patient
does not require advanced emergency medical
care as defined by recent legislation. Types
of care include:
1) bandaging
2) splinting
3) control of bleeding
4) extrication
Types of medical care include:
1) IV cannulation;
2) cardiac monitoring and dysrhythmia
recognition;
3) the administration of medication, either IV,
IM or sub Q;
4) MAST application;
5) advanced methods of maintaining a patient
airway (i.e., assisted ventilation, nasal or
esopharyngeal airway, etc.);
6) initiation of BLS techniques (CPR);
7) initiation of ACLS techniques
a. monitoring and/or defibrillation
b. esophageal or endotracheal intubation
c. the administration of cardiac drugs
TP T T,E IV
SERVICE/LOCATION
CONTACT
PERSON
NUMBER OF
VEHICLES
LEVEL OF
SERVICE
BASE
PERSONNEL
RATES
L. Mary Greeley
Mike Young, EMT-
Two currently. Will
EMT-P
Hospital
1 EMT-P
Base Rate: $60.00
(Ames)
P, Service Coor-
dinator
have three in spring.
1 Basic EMT
Plus $1.50/loaded
mile
Pop. 41,700
(5:17 Employees
are female)
ALS: $120 Plus
$1.50/loaded mile
Chargeable Supplies
Suction Catheters
Monitor Electrodes
Oxygen
/
Dressings
•
Suction
-
Monitor
. Area Ambulance
Tim Trosky
Three
EMT -II
Hospital
1 EMT -II and
Base Rate:
Service
EMT -II
1 EMT -I or
City - $57
(Cedar Rapids)
Ambulance Super--
Basic EMT per
County- $64 non -
op. 109,900
visor
•
Team
emergency plus
$ .74/mile
13 EMT-II's
Port-P.ort
9 EMT-I's
Standby - $57/hour
•
9 Basic EMT's
Supplies:
(8:13 Employees
are female)
Monitor - $50
Telemetry - $130
.
40% of salaries
Major Trauma - $13
Dffset by traumMinor
center
Trauma - $6.50
SERVICE/LOCATION
CONTACT
PERSON
NUMBER OF
VEHICLES.
LEVEL OF
SERVICE
BASE
PERSONNEL
RATES
1. Johnson County
Mike Deeds, RN
Three (Two Primary
EMT -II
Private
1 EMT -II and
Base Rate:
Ambulance
(Iowa City)
EMT -II, Coordin-Response
ator
Johnson County
Vehicles,
One Standby)
(Between 080
1200 and
1900-2200
1 Basic EMT
Per Unit
$60 plus $1.50/
loaded mile
op. 46,850
Ambulance Ser-
Respond from
Currently employ
vice
Mercy and U
9 EMT-II's
Advanced Care:
of I Emergency
11 Basic EMT's
Department
(2:20 Employees
are female)
$150 plus $1.50/
loaded mile
Standby:
,i
$7.50/hr/attend.
-
Plus $30/hour for
the vehicle
Supplies:
Cervical Collar - $8
Oxygen - $8.00
Suction - $5.00
Dressings - $6.00
Splints - $6.00
. Capital -City
Marty Hutt,
Eight Units
Current EMT-
Private
Basic EMT's
Base. Rate:
Ambulance
Service.Coor-
Basic Planning
dinator
80% of calls are non-
on Paramedic
(1:45 employees
$45 plus $1.60/loade(
(Des Moines)
op. 194,000
emergency .
Service
Majority of per-
are female)
mile
Supplies:
sonnel have been
trained in coro-
nary care
Oxygen - $10.00
Splints - $5.00
Medical Supplies -$5.
Rates will rise when
advanced care is pro-
vided
SERVICE/LOCATION
CONTACT
PERSON
NUMBER OF
VEHICLES
LEVEL OF
SERVICE
BASE
PERSONNEL.
RATES
5. Des Moines Fire
Chief Murray
Four Primary Response
Basic EMT
Fire Dept.
1 Senior Medic
Not available at
Department
vehicles, two standby
vehicles
(Basic EMT)
1 Fire Medic
this time
Pop. 194,000
(Basic EMT)
Approximately 8,000
calls/year
All employees
are male
6. Midwest Inter-
Doug Cummings,
Three Emergency, One
Basic EMT
Private
All Basic EMT's
Base Rate:
City Ambulance
Coordinator
Non -Emergency
(Obtained
with the ability
(Sioux City)
Approx. 6,500 calls/
City contractto
6/1/79)
provide /
cardiac monitor -
$50.00
Pop. 82,000
year
ing
Emergency Response =
'
$12.00
Night Response - $8.00
Supplies:
CPR - $25.00
Monitor - $20.00
Oxygen - $12.00
*-Maximum charge of
$75 for patients
within city limits -
specified in city
contract
SERVICE/LOCATION
CONTACT
PERSON
NUMBER OF
VEHICLES
LEVEL OF
SERVICE
BASE
PERSONNEL
RATES
7. M & M Ambulanc
Service
(Davenport)
Pop. 100,300
Darryl Chris-
tensen, Coor-
dinator
Three Primary Response
vehicles
Two Standby vehicles
Basic EMT
No Advanced
Care provided
Private with
city contract
Basic EMT's
(4:21 employees
are female)
Base Rate:
$55.00 in city
County calls:
$55.00 plus $1.50/
loaded mile
All supplies used ar
charged to the
patient
8. Superior Ambu-
lance Service
(Burlington)
Pop. 29,900
Don Morgan,
Coordinator
Two Primary Response
vehicles
One Standby vehicle
Approximately 800
calls annually
Basic Care
Service will
accept only
non -emergency
calls
Private
1 Basic EMT
Remainder of
personnel
trained in ad-
vanced first -
aid
Base Rate:
$65.00 in city
County Calls:
$65.00 plus $1.50/
loaded mile
Supplies:
Oxygen - $7.50 city
- $15.00 out
of city
9. Burlington Fire
Department
Pop. 29,900
Fire Chief Don
Mosey
Four vehicles -
three of these are
fully equipped
modular. -type ambu-
lances
Basic EMT
Fire Depart-
ment
Currently employ
two Certified
EMT-II's with
the remainder
being Basic
EMT's
Base Rate:
$75.00
Out -of -Town Trans-
fers (i.e. Iowa City
$205
1
SERVICE/LOCATION
1.
CONTACT
PERSON.
NUMBER OF
VEHICLES
LEVEL OF
SERVICE
BASE
PERSONNEL.
RATES
). Waterloo Fire
Chief Harold
Three Primary Re-
Basic EMT
Fire Depart-
Basic EMT's
Base Rate:
Department
Smith
sponse vehicles
ment •
(2 of the Pri-
mary Response
$37.50 (to be raised
op. 71,500
Two Standby vehicles
Approximately 3300
calls/year. No trans-
vehicles are
staffed with
on -duty fire
fighters)
to $50.00) plus
$1.50/loaded mile.
This service is sub-
sidized by tax dollar
fers
Council Bluffs
Wayne McCunn
Two Primary Response
Currently Basic
City owned
Basic EMT's
Base Rate:
Ambulance Ser-
vehicles
EMT with cardiacand
operated
'
vice
monitoring ca-
(Seven employees$65.00
plus $1.00/mil
'op. 60,500
3500 calls annually
pabilities
Both vehicleshave
based at
fire station
completed
Creighton Uni-
versity's Para-
Port -to -Port
County:
medic Training
Program in 1976
$91.00 plus $ .50/
loaded mile
•
Round trip rate .
(within corporate
limits and return
trip within 5 hours)
$85.00 plus mileage
Supplies:
Oxygen - $10.00
.
OPULATION OF
UBUQUE - 63,000
11
Honorable Mayor and Members of City Council
January 15, 1980
1 The Ambulance Study Task Force recommends that a 13-member ambulance commission
be established with the following purposes:
a) To enforce the policy that the ambulance service in one hospital does not
adversely affect the patient's option to go to the hospital of his/her
choice. (if the condition of the patient was such that he/she could not
make a choice and there was no relative or other responsible person at
the scene to make a choice, then the patient would go to the nearest
hospital as defined by a geographic division of the City.) The Task
Force felt very strongly about protecting the right of the patient to go
to the hospital of his/her choice.
b) To set and review rates.
c) To oversee the continuing education of ambulance driver/attendants in order
to achieve and maintain the level of care called for.
d) To cause protocol to be reviewed and approved by the appropriate medical s
personnel at the appropriate time intervals.
e) To address complaints, perhaps through a hearing procedure, both from
within and outside the ambulance service.,
The 13-member ambulance commission would be made up as follows:
2 representatives from each hospital
2 consumers, residents of Dubuque
1 consumer, resident of East Dubuque
1 consumer, resident of ambulance service area not from Dubuque or East
Dubuque
1 nursing home representative
1 Dubuque City government representative
1 physician appointed by the Dubuque County Medical Society
13
2. The City should continue to receive calls from the general public for emergency
ambulance service and relay such requests to the hospital based ambulance
service for prompt dispatch. Requests for transfer service would be handled
directly by the hospital based ambulance service. The City should continue
to provide the telephones currently in place. Any additional telephone
expense would be the responsibility of the hospital based ambulance service.
Page 19 of 21 pages
Honorable Mayor and Members of City Council
January 15, 1980
3. The City of Dubuque should continue to provide first responder vehicles and
dispatch the nearest engine company to all cardio/pulmonary life threatening
calls. Often the engine company can arrive at the scene before the ambu-
lance and begin CPR or other emergency procedures prior to the arrival of the
ambulance.
4. It is recommended that the Mercy Hospital ambulance service begin operation
not later than 120 days from the time of City Council approval.
TIMETABLE FOR IMPLEMENTATION
It is anticipated that the Mercy Hospital based ambulance service could be ready
for operation within 120 days after City Council approval. However, before it can go
into operation, it must receive approval through the Health Systems Agency process.
Such process would not take longer than 120 days and includes the following steps:
1. Mercy Hospital submits a letter of intent to the Office of Health Planning
of the Iowa State Department of Health.
2. Sixty days later, Mercy Hospital will receive a letter from the Iowa State
Department of Health, requesting that an application be filed. Appropriate
forms will accompany the letter.
3. The application is prepared and submitted.
4. The review process then begins and takes from 50 to 60 days:
a) Community informational meeting;
b) Project review;
c) Subarea review;
d) Board review; and
e) Committee on Need Counsel review.
Pending the Health System's Agency approval, Mercy Hospital will begin immediately
recruiting and training ambulance personnel. Members of the Ambulance Commission could
also be appointed during this period and organizational meetings held.
CONCLUSION
The Ambulance Study Task Force was established by the Dubuque City Council to re-
view and evaluate the current ambulance service being provided by the Dubuque Fire
Department and make suggestions, identify alternatives and make recommendations. The
Page 20 of 21 pages
Honorable Mayor and Members of City Council
January 15, 1980
Task Force has met twenty-one times and spent hundreds of hours in its meetings, re-
search and deliberations. It has worked long and hard and should be commended.
This report attempts to summarize the major issues, conclusions and recommenda-
tions of the Task Force. But, at best, it is only a summary and does not purport to
capture all the suggestions, feelings and deliberations of the Task Force.
It is unfortunate that the Task Force and its ultimate recommendation became
controversial. However, it was probably inevitable because of the very make-up of
the group which included representatives of the local hospitals, nursing homes, City
government and community. Some members have prepared written comments which are
attached to and made a part of this report.
Whether you agree with the Task Force recommendations or not, as you evaluate the
report and its recommendations, keep in mind to evaluate each proposal or option using
the criterion of level of service, cost and risk. In this way you can overcome some
of the emotion of the issue and more fairly evaluate and compare the recommendations
and its several alternatives. If you don't keep this criterion in mind, it is easy to
drift into supporting a less expensive alternative but one which also has a much lower
level of care. In the ambulance business, as in other, things, you tend to get what you
pay for. More service, less risk, tends to cost more. Less service, higher risk,
tends to cost less. The important thing is to know what you are getting for your
money and achieve an acceptable balance between the level of care, cost and risk.
ACTION STEP
The action step is for the City Council to review this report, study its recom-
mendations and make a decision(s) on what changes, if any, should be made in the am-
bulance service in the City of Dubuque.
The Task Force stands ready to assist you in your deliberations in any way you
see fit. Please feel free to call upon us.
The Task Force members appreciate the opportunity to serve in this important effort.
cc: Ambulance Study Task Force Members
Respectfully
submitted,
6-e(1A4 'V
W. Kenneth Gearhart, Chairperson
Ambulance Study Task Force
Page 21 of 21 pages
ATTACHMENTS
3 3
Cu (D
-< 2
0
OD -s
v
Q
l0
v 3
LO
MEMORANDUM DATED MAY 8, 1979 FROM KEN CEARHART ENTITLED
"OUTLINE OF STUDY OF AMBULANCE SERVICE"
THE CITY OF
DUBUJQ TE
A
COM4f UN ID( \
GILBERT D. CHAVENELLE CITY MANAGER
CITY HALL D U B U Q U E, I O W A 5 2 0 0 1
TELEPHONE 3 19 - 5 8. 3- 6 4 4 1
April 25, 1979
Honorable Mayor and
City Council
Dubuque, Iowa
Dear Members of the City Council:
Councilman Tully, at the City Council meeting of March l9th, requested
staff to prepare an outline of a study of ambulance service. The purpose
of this letter is to transmit a report on this subject prepared by Ken Gear-
hart.
Time has been scheduled at your briefing session of Wednesday, May 2nd
to discuss the report. If you have any questions on the report please con-
tact Ken Gearhart or myself.
Sincerely,
Gilbert D. C avenelle
City Manager
GDC/jr
Enclosure
cc: Fire Chief
Health Director
Management Systems Analyst
THE CITY OF
DUBUQUE r�\\l l�'\ GILBERT D. CHAVENELLE CITY MANAGER
CITY HALL D U B U Q V E, I O W A 5 2 0 0 1
cT�✓ Vfi 10
cCM'%1UN1T'1 V" TELEPHONE 3 19 - 5 8 3- 6 4 4 1
FACET
April 23, 1979
Revised May 8, 1979
TO: Gilbert D. Chavenelle, City Manager
FROM: Ken Gearhart, Management Systems Analyst
SUBJECT: Outline of Study of Ambulance Service
Introduction
Councilmember Tully, at the City Council meeting of March 19, 1979, requested
staff to prepare a framework or outline of a study of ambulance service. The pur-
pose of this memo is to present such study outline.
Background
The Dubuque Fire Department provides ambulance service to the citizens and
visitors of Dubuque and surrounding areas. The department maintains two fully
equipped first -line ambulances and one reserve vehicle which can be converted
into an ambulance as needed. Ambulance #1, which is the primary or first ambu-
lance to be used, is centrally located at Fire Station No. 4 at 1697 University
Avenue. This ambulance is operated by six Ambulance Driver/Attendants on a three
platoon system (two each 24 hour period) which is the same as worked by fire fight-
ing personnel of the department and averages 56 hours per week. In order to qualify
for appointment as an Ambulance Driver/Attendant an applicant must be certified as
an EMT/A (Emergency Medical Technician/Attendant) and pass a promotional Civil
Service Examination or an entry level Civil Service Examination.
Ambulance #2 and the reserve vehicle are housed at the Fire Department Headquarters
and are manned as required by on -duty fire fighters at the Headquarters Station.
Ambulance #2 is used for emergency calls when Ambulance #1 is on another call.
Likewise, the reserve vehicle would respond to emergency calls when Ambulance #2
is not available.
In addition to responding to emergency calls in the City of Dubuque the ambulance
service will answer non -emergency calls (primarily transporting requests) in the city
and will respond to authorized calls in Dubuque County, East Dubuque, Illinois and
five miles into joDaviess County, Illinois. Calls into East Dubuque and joDaviess
County must be authorized by the East Dubuque Police Department.and calls into
THE CITY OF D U6 UQUE
-2-
Dubuque County by the Dubuque County Sheriff's Department or payment made in
advance by the user. These out -of -city calls are made under written agreement as
authorized by City Ordinance No. 10-74 as included in the Municipal Code as
Section 18-56.
Rates and service area are established by the Municipal Code in Sections 18-52
through 18-55. The current charge for emergency and non -emergency ambulance
service in the city limits is $35.00 per person for transportation to or from any
hospital, doctor's office, nursing home, home for the aged, convalescent home or
other point within the city. For transportingan
to anyhospital Y person from a point outside the city
p' tal or office within the city or transporting a person from any
hospital or doctor's office within the city to any point outside the city is 4
person plus $.50 per mile per trip. In addition, a furthergeolY 0 per hcur
Per
may be charged for delays in excess of ten minutes not caused by the ambulance
driver.
In FY 1977-78, the latest year for which complete statistics are available, the am-
bulance responded to a total of 3,331 calls. This is divided between 1,462 (43.9%)
emergency calls and 1,869 (56. 1 %) non -emergency calls. Ambulance #1 responded to
1,299 (88.9%) emergency calls and Ambulance =2 responded to 163 (11. 1 % em r
calls. Ninety-nine point five percent (99.5%) of the non- r ) e gency
per-
formed by Ambulance I. emergecalls were # In comparison with FY 1976-77 emergency calls were down
31 (-2.0%) from 1,493 to 1,462 and
non -emergency calls increased 376 (25.2%)
1,493 to 1,869. from
FY 1977-78 expenditures for the ambulance operations activity totaled
4The $141,314.06 amount includes a nonrecurring amount of $5,136.58 forequiment
•
but does not include any of the cost for staffing the second ambulances fillin P dur-
ing periods of vacation, sick leave or casual leave; or the cost of dispatchinor
billing services. These costs are assigned to other activities. g
m users
totaled $101,126.12 in FY 1977-78 or 71.6% of the direct cost for ambulance service
of $141,314.06. The city subsidy for ambulance service in FY 1977-78 was therefore
$40,187.94 ($141,314.06 - $101,126.12) or 28.4%of the direct cost. The adopted
FY 1979-80 budget anticipates the subsidybeingP
The accounts receivable as of June 30, 178 was $ 1 , 991. 84 •(37.4 in Charge-offsFY 1 f un-0,
collectable accounts during FY 1977-78 totalled $13,023.96 ($10 3411.92of this amount
was turned over to a collection agency and some income may be forthcoming from
collections) .
THE CITY OF D U B U Q U E
-3-
Proposed Outline of Ambulance Study
The following outline for an Ambulance Study was prepared by a special committee
composed of Bob Dunphy, Fire Chief; Art Roth, Health Director and Ken Gearhart,
Management Systems Analyst. Input was received from jay Jones, Richard Jones and
Rudolph Vera.
The proposed study areas are not mutually exclusive but appear
to
approach to studying this important service. The outline sasfollowsesent a logical
Outline of Ambulance Studv
A. Purpose Statement: To review and evaluate ambulance services
provied the
citizens and visitors of the City of Dubuque and make appropriate recommenda-
tions .
B. Objectives(s): To provide the community with the highest ambulance service consistent with a reasonable level of risk andthee eabil t of
the community to pay for it. Y
C. Proposed Areas to be Studied and Evaluated and Recommendations Prepared as
Appropriate:
1. What Level of Ambulance Service Should be Provided?
This study area pertains primarily to the level of training
attendant(s)
and to the type provided the
of vehicle and medical equipment used. Alter-
native service levels should include the following:
(a) Highest Level - This level of service would involve having a h si '
or physician's assistant riding the ambulance andp Y clan
providing
medical care at the scene of an emergency and enroute to the hospital.
(b) Current Level - The current level of service is a "paramedic" type of
service. The six Ambulance Driver/Attendant positions have received
advanced EMT training and are certified as EMT/A's (Emergency
Medical Technician/Ambulance) . These "technicians" are authorized
to undertake certain advanced medical procedures. They operate under
"standing orders" established by a supervising doctor which identify
what medical response should be given in a certain set of circumstances.
When the emergency circumstances so indicate they may (a) administer
drugs; (b) perform a tracheal intubation;d c
tior.; and () perform a cardiac defibrilla-
() perform other advanced medical procedures. The
THE CITY OF D UEBUQU E
-4-
"technicians" are in contact with the -hospital via radio while per-
forming such advanced emergency medical care.
It should be noted, however, that in those approximately 11% of
emergency calls responded to by Ambulance #2, the level of training
of the attendants and, therefore, the level of service provided
may be less than described above. As stated earlier in this memo,
the second ambulance is manned as needed by on -duty fire fighter
personnel assigned to the Headquarters Station. They probably do not
have the training and proficiency of the full-time Ambulance Driver/
Attendants. The city is trying to assure a high level of training by
providing a salary supplement to each fire fighter who is certified as
an EMT/A ($15.00 per month) and who has successfully completed
the coronary care course ($10.00 per month) .
It should also be noted that the division chief and the nearest engine
company respond to all resuscitator calls. This is done because the
engine company often has a quicker response time than the ambulance
and can begin basic life support care before the ambulance arrives.
(c) Intermediate Level - The attendants at this level of service would be
certified as EMT/A's (Emergency Medical=Technician/Attendant) who
would be able to provide a high level of first -aid but would not be
authorized to perform any of the advanced emergency medical proce-
dures identified under (b) above.
(d) Minimum Level - This level of service would provide for only minimum
or basic first -aid at the scene of an emergency and enroute to the
hospital with the primary purpose of the service to get the sick or in-
jured to the hospital as soon as possible.
(2) What Should the Scope of Service Be?
This study area includes two important facets of providing ambulance ser-
vice. First, should only emergency ambulance service be provided or should
emergency and non -emergency service be provided. This is basically the
question of who handles "transfers." "Transfers" are non -emergency ser-
vice requests which involve transporting a patient from the hospital to their
home, from the hospital to a nursing home, from their home to the hospital
or some similar combination. Transfers represent a significant percentage
of the ambulance service workload and income. Second, should the ambu-
lance service be limited to the city limits or is it appropriate to provide
service into Dubuque county and nearby areas in Wisconsin and Illinois?
THE CITY OF D U B U Q U E
-5--
Alternatives or options to be studied should include the following:`
(a) Emergency ambulance service only?
(b) Emergency and non -emergency service?
(c) Transfer service only?
-- within city limits or service area only?
-- to Iowa City and Rochester?
(d) Does transfer service include taking person transported to their
room or is this responsibility of nursing home?
(e) Service area to be limited to city limits?
(f) Service area to be limited to city limits and Dubuque County?
(g) Service area to include portions of Wisconsin and Illinois?
3. Who Should Provide the Service?.
This study area pertains to who should provide the service. It includes
the question: Is the City Government the best agency to provide ambulance
service? Alternatives or options to be studied should include the following:
(a) Private Sector Organization
(1)
(2)
Hospital based ambulance service
Private contractor ambulance service
(b) Public Sector Organization
(1) City government
(2) County Government
(c) Combination of Private and Public Sector Organizations
THE CITY OF DUF3UQUE
-6-
4. How Should the Ambulance Service be Financed?
This study area is concerned with who
pays (user, how
much. The issue is to what extent is the ambulance lservice to bety, county)nd self-
supporting? That is, paid for by the user. Who should subsidize the
ambulance service if it is not to be totally self-supporting? Items to be
studied under this heading should include the following :
(a)
What is the total cost of the ambulance service including direct and
indirect Fire Department expenses and the cost of billing and collect-
ing for ambulance service?
(b) What percent of the total cost of providing ambulance service should
be paid by the user? (i. e. , 100%, 50%)
(c) What should be the basis of the rate charged the user?
(1) Total estimated cost of service divided by estimated number
of users.
(2) Services provided
(3) Mileage
(4) Time involved
(5) Supplies used
(6) Combination of above
(d) If the ambulance service is not to be 100% self-supporting who
should subsidize the ambulance service?
(1) City
(2) County
(3) Other
(e) What rate should be charged for calls outside the city.
THE CITY OF DUBUQUE
-7-
(f) Should a "surcharge" be charged to out of city calls to cover a
portion of the "standby" cost of providing ambulance service? If
so, how much?
(g) Review ambulance billing and collection procedures.
(h) Identify alternative funding sources and arrangements.
5. Ambulance Personnel Issues
This study area involves certain personnel management issues resulting
from a very small number of highly trained technicians providing a highly
visible and important service. The areas to be studied should include the
following:
(a) Entrance standards for Ambulance Driver/Attendant position
- (b) Salary and benefits for Ambulance Driver/Attendant position
(c) Budget for ambulance operation activity
(d) Lack of promotional opportunities
(e) Should job description be changed
(f) Productive use of time when not on a call
(g) 8 hour work day vs. 24 hour work day
(h) Should Ambulance Driver/Attendant be a member of the Fire Retirement
System or Social Security/IpERS retirement program?
(i) Organizational location and relationship of ambulance service to rest
of department
(i)
(k)
Training level of back-up crews responding with Ambulance #2
Need for ambulance coordinator
THE CITY OF DUBUQUE
-8-
6. Imoact of Proofed State Rules on Ambulance Service
The State Department of Health and the Board of Medical Examiners,
pursuant to legislation passed last year, are in the
process of
rules "relating to the training and certification of and the servicespting per-
formed by advanced emergency medical technicians and paramedics
Part of this study should be to determine the impact, if any, of these rules
on the ambulance service as it is currently bein can the current high level of emergencyg provided. For example,
medical care continue to be pro-
vided after adoption of the training and certification rules by the State
Department of Health and Board of Medical Examiners?
Wilr
qualify for certification as "Advanced EMT -I, Advanced MTlIoIoo personnel
medic" which will authorize them to rovi r Para -
care?" p de "advanced emergency medical
7. Composition of a Task Force or Study Grou to Undertake Stud
Service
Ambulance
If the City Council deems it appropriate that a stud
study ambulance service the following eleven y group be formed to
posed; member study group is pro-
3 members representing 3 area hospitals -- one should be appointed
from each hospital but not necessarily the Hospital Administrator.
The nurse or doctor concerned with supervision of one of the emer-
gency rooms should be appointed.
3 members from the City of Dubuque -- Fire Chief, Health Dir
and one Ambulance Driver/Attendant, ector
1 representative of the Dubuque County Medical Society
1 representative of Dubuque nursing homes
3 citizen members
11 members
Staff support to the Study Group would be provided by the City Manager's
Office.
THE CITY OF DUBUQUE
-9-
Action Required
The Action Step is for the City Council to discuss the need for an Ambulance Study.
If such a study is deemed appropriate the study group should be established by the
City Council; the members appointed; and the "charge" given. A report should be
required within three months.
If you have any questions on this memo, please contact me.
KG/jr
cc: Fire Chief
Health Director
Sincerely,
Ken Gearhart
Management Systems Analyst
3
C
rt
(D
V1
MINUTES OF TASK FORCE MEETINGS
MINUTES OF AMBULANCE STUDY TASK FORCE MEETING
The Ambulance Study Task Force held its first meeting on Thursday, July 5th at
4:00 p.m., in the City Council Chambers. Members present were: Don Allendorf,
Phyllis Anger, Bob Dunphy, Pat Gabrielson, Gary Rieniets, Jack Schaefer and Anne
Sweeney. Members absent were: Dr. Rose, Art Roth and Ken Sargent. The Ambu-
lance Driver/Attendant member had not yet been designated. Others present included
Ken Gearhart, Randy Peck and Rick Jones.
Mayor Wertzberger opened the meeting by expressing the city's appreciation to the
Task Force members for their willingness to serve. The Mayor stated the Task Force
must look at the level of ambulance service consistent with city budget policies and
limitations. Mayor Wertzberger then designated Ken Gearhart, Management Systems
Analyst in the City Manager's Office, as temporary chairman until the Task Force has
had an opportunity to organize itself.
Ken Gearhart said he saw his role as temporary until the Task Force members got to
know each other and felt comfortable in selecting their own chairperson. He further
stated that he saw the primary purpose of the meeting as one of introductions, organi-
zation and selecting the next meeting date and site.
At this time each member was asked to introduce themselves, indicate what their
interest in the ambulance service was and what they hoped to accomplish through the
study.
This was followed by a discussion of the best time, location and frequency of future
meetings. It was the consensus of the group that future meetings should be held at
4:00 p.m. and limited to an hour and a half. It was further agreed that the Task Force
would have to meet weekly in the beginning. It was decided that the next two meet-
ings would be at 4:00 p.m. , Tuesday, July 17th at the Fire Headquarters Training Room
(subsequently changed to City Council Chambers due to unavailability of the Training
Room), and at 4:00 p.m., Tuesday, July 24th at a site to be determined.
The following background materials were distributed for review before the next meeting:
1. Task Force Membership List
,-2'. Resolution establishing Ambulance Study Task Force
3. Memo from Ken Gearhart to Gilbert Chavenelle setting out background
and outline for ambulance service study
4. joint rules of the State Health Department and State Board of Medical
Examiners pertaining to the "Training and Certification of and Services
Performed by Advanced Emergency Medical Technicians and Paramedics."
5. City ordinances pertaining to ambulances
6. Letter from Jim Schreiber, President, Dubuque Professional Fire Fighters'
Association
Ambulance Study Task Force Meeting
Page Two
Ken Gearhart asked the Task Force members to read the letter from the Fire Fighter' s
Association and particularly the paragraph which reads, in part: "In conclusion, the
Association feels that the task force should not discuss mandatory subjects of bar-
gaining (i.e., most of those items under "Ambulance Personnel Issues"). I suggest
that we have a meeting prior to the task force study to discuss what should not be
talked about . ." The "Ambulance Personnel Issues" are found on page 7 of Ken
Gearhart's memo.
Ken Gearhart reported that a meeting on the letter took place Thursday morning in his
office. In attendance were: Jim Schreiber and Pat Kutsch from the Association,
Chief Dunphy, Randy Peck and Ken Gearhart. During the discussion it became apparent
that certain "Issues" were clearly not mandatory subjects of bargaining; some were in
"grey" areas and some clearly were. The Association's concerns centered on item (b)
Salary and Benefits for Ambulance Driver/Attendant Positions; and item (g) 8 Hour Work
Day vs. 24 Hour Work Day.
Although the city does not totally agree that these items cannot be discussed by the
Task Force, it does agree that it serves no useful purposes for the Task Force to have
a loud and long discussion of salaries and working conditions for Ambulance Driver/
Attendants and that these subjects should be left to the bargaining table. The primary
purpose of the Ambulance Study is to look at alternative service levels and associated
risks and costs and need not get into the specifics of salaries and working conditions
for Ambulance Driver/Attendants.
In response to requests for additional information, Ken indicated he would send out:
a) a copy of the budget for ambulance service as approved for FY 1979-80 which repre-
sents direct costs for ambulance service; and b) the portion of the FY 1978 Fire Depart-
ment Annual Report dealing with the ambulance service and would begin to work up and
have ready for the next meeting the total cost of ambulance service including direct
costs and indirect costs. Indirect costs include: a) cost of manpower filling in for
Ambulance Driver/Attendants when they are on vacation or ill or when Ambulance No. 1
is on a call and other fire personnel respond with Ambulance No. 2; b) the communica-
tions or dispatching cost attributable to the ambulance service; and c) the cost of
billing and collecting ambulance bills.
The balance of the meeting involved a general discussion of how the Task Force should
proceed with the study. It was generally agreed that the Task Force members should
study the background material provided and be prepared at the next meeting to: a) ask
any questions they may have on the handouts; b) indicate any additional information
they may need; and c) discuss how they would like to proceed with the study.
The meeting adjourned at 5:10 p.m.
W. Kenneth Gearhart 4/3
Management Systems Analyst
Meeting #2
Members Present:
Others Present:
AMBULANCE STUDY TASK FORCE
July 17, 1979
4:00 p.m., City Hall Basement
Rick Kreiman
Art Roth, Jr.
Gary Rieniets
Jack Schaefer
Don Allendorf
Ann Sweeney
Pat Gabrielson
R. N. Dunphy
W. Kenneth Gearhart
Rick Jones
Don Bradley, R.N.
Dr. Craig Rose
Ken Sargent
Phyllis Anger
Ken Gearhart distributed copies of the preliminary year -ending ambulance activity ex-
penditure report for FY 1978-79 and a report of ambulance calls for this period. The
total amount billed in FY 79 was $111 , 097.50 and the actual fees collected $94, 513. 52,
plus $3,928.10 in delinquent payments. The accounts receivable amount on June 30th
was $17,501.40. The average amount of uncollectibles runs about 10 - 15% a year.
Delinquent accounts are turned over to a collection agency.
Also distributed was a list of "indirect costs" for the ambulance service. These are costs
which, although not directly charged to the ambulance activity, have to be taken into
consideration when discussing "total expense" of the service. Some of these costs are:
1) dispatcher's time spent on ambulance calls; 2) Fire Department personnel to staff back-
up ambulance; 3) fill-in time when regular ambulance driver/attendants are on sick leave,
vacation, or casual day; 4) Finance Department costs for billing; 5) administrative overhead
costs; and 6) depreciation of equipment. Rick Kreiman pointed out that the $70,000 hidden
costs (indirect) is low, and that if an outside agency were to take over the ambulance
service their total expense would be substantially higher. In conjunction with this, there
was some discussion on rate increases. Dubuque has not had a rate increase in several
years and Chief Dunphy remarked that it takes at least a year to a year and a half to have
a rate increase approved by Medicare.
Don Allendorf asked that "emergency" and "nonemergency" calls be clarified. Nonemer-
gency calls are those in which time is not a major factor. The patient would still need
the professional care and handling of the ambulance attendants, but would not necessitate
traveling with the siren going and lights flashing. The ambulance driver/attendant makes
the decision at the scene if the call is an emergency or nonemergency. A call that is dis-
patched as an emergency may in fact be a nonemergency. A majority of nonemergency
calls are transfers.
At this point, Ken Gearhart asked that the group take a minute and decide just what
direction the task force wanted to go. He reminded them that a report would be submitted
to the City Council with the groups' findings and recommendations and that this should be
kept in mind as their goal. Right now, they should decide how they wanted to go about
achieving this goal.
Ambulance Study Task Force
July 17, 1979
Page Two
It was generally discussed and decided that the first item to look at should be what level
of service the group wanted for Dubuque, whether or not it could be maintained, what
training and equipment would be needed, and the cost of this level of service. New state
regulations went into effect July 5th establishing standards for training and certification
of emergency medical technicians and paramedics. These new regulations must be under-
stood by the task force before they can talk about alternative levels of service and cost.
Don Bradley agreed to have a report at the next meeting regarding the state regulations and
what each level of service actually is. Chief Dunphy stated that currently Dubuque is
providing a high -intermediate level of service, however, he questioned whether this could
be maintained under the provisions of the new law.
There was some discussion on the length of time it would take to complete the study. Ken
stated that if more time than the 120 days allotted to the task force by the City Council
was needed, it possibly could be arranged. He stated he would be submitting a progress
report to the City Council within a month or so.
Information which Ken will have available for the next meeting includes what type of cover-
age the city has for liability and malpractice insurance for ambulance driver/attendants;
what percentage of charges are paid by Medicare (80% of the charge is paid by insurance,
20% billed to patient) , and a copy of the letter from the County Board of Supervisors re-
questing that the county have a representative on the task force.
The next meeting will be held at 4:00 p.m., Thursday, July 26th, West Board Room, Mercy
Health Center.
The meeting was adjourned at 5:35 p.m.
July 17, 1979
City of Dubuque
Indirect Ambulance Service Costs
1. Percent of Fire Alarm Dispatcher's time handling ambulance calls.
2. Personnel costs for manning 2nd and 3rd ambulance.
3. Personnel costs for filling in for six assigned Ambulance Driver/Attendants during
vacation, casual and sick leaves.
4. Finance Department costs of billing and record keeping.
5. Administrative costs of department and city government.
6. Amortization of equipment.
1. In FY 1977 the Dispatchers handled 1,427 (32.3%) fire and emergency calls and
2,986 (67.7%) ambulance calls. In FY 1978, 1,546 (31.7%) fire and emergency
calls and 3,331 (68.3%) ambulance calls. Cost of fire alarm activity in FY 1980
is $81 , 952 (68% = $55, 727) .
2. FY 1977 Medic 12 answered 162 calls
FY 1978 Medic 12 answered 172 calls
Time spent on calls apprixmately 100 man hours per year.
3. Minimum fill-in for casual days per year 6
Minimum fill-in for vacation days per year 36
Average fill-in for sick leave days per year 18
60
4. Approximately 20% of Account Clerk ($12 , 000) .
July 17, 1979
City of Dubuque
Approximate Total Cost of Ambulance Service
FY 1978-79
1. FY 1979 Direct Costs 169,973 71.0
2. Fill-in with Medic 12 747 0.3
3. Fill-in for Days Off
7.47 per hour x 24 hours = 179.28 x 60 days
4. Dispatching Expense
5. Billing Expense
10,756
55,700
2,400
4.5
23.2
1.0
239,576 100.0
Meeting #3
AMBULANCE STUDY TASK FORCE
July 26, 1979
4:00 p.m. , Mercy Hospital
Members Present: Gary Rieniets
Robert Dunphy
Rick Kreiman
Art Roth
Dr. Craig Rose
Don Allendorf
Anne Sweeney
Others Present: W. Kenneth Gearhart Shawn Berry, KDTH Joe Jordan, KDUB
Don Bradley, R.N. Bob Freund, T.H.
Ken reported on the liability insurance carried by the city of Dubuque indicating
coverage on the ambulance driver/attendants of $250 , 000 for each occurrence and
$500 , 000 aggregate with a premium of $1 , 075 . In addition the city has protection
of a $500 , 000 base policy with $1 , 000 , 000 umbrella. These policies provide coverage
in the case of an incident where suit may be filed against both the ambulance driver/
attendant and the city.
The matter of a Dubuque County representative on the task force was discussed.
It was reported that the County was agreeable to Jack Schaefer providing this
representation. The Task Force is also agreeable to this, but Ken requests a letter
be submitted from the County stating that this is a satisfactory arrangement.
Ken stressed the importance of understanding the impact of the new advanced
emergency medical care legislation in order to identify levels of service and finally
to come to a conclusion as to what level of service is required in Dubuque.
Don Bradley, R.N., distributed information outlining the four different levels of
advanced emergency medical care and the effects of the new legislation upon each
level. It was noted that the new legislation affects only those services which provide
advanced emergency care (ambulance 11 but not ambulance 12 in this case) .
Basic EMT: This level of service is not affected by the legislation.
EMT -I: The new legislation requires the basic EMT training and successful completion
of modules 1, 2, 3 and 5 of the DOT paramedic guide. It was noted that six Dubuque
ambulance driver/attendants are certified at and beyond this level of service.
Discussion of continuing education requirements indicated that the Medical Director
(Dr. Chapman) has the responsibility of coordinating this program.
EMT -II: The new legislation requires the basic EMT training and successful completion
of modules 1-6 and 15 of the DOT paramedic guide. It was noted that six Dubuque
ambulance driver/attendants have this training with the exception of endotracheal
intubation. A discussion of the procedure by which an ambulance driver/attendant re-
ceives certification indicates that the hospitals provide this continuing education.
Upon the attendant's demonstration of his expertise in a particular area, the hospital
supervisor will direct a letter to the Medical Director indicating this accomplishment,
who will, in turn, submit a letter to Chief Dunphy indicating the same. The letter
will become a part of the driver/attendant's personnel file.
-2-
EMT-P: The new legislation requires the basic EMT training and successful completion
of all modules of the DOT paramedic guide, as well as certification in Advanced
Cardiac Life Support.
The law also states that a certified EMT may challenge the EMT -I or EMT -II test.
However, anyone wishing to challenge the paramedic test must have obtained the
education and training equivalent to the legislated requirements PRIOR to July 5.
It was noted that Dubuque's ambulance driver/attendants did not complete all the
requirements for EMT -II before July 5 (endotracheal intubation) . However, Don
Bradley pointed out a section of the law (132.4, par. 4) whereby Dubuque's driver/
attendants could challenge the EMT -I or EMT -II test. After certification at that
level, they would then be eligible to continue to the next level after completion of
the appropriate material. He suggested the possibility of Dubuque's driver/attendants
challenging the EMT -II test, receiving certification at this level and then having only
to complete the remaining modules through hospital programming and education, before
taking the paramedic test. This would eliminate the need to send personnel to
paramedic school.
Rick Kreiman stressed the importance of assuring that the necessary education and
training is received by the driver/attendants with less value placed on just achieving
a "rating" or "testing out" without the advantage of the knowledge to back up that
rating. The task force agreed that this was not their intention. However, it was
felt that the task force must come to a decision as to what level of service we are
providingtake action to protect that level of service and then proceed from there to
improve upon that service.
The possibility of offering two levels of service was also discussed. It was noted
that this question had never been raised to the authorities and no definitive answer
was available at this time.
Dr. Rose pointed out the feeling that the EMT -II is the minimum level we should
accept for Dubuque. He feels that anything below that would be a loss for the city
and would not serve the needs of a city this size.
Discussion of what has been done so far in attempting to comply with these rules.
The Chief reported that $850 had been appropriated for training this year. Little
action has been taken pending the outcome of this task force. The Chief has also
applied to the Iowa Board of Health for an application for the service program.
Subsequently, each of the EMTs must apply to the Iowa Board of Medical Examiners
30 days prior to the test.
The possibility of offering the test in Dubuque was discussed. It was noted that
if the city could guarantee 20 people to take the test, it could be offered in Dubuque.
The possibility of offering the training program in Dubuque was also discussed. It
was felt that the cooperation of the hospitals and medical staff could be relied upon
if such a program were to be offered in Dubuque.
Ken asked for a survey of feelings of the task force as to what level of service
they feel should be offered in Dubuque. It was decided to strive to protect the
EMT -II rating at this time and then proceed to obtain the education and certification
for EMT-P.
Rick Kreiman presented some thoughts on scheduling two first -line crews with the
manpower available at this time. He will present his idea in more detail at the
next meeting.
Agenda items for next meeting: training requirements, what should the scope of
services be? who should provide the service? how should the service be financed?
Next meeting will be held Thursday, August 2, 4:00 p.m., West Board Room of
Mercy Hospital.
ADVANCED EMERGENCY MEDICAL CARE LEGISLATION
EFFECTIVE DATE: July 5, 1979
Affects only the service programs which elect to provide advanced emergency
medical care (Administration of IV solutions, M.A.S.T., gastric or tracheal
intubation, cardiac monitoring and defibrillation and the administration of
medications either IM, IV or sub Q.
LEVELS OF SERVICE
Basic EMT
EMT -I
TRAINING REQUIREMENTS
CONTINUING EDUCATION
REQUIREMENTS
SUMMARY OF
EXPERTISE
Completion of the U.S. -
Department of Transport&
tion prescribed course
for basic EMT. Involves
80-120 hours.
Certification as basic
EMT and completion of
modules 1,2,3 and 5 of
the D.O.T.'s paramedic
guide
#1: Role and responsi-
bilities
##2: Patient assessment
#3: Shock and fluid
therapy
#5: Therespiratory
system
Not affected by recent
legislation.
Renewal of certificate
is required every two
years. In order to be
eligible the advanced EMT
must have completed at
least 30 hours of contin-
uing education per year.
1) 6 hours of formal
classroom
2) 6 hours of ambulance
run evaluation
3) 6 hours of clinical
experience in the hos-
pital.
4) 12 hours to be deter-
mined by the medical.
director
1) Legal respons-
ibility
2) Anatomy
3) Vital signs
4) Basic Life
Support -"CPR"
5) Hemorrhage
control
6) Splinting
techniques
7) Seizure con-
trol
8) Patient
handling and
extrication
9) Communication
0) Emergency
driving and
traffic con-
trol
All of those
listed above in
addition to:
1) Obtaining
patient history
and able to
assess accuratel)
a change in the
patient's con-
dition.
2) Administratioi
of intravenous
solutions includ-
ing IV cannula-
lation.
3) Able to use
adjunctive equip-
ment for airway
maintenance
a)Robert-Shaw
b)Oropharyngeal
airway
c) EGTA
LEVELS OF SERVICE
TRAINING REQUIREMENTS
CONTINUING EDUCATION
REQUIREMENTS
SUMMARY OF
EXPERTISE
EMT -II
EMT-P
(Paramedic)
Certification as basic
EMT and completion of
modules #1-6 and #15 of
the D.O.T.'s paramedic
guide and certification in
Advanced CArdiac Life
Support
#4-General pharmacology
1/6-Cardiovascular system
#15-Telemetry and com-
munication
Certification as basic
EMT and completion of all
15 modules of the D.O.T.
paramedic guide as well as
certification Advanced
Cardiac Life Support.
#7-Central nervous system
#8-Soft tissue injuries
#9-Musculoskeletal system
It10-Medical emergencies
#11-OB/Gyn emergencies
As above
As above
Does not include
endotracheal
intubation
4) M.A.S.T.
garment applica-
tion.
All of those
listed above in
addition to:
1) Endotracheal
intubation
2) Cardiac mon-
itoring in.cludirq
arrhythmia recog-
nition, defibril-
lation and/or
cardioversion
3) Knowledge of
basic pharma-
cology and admin-
istration of
cardiac drugs.
All of those
listed above in
addition to:
1) Overall in-
crease in knowl-
edge of emergent
pre -hospital
conditions
2) Advanced care
of the newborn
3) Difficult
deliveries
4) Transtracheal
cannulation
(trach)
5) Needle thorac-
otomy (Emergency
treatment for
collapsed lung)
6) Advanced phy-
sician assess-
ment techniques
LEVELS OF SERVICE
TRAINING REQUIREMENTS
CONTINUING EDUCATION
REQUIREMENTS
SUMMARY OF
EXPERTISE
#12-Pediatrics and
neonatal emergencies
#13-Emergency care of
the emotionally'
disturbed
#14-Extrication
Rescue techniques
7) Central
intravenous can-
nulation tech-
niques.
(Jugular, sub-
clavic or
femoral sticks)
8) Familiar
with the tech-
niques for
venous cutdown
Certified EMT's may challenge the EMT=Z and EMT -II certification test.
RNs, physician's assistants and "any individual who has had education
and training equivalent to the. requirements.in the rules prior to their
effective date" July 5, may challenge the paramedic test.
In order for the Dubuque EMT's to challenge the paramedic test they
must first attend an approved 500-800 hour paramedic training program.
Consists of approximately 5 months:
1) Didactic (Classroom): Full-time 7 hours per
day for approximately 2 months.
2) Clinical -Paramedic student is returned to his
"home -hospital" for in-house patient care
(Duration approximately 2 months).
3) Field -Paramedic student is in the field delivering
pre -hospital emergency care under the direct super-
vision of a field preceptor or evaluator.
Approximate cost per man of the University of Iowa Paramedic Training
Program has been estimated at $500.00.
Meeting No. 4
AMBULANCE STUDY TASK FORCE
August 2, 1979
4:00 p.m., Mercy Health Center
Members Present: Robert Dunphy
Art Roth
Dr. Craig Rose
Rick Kreiman
jack Schaefer
Phyllis Anger,
Others Present: W. Kenneth Gearhart
Rick Jones, Ambulance Dr . /Att .
Rick Bankson, Ambulance Dr./Att.
R.N.
Don Allendorf
Ken Sargent
Sue Reilly (for G. Rieniets)
Shawn Berry, KDTH
Bob Freund, T.H.
Joe Jordan, KDUB
Art Hackett, WMT
Rick Kreiman distributed a comparison survey outlining the ambulance services and
rates in other Iowa cities. After a brief presentation by Rick, the information was
discussed by the membership. It was noted that several Iowa metropolitan areas were
not included in the survey (Davenport, Waterloo, Sioux City, Fort Madison) . Several
members expressed the need for greater representation of major Iowa communities on
the survey. After some discussion of this point, it was questioned whether or not
the Task Force should really concern themselves with the services and rates of other
Iowa communities at this time. It was felt by some members that this Task Force
should decide what service Dubuque wants to provide and what charges they must
make in order to provide that service without the limitations of comparison. It was
pointed out that comparisons can be helpful in justifying rate increases to both the
City Council and Medicare. The consensus was that for the time being, comparison
need not be investigated further.
Alternate No. 1 - Rick Kreiman presented an alternate whereby both ambulance 11
and 12 would be staffed with a team of one EMT -II and one Paramedic. The staffing
would call for six people assigned to each of the ambulances to cover all shifts for
a total of 12. Rick stressed that this alternate would provide not only a first -line
ambulance to handle emergencies, but would also provide the same first -line
ambulance service as a back up unit. He further presented an"Expenses and Income"
chart outlining his recommendation of financing this program. The matter of vacation
and sick leave allowance, as well as the accuracy of the figures used in financing
this alternate were discussed. Rick further stressed the need to call for County and
East Dubuque subsidy of the service.
jack Schaefer indicated that although city of Dubuque residents do support the
ambulance service through taxes, that it must not be forgotten that non-residents
also support Dubuque indirectly through their purchase of Dubuque services and products.
Alternate No. 2 - jack Schaefer presented an alternate whereby the city would license
a private transport service. This private transport service would contract with either
the discharging or admitting facilities and such facility would guarantee that company
85 percent of their licensed rate. The transport service would handle any call to and
from a private institution on a COD basis. The Fire Department, Emergency Medical
Division, would respond to any and all emergency calls. They would transport any
individual who they consider to be unqualified to be transported by a private transport
service. The Fire Department would collect that portion of the revenue they deem
necessary to support the emergency service. This would result in the elimination
of the transfer service through the Dubuque Fire Department, thereby giving that
Department the opportunity to respond to emergencies at the highest possible
percentage of the time.
Jack indicated that his proposal is based on the feeling that the obligation of providing
transfer service appears to hinder the provision of emergency service. With the
elimination of the transfer responsibility, the ambulances are free to provide the
highest degree of emergency service at the highest percentage of the time possible.
Discussion of pros and cons of this alternate continued including loss of transfer
business revenue, City Council reaction to cost of program, advantage of concentrating
efforts solely on emergency service. Dr. Rosestressed that no matter who handled
the transfer service, he felt that Dubuque still needed two units to provide the area
with adequate coverage.
After the presentation of the two alternate proposals, the Task Force felt it necessary
to spend some time in the discussion of "scope of services." Ken Gearhart presented
two facets to the term, first, as it relates to emergency vs. transfer, and seccnd,
as it relates to the geographical area of service.
The question was raised regarding legal obligation to provide emergency ambulance
service on a local or state level. It was noted that no legal obligation to provide
an emergency medical service exists. Task Force members stressed that if this
was not a legal obligation, it must be made a strong moral obligation.
The question was posed: Do any Task Force members feel that, no matter who provides
the service, some facility should provide both emergency and transfer service. Not
all members were necessarily in agreement with this statement,, but it was the majority
feeling that because of revenue considerations the organization providing the service
must provide both emergency and transfer service.
The question was posed: Do any Task Force members believe that the geographic
area presently being served is inappropriate? The membership agreed that the area
covered was appropriate with several conditions. It was noted that at least two
vehicles were necessary to provide the coverage. It was also noted that subsidies
on the part of other jurisdictions being served should be sought, however, it was
decided that this was a matter to be dealt with at a later time.
The next meeting will be held Thursday, August 9, 4:00 p.m. , West Board Room,
Mercy Health Center. Requested agenda topics include: financing, continued
discussion of subsidizing the program and continued discussion of who should provide
the service.
Meeting adjourned at 5:40 p.m.
COMPARISON SURVEY: IOWA AMBULANCE RATES
SERVICE
TYPE
BASE RATE
MILEAGE
B.L.S.
A.L.S.
SUPPLIES
STANDBY
TRANSFER
3eckman-Jones
Iowa City
Basic
Day: $60.00
Night:65.00
Day:$1.42/mi
Night:1.56/mi
N.A.
N.A.
N.A.
Base Rate
Base Rate
:apital City
)es Moines
Basic
$40.00
$1.50/mi
$15.00
N.A.
Base Rate
Plus $20.00
Base Rate
Base Rate
3)
lrea Ambulance
:edar Rapids
Advanced
$57.00 City
68.00 County
$ .74/mi
N.A.
$130.00 Plus
Base Rate
$13.50 Initial
Charge
Oxygen $8.00
Suction 5.50
$57.00/Hour$64.00
Plus
.74/mi
Lary -Greeley
Ames
Advanced
$45.00
$ .75/mi
$15.00
$100.00
At Cost of
Replacement
Oxygen $15.00
$45.00/HourBase
Rate
Plus Mileage
i)
Jashington
;ounty AmbulanceAdvanced
Jashington
Day: $35.00
Night:40.00
$1.50/mi
N.A.
$85.00
At Cost of
Replacement
Oxygen $8.00
$40.00/HourPlus
Base Rate
Mileage
i)
Johnson County
:owa City
;1978 Rates)
Advanced
$35.00
50.00 Out of
County
None
N.A.
$60.00
Oxygen $5.00
Suction 5.00
$10.00/2 hr
$35.00
7)
Johnson County
:owa City
:1979 Rates)
Advanced
$60.00
$1.50/mi
N.A.
$100.00 Plus
Base Rate
Plus Mileage
Oxygen $8.00
Suction 5.00
Dressing 6.00
Splints 6.00
Cervical
Collar 8.00
$30.00/HourBase
for
Ambulance
$7.50/Hour/
Attendant
Rate
Plus Mileage
AVERAGE CHARGES FOR A.L.S. CALLS
Area Ambulance, Cedar Rapids: $207.00
Mary -Greeley, Ames: 170.00
Johnson County Ambulance, Iowa City: 150.00
Washington Cty.Ambulance,Washington: 105.00
Projected Revenue Increase With 1979 Rate Adjustment for Johnson County Ambulance:
(Based on 2,107 Calls at 100% Collection)
Revenue Increase from Mileage Charges:
Revenue Increase from Base Rate:
Projected Total Revenue Increase
$17,937.00
23,644.00
41,581.00
-Meeting No. 5
AMBULANCE STUDY TASK FORCE
August 9, 1979
4:00 p.m., Mercy Health Center
Members Present: Robert Dunphy
Don Allendorf
Phyllis Anger, R.N.
Kenneth Sargeant
Others Present:
Patricia Gabrielson
Craig Rose, M.D.
Gary Rieniets
Art Roth
Ken Gearhart, City Manager
William McDermott, Epworth
Ric Jones, Ambulance Dr./Att.
Larry Felderman, Ambulance Dr./Att.
Rick Kreiman
Ann Sweeney
Jack Schaefer
Shawn Berry, KDTH
Bob Freund, T.H.
Daniel McDermott, EMT, Epworth
Chief Dunphy presented two pieces of information, 1) a letter to City Manager with a
report of the city ambulance operations for July, 1979; and 2) Projected Costs of
Operation for Ambulance Service, FY ' 80 , along with an explanation of the figures used
in order to reflect the financial status of this operation. Present operational expense
was shown as $156,767.04 and this figure was doubled to show the cost of a two
ambulance operation at $313,534.08. It was noted that the expense would not
actually need to be doubled in order to reflect the two ambulance operation, and it was
decided that the project could be accomplished for $305,500.
The question was posed to the Task Force: Who should provide the ambulance service?
Discussion of this topic brought the membership to the question: Is there any private
agency which wants to provide the service? It was decided that no private agency was
interested in providing ambulance service, especially when they attempt to provide the
same quality of care as currently being offered and still meet the rates charged by the city.
The question was posed: Does anyone on the Task Force feel that some agency other
than the city should offer the service? Several ideas were expressed including a totally
hospital based service and a hospital/city shared service. A handout was distributed
describing the services at Mary Greeley Hospital in Ames. It was noted that the article
was slightly outdated, but that it was not intended to be a specific example of what
Dubuque should strive for, but rather act as an instigation of discussion on the pros and
cons of a hospital based service. Ken Gearhart also presented a brief description of
the ambulance service in Sioux City where the three hospitals shared the ambulance
service and emergency room facilities on a rotating basis during the year.
The ramifications of a hospital based program were discussed. Rick Kreiman stressed
that, from the standpoint of the ambulance driver attendant, the cutback from a 56-hour
week to a 40-hour week would be economically unfeasible.
The matter of "non -revenue producing time" was also discussed. It was noted that
25% of all calls come between 8:00 p.m. and 8:00 a.m., many of these calls being more
intense compared to daytime calls. It was further noted that averages of "busy" and
"slack" times are extremely difficult to obtain because of the great variances in types
and number of calls received on a day to day basis. The Task Force attempted to
develop some general answers to the following questions:
1. From 8:00 a.m. to 8:00 p.m., how many hours would the ambulance driver/
attendant be available to work elsewhere. Answers ranged from 2 to 7 hours.
2. From 8:00 p.m. to 8:00 a.m., how many hours would the ambulance driver/
attendant be available to work elsewhere? Answers ranged from 9-10 hours.
This prompted the discussion of "rest time" or "slack time". It was stressed that if
the ambulance driver/attendant is given no slack or rest time during the course of a day,
he would be physically unfit to handle the intensity of emergency calls after 8:00 p.m.
Jack Schaefer presented information on the ambulance service provided by West Allis,
Wisconsin, a city comparable to Dubuque. The service consists of one paramedic
unit, one main transfer ambulance and two back-up transfer ambulances. Personnel
manning these units are also firemen and do respond to fire calls, working on the outer
parimeters of the fire in case an emergency call should come in. As part of the Fire
Department, they are able to advance through the ranks. Each squad is manned with
an officer, a driver and an attendant, each paid at their respective rates. Nearly all
of the Fire Department has EMT training. It was questioned whether or not this procedure
were worthwhile since, if a person does not use his EMT skill on a daily basis, he will
soon lose that expertise.
The procedure of requiring all firefighters to complete EMT training led to a discussion of
the ambulance crew becoming a "low man job." It was felt by some that this procedure
would cause the ambulance attendant to become a position filled by new personnel with
the result that it be a job to advance FROM rather than to advance TOWARD. Rick
Kreiman felt that the job of firefighter and that of ambulance driver/attendant are two
distinctly different jobs and should not be shared.
The question was posed to Rick Kreiman regarding discussion of Task Force activities
with coworkers in order to grasp the general feelings of all the ambulance driver/
attendants. Rick indicated that the ideas presented through the Task Force had been
discussed informally with some of the other men, but not all. He felt that, generally
speaking, many of the present ambulance driver/attendants would chose to abandon
the program if it became a hospital based, 8-hour shift program. The Task Force
concluded that the 56-hour week economic factor was a determining factor for the
ambulance crew.
The risk involved with having only one ambulance in service during the night was
discussed with the suggestion that two ambulances be run during the day and one
ambulance with one back-up be run during the night. This back-up crew could have
as their main function, assigned work in the hospital with the understanding that they
would then respond to any calls as a back-up crew. It was decided that it would be
helpful to have records of calls of the present back-up ambulance. Chief Dunphy will
provide this information at the next meeting.
The system of one ambulance provided by the city and one by the hospital was also
mentioned. However, it was noted that this would require overstaffing to cover both
the ambulance crew and emergency room minimum staff at all times.
Conclusions - The Task Force attempted to draw conclusions to today's discussions:
The concensus feels that private ambulance service was not a viable alternative.
Ken Sargeant felt, however, that it was important that the Task Force attempt to identify
a city comparable to Dubuque where there is a single private provider operating a success-
ful ambulance service. Although the membership is not sure that such a program exists,
they feel it important to do a complete investigation on this topic. Art Roth, Chief
Dunphy and Ken Gearhart will work through the State Health Department to attempt to
answer this question.
The Task Force would also like investigation done on the possibility of city/hospital
shared ambulance service, as well as a totally hospital based service. Gary Rieniets,
Ken Sargeant and Phyllis Anger will form a subcommittee to explore these possibilities
and present a report at the next meeting.
The next meeting will be Thursday, August 23, 1979, West Board Room., Mercy Health
Center, 4:00 p.m.
Meeting adjourned at 5:50 p.m.
PROJECTED COSTS OF OPERATION FOR AMBULANCE SERVICE
FISCAL YEAR 1980
AMBULANCE DRIVER/ATTENDANT
BASE PAY $14,992.64
ESTIMATED C.0 L A 1,698.64
HOLIDAY PAY 576.80
CLOTHING ALLOWANCE 225.00
SUB TOTAL $17,493.08
CITY SHARE OF PENSION COST (31.58%) $ 5,271.11
HOSPITALIZATION INSURANCE (FAMILY PLAN) 1,500.00
LIFE INSURANCE 60.22
A. D. & D. INS 134.93
SUB TOTAL $ 6,966.26
GRAND TOTAL $24,459.34
OPERATING EXPENSE
SUPPLIES: OFFICE SUPPLIES: MATERIALS & SUPPLIES:
VEHICLE OPERATION & MAINTENANCE: MACHINERY AND
EQUIPMENT MAINTENANCE• $ 4,765.00
SERVICES: TRAINING: PRINTING: INSURANCE: POSTAGE:
MISCELLANEOUS SERVICE & CHARGES• 5,246.00
OPERATING COSTS $19,011.00
PRESENT OPERATION
PERSONNEL (6 x $24,459.34) $146,756.04
OPERATING EXPENSE 10,011.00
$156,767.04
TWO AMBULANCE OPERATION
$156,767.04
156,767.04
$313,534.08
THE CITY OF
R. N. DUNPHY, Chief
August 8, 1979
Mr. W. Kenneth Gearhart
City Manager
Dubuque, Iowa 52001
Dear Sir:
FIRE DEPARTMENT
9 T H « CENTRAL
DUBUQU E. I O VV A 52001
Telephone 319 522-2577
Following is a report of the Operations of the City Ambulances for the
month of July, 1979:
Emergency/Sick
Emergency/Accident
Vehicular Accident
Transfer
Unnecessary
Totals
MEDIC 11
47
28
24
87
19
205
GRAND TOTALS CALLS
Amount Charged
Amount Collected
Time worked on calls
Man hours worked on calls
Time spent on recordkeeping
Time spent on medical equip.
Time spent on vehicle maint.
Out of service for repairs
Miles traveled
Gasoline used (gallons)
Laundry Cost
Respectfully submitted,
R. N.cDunphy
Chief
jf
$ 1,688.00
1,039.00
952.00
3,089.00
0
$ 6,768.00
218 COST
$ 6,768.00
0
260:22
520:44
70:00
maint. 72:00
48:00
6:00
1,559
197
0
MEDIC 12
7
1
4
1
0
$ 245.00
35.00
160.00
45.00
0
13 $ 485.00
7,253.00
$ 485.00
0
6:22
12:44
3:00
10:00
15:00
0
225
51
0
Ara
Answ'r to
the.
Paramedic
Program
inIowa
By Mike Stevens
ABOUT THE AUTHOR: Mike Stevens
is Director of the Mary -Greeley Memo-
rial Hospital Ambulance Service and has
been active in state and area emergency
care development. He is. a Registered
Emergency Medical Technician and is
certified to provide emergency coronary
care in the field.
many other states, there are no laws re-
garding the training levels of personnel
or minimum equipment standards for
ambulance services. Only in the last four
to five years has the Emergency Medical
Technician (EMT -A) course surfaced in
Iowa. The program has had time to
prove its worth, so more and more
EMT -As are being trained.
The purpose of this article is to de-
scribe what occurred when the medical
staff of Mary Greeley, Memorial Hospi-
tal realized the importance of sending
trained personnel to the aid of their
patients. Since the service is hospital -
based, the need to utilize EMTs in the
hospital, while they are not on ambu-
lance calls, was recognized. This concept
has permitted the hospital to turn a
medically necessary service that tradi-
tionally loses money into one that pays
its way.
Ames, Iowa, is a city of 40,000 peo-
ple in the heart of a rural area. Approx-
imately half the total population con-
sists of college students. Ames is also on
two major highways (U.S. 69 and 30)
and Interstate 35. As a result, the am-
bulance service must respond to a wide
variety of calls.
The 14 REMT-As (Registered Emer-
Mary Greeley Memorial Hospital EMTs "packaging" a victim of a car/truck accident
for transportation.
working for this service received the
Department of Transportation 81-hour
EMT -A course before applying for na-
tional registry. Following basic EMT
training, the ambulance personnel em-
ployed at this hospital receive advanced
training in intravenous (IV) therapy, en-
dotracheal intubation, inhalation thera-
py, and coronary care, including a phar-
macology segment. Medical staff mem-
bers teach the advanced training cours-
es. The coronary care course is the same
course nurses take prior to working in
the coronary care unit and is equivalent
to the intermediate coronary course
offered by area community colleges.
The total class • time spent in these
various courses is over 200 hours. There
are many hours of practical experience.
The hospital medical staff donates
much of its time helping to train, test,
and recertify the EMTs. The medical
advisor is a member of the medical staff
and serves as liaison between the medi-
cal staff, hospital administration, nurs-
ing department and ambulance service.
The medical advisor sets up the ad-
vanced training classes and certifies each
person on an individual basis following
training. He coordinates retraining and
recertification classes with physicians,
who teach the classes, in cooperation
with the ambulance service training of-
ficer. When possible, emergency depart-
ment nurses are trained with EMTs to
build a strong rapport between co-
workers. Both nursing and ambulance
personnel benefit from the classes. If a
new protocol is introduced, the medical
advisor takes the protocol to the medi-
cal staff for approval.
To help offset direct costs, some jobs
previously held by other personnel are
now staffed by EMTs, whose time is al-
located to these departments to reduce
ambulance service salary expense. These
additional areas of responsibility are re-
lated to their responsibilities in the
field. Because theyare performing these
duties daily, they are in constant train-
ing. The additional duties include:
1) ECG department, which is com-
pletely staffed by EMTs. The
ECGs were previously handled
by the X-ray department; EMTs
have replaced 2.3 full-time
equivalents (FTEs). Constant ex-
posure to ECG abnormalities
permits the EMTs to have con-
stant "practice" in seeing ar-
rhythmias. Approximately 14
percent of the EMTs' time is al-
located to this department.
2) Inhalation therapy department
receives approximately 8 percent
EMERGENCY PRODUCT NEWS
thoroughly trained in inhalation
therapy so they can supplement
the I.T. staff. Some EMTs are
taking their certification tests
for inhalation therapy.
3) IV team is comprised entirely of
EMTs. The nurses on the floors
have the option of starting the
IV or calling an EMT to start the
IV. Usually the nurses will try to
start the IV before calling an
EMT. Doctors are rarely called
upon to start IVs in the hospital.
Approximately 2 percent of the
EMT -As' time is spent in this
area.
4) Emergency department• nurses
asked that their orderlies be re-
placed by EMTs. The EMTs
spend 24 percent of their time in
this department. At least one
EMT is available in the depart-
ment 98 percent of the time.
This area provides a vast amount
of experience for EMTs, and
they work closely as team meter
bers with the nurses.
5) Resuscitation team includes two'
EMTs who do CPR, start IVs
and intubate patients.
6) Security department is staffed
are no other male personnel in
the hospital 24 hours per day.
Approximately 22 percent of
EMTs' time is spent in security
checks and handling security
problems.
As can be seen, 30 percent of the
EMTs time is actually spent in ambu-
lance work. By allocating these percent-
ages of time to other areas, the cost of
keeping highly trained people is re-
duced. Also, with the exception of se-
curity, all the additional areas in which
EMTs work provide constant training
which can be used in the field.
The role of EMTs as educators in the
community increases every year. They
teach cardiopulmonary resuscitation
(American Heart Association Basic Life
Support- Course) to service clubs and
schools, and certify the fire department
personnel, who also respond to resusci-
tation calls. The EMTs also assist in
teaching segments of the coronary care
course and orienting new employees to
CPR.
By providing programs to service or-
ganizations in the community, the ser-
vice has been able to raise donations for
equipment. The specialized equipment
received through these donations for the
usvunu uI Lc113i ve/t,Ui Ufldr y care unit 15
an asset to the highly trained personnel.
The public also benefits by receiving
updated education on various topics.
In the last three years, the service has
developed and progressed to the degree
of a highly specialized "paramedic"
unit. It is recognized as the first and
only such unit in Iowa. Although there
are no state laws governing ambulance
services, this service has set a precedent.
There are now other hospital -based ser-
vices utilizing their personnel as this ser-
vice does and some are currently using
different segments of the program.
The basic program can be adapted to
fit most hospital -based ambulance ser-
vices. The concept of taking the care to
the patient and not taking the patient to
the care has allowed patients to arrive in
the emergency department with less
damage to their existing injuries and, in
some cases, alive instead of dead.
There have been many challenges to
overcome, both medically and legally.
Sincere and solid support of the medical
staff is imperative. The nursing staff,
hospital administration and mature, in-
telligent EMTs are also prime factors in
making the system work favorably. For-
tunately, these professional people saw
the need to put patient care first.
0
g YOUR TOWN
U.S. A.
No 005793
OFFICIAL
IDENTIFICATION E. M.T.
Last name First Middle
TAYLOR LINDA A.
Title Date of birth
E.M. TECHNICIAN 1/15/49
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F 5'6" 128 BROWN GREEN
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Issue date
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JUKE, 1976
CTR-8FS
Automatic
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_Meeting No. 6
Members Present:
AMBULANCE STUDY TASK FORCE
August 23, 1979
4:00 p.m. , Mercy Health Center
Rick Kreiman
Don Allendorf
Ann Sweeney
Pat Gabrielson
Robert Dunphy
Ken Sargent
Others Present: Ken Gearhart, City Manager
Bob Freund, T.H.
Gary Rieniets
Phyllis Anger
Arthur Roth
Art Hackett, WMT
Tim Berry, KDTH
J. Jordan, KDUB
As per request of last meeting, Chief Dunphy presented information outlining the
number and type of calls of Medic 12 (back-up ambulance) . The Task Force studied
and discussed the report briefly.
A second handout was distributed pertaining to the private ambulance service of Sioux
City, Iowa. Chief Dunphy also reported that he had made inquiries about the private
service in LaCrosse, Wisconsin, but had not received a response yet. The information
he did have on LaCrosse was outdated. The Task Force studied and discussed the
information presented on Sioux City's private ambulance service. Topics of discussion
included possible subsidy, population of area covered, level of service, fees charged.
A Task Force Subcommittee met Thursday, August 16, to investigate the possibility of
a city/hospital shared ambulance service, as well as a totally hospital based service.
Minutes of the meeting were distributed and the findings of the subcommittee were
discussed. After investigation, the subcommittee concluded that "there is no economic
benefit to the community to have the ambulance hospital based." The specific elements
resulting in this finding were discussed. The Subcommittee further presented three
recommendations to the Task Force: 1) further exploration of private ambulance service;
2) hospital provision of education of ambulance personnel; 3) raise present ambulance
charges in accordance with level of care provided.
Some dissatisfaction was expressed with the lack of a cooperative effort for a city/
hospital shared service. However, the Task Force also acknowledged the hospitals'
efforts in the area of education of ambulance personnel.
The Task Force looked closer at the recommendation to investigate private ambulance
service. It was suggested that a group be designated to look at this area specifically.
It was felt that the only productive way to investigate this matter further would be to draw
up specifications and request contract offers from private services. The concern of loss
of controlwith private service was brought up. However, 't was pointed out that control
of the level of service could be gained through contract as well as through state law.
The Task Force also discussed the risk involved in contracting with a private ambulance
service and facing possible termination of the contract a short time later. This could
become a costly risk in light of procurement of equipment and personnel.
The Task Force moved to discussion of the financing of the ambulance service. The
discussion centered at first around the delays involved in transfers. Several problem
areas were discussed regarding procedure of nursing home transfers. It was suggested
that the back up ambulance handle transfer calls. However, it was pointed out that on
occasion a "transfer" may turn into an emergency in which Advance Cardiac Life Support
is necessary.
The suggestion of raising rates was discussed. It was suggested that levels of
service be divided into three categories and that appropriate fees be charged for each
category. Suggested categories were: Basic Life Support, Advance Cardiac Life Support,
Full Code
It was suggested that the Task Force look at records of the types and number of calls
the ambulance service has responded to in the past, categorize them as suggested
and assign suggested rates. This study would then show an expected total revenue.
Rick Kreiman reported that his records contained the necessary information. It was
further suggested that Rick use his records in order to determine what rates would have
to be charged in order to support his proposal of several meetings ago. Discussion
ensued regarding what elements would have to be considered, including supplies charge
if any, percentage of non -collectibles, etc. The suggestion was made that a subcommittee
be established to gather the information. However, it was decided that rather than
establish a separate subcommittee, Ken Gearhart would work with city staff including
Chief Dunphy and Rick Kreiman to gather the necessary information and would present
it at the next meeting.
Next meeting is scheduled Friday, August 31, 3:00 p.m., West Board Room, Mercy
Health Center.
Meeting adjourned at 5:50 p.m.
AMBULANCE STUDY TASK FORCE
SUBCOMMITTEE MEETING MINUTES - August 16, 1979
The Ambulance Task Force Subcoduittee met on August 16, 1979 at
Mercy Health Center. Present were Phyllis Anger, Finley; Gary Rieniets,
Xavier; and Ken Sargeant, Mercy.
The subcommittee was formed in order to investigate the possibility
of city/hospital shared ambulance service, as well as a totally hospital
based service.
The subcommittee studied the hospital based services provided in the
Sioux City and Cedar Rapids areas. After lengthy discussion, the committee
arrived at the following conclusion:
There is no economic benefit to the community to have the ambulance
hospital based. Even if ambulance personnel worked part of the time
in the hospitals, staffing would still have to be doubled in order
to cover the ambulance personnel when they are on a call. Due to
economics and labor problems, the practicality of this arrangement
is not feasible.
RECOMMENDATIONS:
1) We feel that private ambulance service should be further explored
When considering private service, we should a) have a guarantee
that the level of care will be the same as that reconmiefided by the
Ambulance Study Task Force and b) obtain bids from interested priv-
ate services in regard to charges.
2) We see the educational activity of ambulance personnel as a speci-
fic role for hospitals, with no charge to the city.
3) We feel that the present ambulance charges should be raised:in
accordance with the level of care provided.
The meeting was adjourned at 12:40 P.M.
Respectfully,
Phyllis a Anger,
MEDIC 12 EXPERIENCE
TIME EMER. SICK EMER. ACC. VEH. ACC. TRANSFER TOTAL
JANUARY THRU MARCH 1977
i 8-5 11 14 4 29
5-10 5 4 9
10-8 1 1 2
8-5 16
5-10 7
10-8 2
APRIL THRU JUNE
1
3
3
7 1 25
10
1 6
JULY THRU SEPTEMBER
8-5 15 10 2
5-10 2 4 3
10-8 4 2
OCTOBER THRU DECEMBER
2
29
9
6
8-5 9 11 2 3 25
5-10 4 1 1 6
10-8 3 3 1 7
JANUARY THRU MARCH 1978
8-5 17 12 8 37
5-10 6 1 4 1 12
10-8 3 1 4
APRIL THRU JUNE
8-5 16 6 8 30
5-10 4 2 1 7
10-8 2 1 3
JULY THRU SEPTEMBER
8-5 14 16 6
5-10 4 2 3
10-8 2 1 1
OCTOBER THRU DECEMBER
1
1
37
10
4
• 8-5 14 10 7 1 32
5-10 3 4 7
10-8 2 1 3
JANUARY THRU MARCH 1979
8-5 26 7 1 1 35
5-10 5 4 9
10-8 2 1 3
APRIL THRU JUNE
8-5 18 9 4
5-10 1 3 2
10-8 1 2 2
2
33
6
5
Meeting No. 7
Members Present:
Others Present:
AMBULANCE STUDY TASK FORCE
August 31, 1979
3:00 p.m., Mercy Health Center
Robert Dunphy
Rick Kreiman
Don Allendorf
Pat Gabrielson
Craig Rose, M.D.
Ann Sweeney
Ken Gearhart, City Manager
B.J. Sisson, Adm. , Americana Healthcare
Rick Bankson, Ambulance Dr./Att.
Ric Jones, Ambulance Dr./Att.
Gary Rieniets
Phyllis Anger
Ken Sargent
Joe Jordon, KDUB-TV
Shaun Barry, KDTH
Several Task Force members reported on the recent ACOG meeting. Apparently, there
was a question whether or not the County recognized Jack Schaefer as their representative
on the Task Force. Don Allendorf indicated that, as directed at the July 26 meeting, he
requested a letter from the County stating that Jack Schaefer would be the County's
representative on this Task Force. Chief Dunphy reported that the Countywould like to
have a representative from the County ambulance service. The consensus was that any
interested party could sit in and contribute to the meetings. However, only official Task
Force members would have voting power. Other subjects discussed at the ACOG meeting
included the county's plans to initiate a task force to look at county ambulance service.
However, they decided to wait for the outcome of the City Task Force before initiating
their own study.
Pat Gabrielson distributed minutes of the Dubuque Nursing Home meeting held on June 6,
1979. Mr. B.J. Sisson was present to discuss the nursing home role in the Dubuque
ambulance service. Discussion included transfer scheduling, "transfer" vs„ "emergency"
calls, communications between nursing homes and ambulance driver/attendants.
The Task Force focused on the cost factor involved with the ambulance service. Figures
used to cost several alternatives were presented to the Task Force for review and
discussion. The first handout, "Costs for Use in Calculating Ambulance Rates" showed
the specific costs involved in the ambulance service. The second handout presented six
alternatives: 1) no change in present service; 2) elimination of transfer service; 3) provide
transfer service with current on -duty personnel; 4) add two civilian, 40-hour week
personnel to provide transfer service only; 5) add six ambulance driver/attendant positions;
6) private ambulance service. The options and their results were discussed by the Task
Force. The Third handout, "Rate Projections for Various Alternatives" presented the
rate projections for each of the previously discussed alternatives using the cost calculations
in the first handout. Rates were figured for 100% supporting program and an 80% supporting
program (indicating 20% subsidy of some kind) .
The question of the need of a second ambulance was discussed including the risk factor
involved. Ken Gearhart presented findings indicating that under Option 4 the current
Advanced Cardiac Life Support ambulance would be available to respond to calls 98% of
the time. Only 2% of the time would the first ambulance be unable to respond and the
second ambulance be called upon. The question was raised, was this 2% factor enough
of a risk to warrant the addition of a second ACLS ambulance? Discussion pursued
including the validity of the 2% risk factor presented, amount of risk the city is willing
to take and amount of fee an ambulance user is willing to pay for services. The question
of subsidy was also discussed. Several members felt that the general public would be
willing to subsidize the service as a type of "insurance policy" should they some day
be a user of the service. The alternate opinion was also raised that only those who use
the service should pay for it. It was suggested that good public relations for the
ambulance service would perhaps increase the general public's willingness to support the
service through taxes. For the most part, it was felt that the public was not aware of
the type of service Dubuque offers them and the costs incurred because of the program.
If the public was made aware of the services offered and had the knowledge that the
service would be there if he needed it, that taxpayer would be more than willing to support
it through his tax dollars. It was also pointed out that the nursing home population is
often on fixed income and would find great hardship in meeting higher costs of the service
without tax subsidy. It was also stressed that the public would probably be more concerned
with the level of service being provided than the cost of that service.
In concluding the Task Force took another look at the alternatives presented. It was
felt that options 1, 2 and 3 did not offer the best solution. The effects of option 4 were
discussed, including whether or not it would actually upgrade the present service, the
transfer problem on weekends and evenings, and the problem involved in determining over
the telephone what type of skilled service to send to a call. This led to a discussion of
"transfer" calls vs. "emergency" calls. This is a very gray area and needs to be refined.
One suggestion was that "transfer" refer to anything that can be scheduled. All others
are "emergencies."
Option 5 was also discussed. Several members felt that this option was the very least
that could be considered for a community the size of Dubuque. They stressed that
options 1-4 would not upgrade the present system by any means.
Ken Sargent reported that Cedar Rapids has a city/hospital ambulance service which is
apparently quite successful. Representatives of this service have expressed an interest
in talking with the Task Force. Members felt that this might be helpful if the representa-
tives were willing to discuss specific topics such as budgeting, cost factors, rates
charged, personnel, etc. Ken will discuss possible dates for this presentation and
report back to the Task Force.
Next meeting will be Wednesday, September 5, 4:00 p.m. , West Board Room, Mercy
Health Center.
mericana Healthcare Center
LA
tro
.*:- - 901 WEST3RD • DUBUOUE.IOWA 52001 • TELEPHONE 319.556-1181
June 14. 1979
ME 0 To All Dubuque Nursing Homes
Area Administrators Meeting P)inutes
Date: June 6th, 1979
Time: 1 :OOPy1
Place: Americana
Centers Represented
Bethany
Dubuque'Healthcare
Stone Hill Care Center
Sunnycrest Manor
Americana
Subject of discussion:
1)' Assignment of a represenative to the task forces
to look into -Ambulance -service in Dubuque. 11rs.
Pat Gahrielson will represent, Dubuque Nursing Tomes.
2) Problems with ambulance services seem to be:
A)Questionahle need for additional transporting
service. Many of the homes felt that trans-
ferring of residents to home and other facil-
ities is very often slow do to an apparent
need for emer.gencv use of .our local ambulances.
3) Who is responsible and when seems to be a problem.
More specific guidelines for delivery of services
or verypossibly merely making this knowledge known
to area homes.
4) All homes felt that we have occasional attitude
problems with the attendants. Abrupt gesture,
speech, non -caring feelings toward residents
being transported, ect...
If there are any questions to these minutes or additions
please feel free to contact me at Americana. Our next
meeting will be in August, if you have any suggestions
for programming of this meeting please let me know.
Sincerely ,vpurs,
.J. Sisson
Where better health care is a tradition
August 31, 1979
COSTS FOR USE IN CALCULATING AMBULANCE RATES
FY 1979-80 Costs
Current Second
Arrangement ALS
(1 ALS Amb.) Ambulance Total
Payroll $104,600 $ 97,100 $201,700
Benefits 38,500 16,000 54,500
Total Employee Expense $143,100 $113,100 $256,200
Supplies $ 6,000 $ 500 $ 6,500
Training 2,500 2,500 5,000
Services 4,000 500 4,500
Total $ 12,500 $ 3,500 $ 16,000
Depreciation $ 6,800 $ 6,800 $ 13,600
Equipment 500 500 1,000
Total $ 7,300 $ 7,300 $ 14,600
TOTAL $162,900 $123,900 $286,800
FY 1980-81 Costs
Total $182,500 $138,800 $321,300
August 31, 1979
ALTERNATIVE AMBULANCE STAFFING AND SERVICE LEVELS
1. No Change - Continue current staffing arrangement (6 Ambulance Driver/Attendants).
Add depreciation expense and increase supplies and training budget.
Provide 1 ALS ambulance.
Transfers handled by ALS ambulance.
Back-up and fill-in from Fire Department on -duty personnel.
2. Eliminate Transfers (transfers to be provided by somebody else)
Provide 1 ALS ambulance with no transfer duties.
Back-up and fill-in with Fire Department on -duty personnel.
3. Provide transfer service with current on -duty personnel.
Provide 1 ALS ambulance with no transfer duties.
Back-up and fill-in with Fire Department on -duty personnel.
4. Add 2 civilian, 8 hour, 5 day a week personnel to provide transfers
Provide 1 ALS ambulance with no transfer duties.
Additional transfers and back-up and fill-in from Fire Department
on -duty personnel.
5. Add 6 Ambulance Driver/Attendant Positions
Provide 2 ALS ambulances with transfer duties.
Back-up and fill-in from Fire Department on -duty personnel.
6. Go out for bids to provide ambulance service.
RATE PROJECTIONS FOR VARIOUS ALTERNATIVES
1) $182,500 + 22,800 Noncollectible = $205,300
100%
August 31, 1979
80% ($164,240)
Basic Care $ 65 $166,140 $ 50 $127,800
Intermediate Care 85 • 31,875 85 31,875
Advanced Care 100 6,900 100 6,900
$204,915 $166,575
2) No Transfers
$182,500 + 22,800 Noncollectible = $205,300
100% 80% ($164,240)
Basic Care $110 $102,630 $ 75 $ 69,975
Intermediate Care 210 78,750 200 75,000
Advanced Care 310 21,390 300 20,700
$202,770 $165,675
3) $182,500 + 48,700 transfer expense + 26,600 Noncollectible = $257,800 11
100% 80% ($206,240)
Basic Care $ 80 $204,480 $ 65 $166,140
Intermediate Care 110 41,250 85 31,875
Advanced Care 150 10,350 100 6,900
$256,080 $204,915
1/ Plus additional vehicle
Rate Projections for Various Alternatives
Page Two
4) $182 , 500 + 32,000 transfer expense + 26,800 Noncollectible = $240 , 300 1/
100% 80% ($193,040)
Basic Care $ 75 $191,700 $ 60 $153,360
Intermediate Care 100 37,500 85 31,875
Advanced Care 160 11,040 125 8,625
$240,240 $193,860
1/ Plus additional vehicle
5) $321,300 + 40,160 Noncollectible = $361,460
100% 80% ($289,200)
Basic Care $115 $293 , 940 $ 85 $217,260
Intermediate Care 150 56,250 150 56,250
Advanced Care 200 13,800 200 13,800
6) Unknown
$363,990 $287,310
August 31, 1979
Base rate calculations on 3,000 calls as follows:
Basic Care-1/
Intermediate Care (ALS)
Advanced Care (Code)
1/ Includes transfers
2,556
375
69
85.2%
12.5
2.3
3,000 100.0%
Excluding 1,623 transfers the numbers are as follows:
Basic Care 933 67.8%
Intermediate Care 375 27.2
Advanced Care (Code) 69 5.0
1,377 100:0%
Meeting No. 8
AMBULANCE STUDY TASK FORCE
September 5, 1979
4:00 p.m. , Mercy Health Center
Members Present: Robert Dunphy
Rick Kreiman
Don Allendorf
Dr. Craig Rose
Ann Sweeney
Gary Rieniets
Ken Sargent
Jack Schaefer
Art Roth
Others Present: B.J. Sisson, Adm., Americana Healthcare
Ken Gearhart, City Manager
Ric Jones, Ambulance Dr./Att.
Larry Felderman, Ambulance Dr./Att.
Pat Gabrielson
Phyllis Anger
John Hutchcroft, Amb. Dr./Ate.
Joe Jordan, KDUB-TV
Art Hackett, WMT
Tim Berry, KDTH
Dr. Craig Rose presented to the Task Force percentage figures he compiled on the
availability of the ambulance to respond to calls. His figures stated that under present
circumstances, we are without an ACLS ambulance 35.66% of the time. Under proposal
44 as presented at the August 31 meeting, we would be without an ACLS ambulance 23%
of the time. It was felt that the information presented at the August 31 meeting was
inaccurate in saying that 2% of the time the ACLS ambulance was unavailable. In fact,
the 2% reflects the time when both ambulances would be unavailable. It was felt that
the minutes of the August 31 meeting did not reflect the true implications of this 2% risk
factor, and that if the minutes were to be an accurate record, they should be corrected.
It was decided to wait till Ken Gearhart arrived in order to discuss the matter in more
detail as he had presented the 2% figure originally.
Further investigation of the minutes prompted discussion of option 5. The minutes state
that several members felt option 5 was the very least that could be considered for Dubuque.
The minutes further state that members felt "options 1-4 would not upgrade the present
system by any means." It was felt that this statement did not truly reflect the opinions
of the members and that although some members feel option 5 to be a better alternative,
that is not to say that options 1-4 would not upgrade the system by any means.
The Task Force turned the discussion toward the financing aspect of the ambulance study.
A discussion of the cost figures presented at August 31 meeting showed that the member-
ship felt that the figures were "conservatively reasonable." Other topics of discussion
included noncollectible rate, a falling off of transfer calls due to increased rate,
Medicare's role in transfer expense and amount of subsidy. Several members felt that
more than 20% subsidy would be feasible, stating that the public would be most likely
willing to support the service if they knew that service would be there when they needed it.
The question of level of care was brought up. It was felt that perhaps the level of care
should be decided upon before financing could be discussed. The question was raised,
does the Task Force want to decide upon level of care and then proceed to ways to
finance that level of care, or does the Task Force wish to look at financing in order to
decide on level of care that we can afford? It was pointed out that for our purposes of
discussion, it was difficult to separate the level of care and cost involved. It was felt
that perhaps these should be considered together.
Rick Kreiman felt that perhaps the Task Force should decide upon option 5, then proceed
to investigate the financing of it. If it is found that option 5 is not financially feasible,
then go to the next alternative and investigate that one.
Jack Schaefer pointed out that option 4 could be implemented with the plan to work
toward option 5. He would like to have some comments from Chief Dunphy regarding
personnel, scheduling and other administrative issues. Chief Dunphy pointed out the
experience of seeing a fall off in calls when rates go up and stressed that the non -
collectibles would also rise with the increased rate.
Discussion led to the transfer patients and the type of service they need. Mr. Sisson
pointed out that most transfer patients do not need the ACLS equipment this Task Force
is considering. Mr. Sisson also sees a hardship for these transfer patients in meeting
the rising rates being considered to provide this ACLS equipment. Rick Kreiman pointed
out that although the rate hike would be a hardship for some of the transfer patients and
although that patient may not make use of the ACLS equipment, the rate hike is
instituted in order to guarantee the best level of service to the community as a whole.
The suggestion was made to recommend option 4 as the first alternative and option 5 as
a second alternative. After some discussion of this matter, it was felt that a consensus
should be reached on one recommendation to be submitted to Council.
Ann Sweeney suggested a compromise alternative of option 4 and 5. Her suggestion
consisted of two ACLS ambulances, one operating 24 hours a day as usual, and one
operating only during the busy hours (suggestions included 8 am to 8 pm or 8 am to 5 pm) .
This would provide the two ACLS ambulances and cut back on the unavailability risk
factor to some extent. This suggestion was discussed including the personnel,
scheduling and other administrative factors involved.
John Hutchcroft suggested an option whereby two ACLS ambulances would run with the
present staff. Each ambulance would be manned with one ACLS attendant and one other
attendant. The implications of this proposal were also discussed including the alternating
role of ambulance driver/attendant and firefighter necessitated by this proposal,
scheduling and other administrative factors involved.
The Task Force agreed that in order to consider these options equally with previously
presented options, they would have to be costed out. Ken Gearhart will work with staff
to present cost figures on these proposals at the next meeting.
Ken Sargent reported that the representatives from Cedar Rapids had not yet responded
with available dates on which to speak to the Task Force. The membership felt that
at this point they would like to forego the Cedar Rapids presentation with the thought
that it can be scheduled at a later date if necessary.
Next meeting scheduled for Tuesday, September 11, 3:00 p.m. , West Education Room,
Mercy Health Center.
Meeting adjourned at 5:50 p.m.
AMBULANCE TASK FORCE
SEPTEMBER 5, 1979
The following figures are based on information given to the
Task Force by Chief Dunphy and Mr. Gearhart:
1) Under the present circumstances we are without an
ACLS ambulance 35,66% of the time.
2) Under proposal #4 ( 1 full-time ACLS ambulance not
involved in transfers) we will be without an ACLS
ambulance 23% of the time.
3) Under proposal #64 of all emergency calls will
be with a non ACLS ambulance.
Craig Rose, D.O.
Meeting No. 9
AMBULANCE STUDY TASK FORCE
September 11, 1979
3:00 p.m. , Mercy Health Center
Members Present: Ken Sargent
Pat Gabrielson
Robert Dunphy
Phyllis Anger, R.N.
Others Present:
Gary Rieniets
Art Roth
Jack Schaefer
Rick Kreiman
Ken Gearhart, City Manager
Bob J. Sisson, Adm. , Americana Healthcare
Don Bradley, R.N.
John Hutchcroft, Dbq. Fire Department
Don Allendorf
Ann Sweeney
Craig Rose, M.D.
Bob Freund, T.H.
Art Hackett, WMT
Ron Bock, KDUB-TV
Jane Williams, citizen
Mary Kass , citizen
Ken Gearhart clarified further the 2% risk factor information he had presented at a
previous meeting. He noted that based on the average, Medic 12 is needed 2% of the
time, that is when Medic 11 is out on a call and a second call comes in. There is a
period of time when Medic 11 is on a call, but no second call comes in. Regarding
figures presented by Dr. Craig Rose, Medic 11 is available 80% of the time or not
available 20% of the time. It should be noted that July figures show that during this 20%
of the time during which Medic 11 was not available, Medic 12 was used 13 times for a
total of six hours. The question comes down to the probability of a call coming in while
Medic 11 is out --or when both ambulances are out. These questions and risks involved
were discussed.
Chief Dunphy reported on cost figures of proposals 7 and 8 presented at the last meeting.
He noted that it was difficult to arrive at accurate cost estimates because hypothetical
figures had to be used in computations. Proposal 7 (submitted by John Hutchcroft, using
present personnel and staffing each ambulance with one ACLS attendant and one other
attendant) would cost approximately $5 , 000 more in the first year than the present
system; and depending on how many firefighters pursue the program, this cost would
rise thereafter to $10,000-$15,000 per year more than the present system. This
option was discussed in greater detail including probability of firefighters being
interested in the program, dual role of firefighter and ambulance driver/attendant,
administering the proposal, alternating assignment to emergency ambulance vs. transfer
ambulance, wage incentive for firefighters to pursue the ambulance assignment, etc.
Proposal 8 (submitted by Ann Sweeney, whereby one ACLS ambulance would run 24 hours
per day and one ACLS ambulance would run 8-12 hours per day) would cost approximately
$15,000 per man per year more than the present system. This option was also discussed
in greater detail. It was felt that the combination of 56-hour week personnel and 40-hour
week personnel would pose great administrative difficulties.
Pat Gabrielson reported that she had spoken with a representative of a private ambulance
service in Clinton, Iowa . According to her information, the city of Clinton provides
emergency ambulance service, with a private agency providing the transfer service. It
was noted that this private service also provides emergency service occasionally, however,
level of care was not known. Pat will contact the private service to obtain more information
for the next meeting. Chief Dunphy will contact the Clinton Fire Chief to obtain information
on the city's role in this program and report at the next meeting.
Ken Sargent reported on more details involved in the ambulance service of Cedar Rapids.
This system uses an Ambulance Review Board composed of representatives from the
hospital, city and perhaps others. The Review Board is the policy making body for the
ambulance service which is based at the hospital.
The Task Force discussed "ideal" solutions vs. "acceptable" solutions, that is providing
the desired level of care and yet staying within the budget limitations. The original order
from the Council was brought up, specifically, the direction to the Task Force that their
recommendation be within the financial capabilities of the city of Dubuque. Some members
felt there was little value in submitting a recommendation that had little chance of
acceptance by the City Council. Dr. Rose stressed that two ACLS ambulances was the
minimum that a community the size of Dubuque should settle for. He acknowledged that
this was perhaps an expensive alternative, but he felt that it was a necessary one. He
further stressed that if it was felt that two ACLS ambulances was financially unfeasible,
then he would have to recommend that the ambulance service be geographically restricted
and exclude transfer commitment. Phyllis Anger, R.N. also agreed with Dr. Rose on this
matter stating that settling for less than two ACLS ambulances was regression for Dubuque.
Both members stressed that without the ACLS equipment on the street, that the hospital
equipment and facilities were often of little use.
Ken Sargent pointed out that public acceptance of any proposal needed to be considered.
He referred to the radio program, "Sound Off," in which public opinion seemed to be against
increased public subsidy of the ambulance program. Questions were raised whether or not
the callers on this program could be considered representative of the Dubuque population.
Rick Kreiman stressed the need to educate the public regarding the type of service that is
offered to them at present and the possibilities for upgrading. Several members felt that
a type of public relations/education program about the ambulance service would add to
the willingness of the public to support the program.
Rick further stressed that the Task Force should not submit a recommendation based on
its "acceptability" to the City Council or the general public. Rather the Task Force
should submit a recommendation of the best service possible. Then if the City Council
or the general public feels it is financially unfeasible, they can make that determination.
However, it was also noted that a recommendation with little or no possibility of acceptance
by Council or the public would serve no productive purpose.
Ken Sargent reported that the Cedar Rapids representatives have again offered to present
information on the program currently in operation there. The Task Force feels that it may
be worthwhile at this point if the representatives are willing to share specific financial
information. Ken will try to schedule them for the next meeting.
Ken Gearhart noted that the 120 days allotted the Task Force to reach a recommendation
is near. After some discussion, it was decided that a 60 day extension should be
request ed . Ken Gearhart will proceed with the necessary steps.
Next meeting is Friday, September 21, 1979, 3:00 p.m. , Mercy Health Center.
Meting No. .10
AMBULANCE STUDY TASK FORCE
September 21, 1979
3:00 p.m., Mercy Health Center
Members Present: Arthur Roth
Robert Dunphy
Pat Gabrielson
Don Allendorf
Others Present:
Rick Kreiman
Ken Sargent
Ann Sweeney
Ken Gearhart,City Manager
Don Bradley, R.N.
John Hutchcroft, Amb. Dr./Att.
Sr. Judith Meyers, Cedar Rapids
Jack Schaefer
Gary Rieniets
Craig Rose
Bob Freund, T.H.
Joe Jordan, KDUB-TV
Art Hackett, WMT
Sister Judith Meyers was present to provide information on the ambulance service based
at Mercy Hospital, Cedar Rapids. There are two hospitals located in Cedar Rapids --
Mercy Hospital and St. Luke's Hospital with the ambulance service based at Mercy.
The service is owned by the city of Cedar Rapids which entered into a Memorandum of
Agreement with the Cedar Rapids Hospital Council, who in turn, has an agreement with
Mercy Hospital tooperate the ambulance service. All ambulance personnel are employees
of Mercy Hospital, are paid by the hospital and are subject to the personnel and
administrative policies of the hospital. Mercy also has control and responsibility for
the ambulance vehicles. The city has agreed to underwrite all losses incurred, as well
as assume all profits of the service. Charges are as follows:
In city call
Outside city limits
Cardiac care call
Transfer
Intra-hospital
$57 per person plus charge for supplies
$68 per person plus charge for supplies plus $.74 per mile
Above charge plus $50 additional
$57 per person
No charge
Sister Judith feels there are several advantages to having a hospital based ambulance
service. During "down time" the ambulance attendants serve as emergency room
technicians allowing them to continue to practice their skills and thereby maintain their
expertise. This is an important factor in maintaining a high level of care. The attendants
are also involved in service programs, medical case discussions, etc. which adds to
this maintenance of expertise.
Staff is scheduled as follows:
three teams
two teams
two teams
7:00 a.m. - 3:00 p.m.
3:00 p.m. - 11:00 p.m.
11:00 p.m. - 7:00 a.m. (one team sleeps)
Staff consists of 35 full and part time employees with 6 dispatchers. Entrance level is
EMT with a pre condition of employment being that they advance to EMT -II.
The Task Force questioned possible personnel problems between emergency room staff and
ambulance attendants. Sister Judith acknowledged that some problems had existed, but
that steps had been taken to overcome these difficulties including an employee meeting once
a month in which employees have the opportunity to discuss problem areas. She reported
that these meetings are no longer being held on a routine basis due to the fact that they
are no longer felt to be necessary. Sister Judith stressed that she felt that any past
personnel difficulties had been solved and that morale of the employees was quite good
and working relationships were positive.
A discussion of wage scale indicated a range of approximately $13,000 - $14,000. Sister
Judith believed that a paramedic's starting pay was approximately $6.19 per hour.
However, she stressed that she did not have accurate figures with her and these mere
merely estimates.
Ambulance attendants are trained at Mercy Hospital and Kirkwood College.. There is no
subsidy for the time and expense of education. It is a pre condition of employment that
ambulance attendants take it upon themselves to obtain the necessary education,
It was noted that the city of Cedar Rapids had encouraged the ambulance service to advance
to the paramedic level and in doing so, had agreed to underwrite any additional expense
incurred due to this advancement in quality of care. The rate structure is designed to
avoid any loss as much as possible. It was noted that rates are usually raised annually
to keep pace with rising costs. It was noted that because of the constant working relation-
ship between the hospital accounting department and Medicare and Medicade, that delays
were not encountered in these agencies acknowledging rate changes.
Transfer procedures were discussed. Transfers are handled by the third team and they
are scheduled as best as possible. The ambulance service notifies the nursing home when
the ambulance crew leaves the hospital so that nursing home personnel can be ready.
The question of emergency room overstaffing was raised. She indicated that a basic
emergency room staff was scheduled. If all ambulances were out., leaving the emergency
room understaffed, personnel from other departments would be called to assist for that
period of time.
The question was raised, has there ever been a negative public reaction to the increase
in charges for the ambulance service. Sister Judith indicated that there had never been
any complaints other than on multiple patient calls where each patient is charged full
rate regardless of whether they are taken in the same ambulance.
A recap of August calls in Cedar Rapids indicated:
218 emergency calls
150 immediate calls
78 routine transfers
9 standby
It was noted that the percentage of transfer calls was dissimilar to Dubuque where 45-50%
of all calls are transfers.
3
Task Force members reacted to the information presented. Craig Rose indicated that he
felt the idea of the attendants being a part of the emergency room staff was positive. He
described the rapport among different levels of emergency room personnel resulting in a
good working relationship. To incorporate the EMTs into this environment would be a plus
for the program he felt.
Sister Judith noted that physicians like the system because it gives them an opportunity
to see the ambulance attendants working, and they are able to be aware of their level of
expertise.
Ken Gearhart asked if this option should be reconsidered by the Task Force. The consensus
felt that the option should be reconsidered in light of this new information.
Ken Gearhart asked if a copy of the ambulance budget could be obtained. Sister Judith
indicated that we should work with the Accounting Department and most likely the informa-
tion could be provided.
The possibility of compiling a preliminary budget for such a program in Dubuque was dis-
cussed. It was pointed out that others, particularly hospital boards, should be brought
in on the decision making process. It was suggested that several Task Force members
use the information received from the Cedar Rapids ambulance budget in an attempt to
compile a realistic budget for such a program in Dubuque. This would then be presented
to the tri-hospital board for their input. It was decided that for the time being, the
budget information would be presented -to the hospital administration by Ken Sargent,
Gary Rieniets and Phyllis Anger. In order for a realistic preliminary budget to be
established, a level of care must be ascertained. The Task Force concluded that the
level of care should be EMT -II.
Findings of this investigation and discussions will be presented at the next meeting.
Chief Dunphy reported on his investigation of the ambulance service in Clinton. He reported
that it was a very weak program. The Fire Departments makes all emergency and other
types of calls. The ambulances are manned with basic EMT who also respond to fire calls.
At the present time, Clinton is attempting to pursuade the hospitals to take over the
service. There is no charge for the service. Pat Gabrielson also noted that the private
ambulance service in Clinton is also basic EMT level of care.
Des Moines is embarking on a paramedic program. Des Moines has four ambulances
manned with two firefighter medics who also answer fires in their district and act as
firefighters. After the paramedic level is attained, this dual system will continue.
Ken Gearhart distributed information on several alternative options along with some
different rate structures for review by the Task Force. The information emphasized the
question of special transfer rates and whether or not such special rates should exist.
Task Force members will review the material and discuss it at the next meeting.
The next meeting is scheduled Friday, September 28, 1979, 3:00 p.m. West Board Room,
Mercy Health Center.
ATV:?IJLANCE SERVICE AGREEMENT
It is hereby agreed by and between CEDAR RAPIDS HOSPITAL
COUNCIL, INC. and MERCY HOSPITAL to provide the ambulance service
contemplated by the Memorandum of Agreement between the Cedar Rapids
a.Tosp?tal.Council,Inc. and .the: City of Cedar Rapids, Iowa dated the
day of , 1971 as follows:
1.. Mercy Hospital shall establish an ambulance department w,Yhtch
:thall operate under the name of CEDAR RAPIDS AMBULANCE SERVICE,
:_ereinaiterreferred to as the SERVICE, as a regular department of the
hospital.
2 Mercy Hospital shall assume control and be responsible for
the garaging, care and operation of the .ambulances provided to it. Mercy
1 o�pital shall have the authority to enter into contracts for the servicing,
fueling, maintenance, cleaning, etc. of the ambulances or other equipment
on a•bid-contract basis.
3. Mercy.Hospital.shall recruit and trainsufficient personnel
necessary to man the ambulances at all times, but said personnel shall be
,vailable for assignment by Mercy Hospital for related or equivalent tasks
when not required for. active .ambulance duty. Personnel shall include one
department supervisor who shall not. except in emergencies, be expected
to be a member of an active ambulance crew. Mercy Hospital shall' include
the personnel in the ambulance d.epartnient on a payroll as hospital employees
the same as other established departments of the hospital.
4. Mercy Hospital shall provide appropriate emergency telephone
s:;-rvIce for the exclusive use of the SERVICE and shall provide any necessary
space for any other means of -emergency communication hereinafter provided
to or required by said Memorandum of Agreement.
-1-
5. Mercy Hospital shall provide adequate accounting procedures
and records for billing, paying of expenses, collections of delinquent
accounts and to account for all income and all expenses relating to the
ambulance service which shall include a reasonable fee for administrative
sorvices by hospital personnel other than those in the ambulance depart--
rnent. Mercy shall make such reports about the financial operation of the
srvice as may be required by the. Hospital Council or Ambulance Service
Advisory Board. The initial program shall be started on the basis of
current estimate attached hereto as Exhibit A.
6. Mercy Hospital shall make such charges for ambulance services
as may be recommended by it and approved by the Ambulance Service Ad-
vi,ory Board unlesssuch rates shall be determined otherwise by the joint
action of the COUNCIL and the CITY. The rates shall be established as
near as possible to operate the service without profit or without loss. If
at any time 1Viercy feels the ambulance service is resulting in anysignificant
profit or loss, it shall immediatelyreport such situations to the Ambulance
Service Advisory Board with a recommendation for appropriate alternations
in the service charges as are best calculated to return the service to a
nonprofit and nonloss basis in accordance with the accounting system
established and approved by the BOARD.
7. All ambulance patients shall be transported to the hospital of
their choice or as may be designated by the person making the call if a
physician, dentist, relative, friend or fiduciary of the person requiring
the service. All other ambulance patients shall be alternately delivered
between Mercy and St. Luke's Hospitals.
8. Mercy Hospital shall apply for funds from any governmental
agency from which funds might be available for addition to or improvement
of ambulance service.
9. This contract may be terminated upon ninety (90) days written
notice by either party hereto.
MERCY HOSPITAL
CEDAR RAPIDS, IOWA
JOB DESCRIPTION
JOB TITLE: Ambulance Supervisor
CODE: 0-874 DATE: July 23, 1973
DEPARTMENT: Ambulance REVISED: August, 1978
Job Summary
Supervise and administer the Ambulance Service; assign duties to
Ambulance personnel, assist in orientation of personnel to the
Ambulance Service and in the educational program for continuing
education; identify and study problems and assist in the solution
of the same; supervise the maintenance of records of services
executed by the Ambulance Attendants and perform related duties.
Responsibilities
1. Develop and carry out departmental objectives.
2. Organize, supervise, and direct the work of Ambulance personnel.
3. Orient new personnel to department.
4. Provide for staffing and scheduling.
5. Assist doctors in the care and treatment of patients.
6. Attend and participate in hospital related meetings.
7. Participate in the preparation of the annual budget.
8. Organize and conduct departmental meetings.
9. Evaluate ambulance personnel in the unit and effect disciplinary
action when necessary.
10. Promote harmonious working relationships with- other departments in
the hospital.
11. Provide and encourage open lines of communication within the depart-
ment.
12. Provide for proper maintenance of vehicles and equipment.
13. Support Administrative decisions and policies,
14. Perform other such duties in keeping with responsibility and authority.
Qualifications
1. Graduate of an approved E.M.T. course with certification.
2. Be certified as an Advanced Rescuer by the American Heart Association
Committee on Cardiopulmonary Resuscitation and Emergency Cardiac Care.
AMBULANCE SUPERVISOR
JOB DESCRIPTION CONTINUED 2
Qualifications
3. Interest in professional development as evidenced by continuing
education.
4. Knowledge and/or experience in ambulance work.
5. Demonstrates leadership ability.
Responsible To
Administrative Director
MERCY HOSPITAL
CEDAR RAPIDS, IOWA
JOB DESCRIPTION
JOB TITLE: Advanced EMT -A II (Coronary Trained) CODE: 0-876
DEPARTMENT: Area Ambulance Service DATE: July, 1978
Job Summary
Provides emergency medical aid to patients in keeping with EMT -A job
duties and responsibilities. Initiates advanced life support assistance
to patients as designated by physicians of the Medical Staffs of the Cedar,
Rapids Hospitals. Performs procedures for which special "paramedic" edu-
cation has been given.
Responsibilities
1. Performs all duties described in job description by EMT -A. (See
attached.)
2. May intubate patients upon order of physician and/or under authority
of guidelines established in standing orders approved by the Medical
Staff.
3. May defibrillate patients upon the order of a physician and/or under
authority of guidelines established in standing orders approved by
the Medical Staff.
4. May give only the drugs approved by the Medical. Advisory Committee
of the Area Ambulance Advisory Board. Drugs may be given upon the
order of a physician and/or under authority of guidelines established
in standing orders.
S. Attend monthly run critique meetings for Coronary Trained EMT-A's.
6. Maintain either State or National EMT certification and also Advanced
Cardiac Life Support certification.
7. Perform other duties as designated by the Ambulance Supervisor or his
or her designee.
Qualifications
1. High school graduate or equivalent.
2. Be certified as an Advanced Rescuer by the American Heart Association
Committee on Cardiopulmonary Resuscitation and Emergency Cardiac Care.
3. Be certified as either a State or National EMT -A.
ADVANCEDMT-A II (CORONARY TRAINED) 2
4. I.V. certified by Mercy Hospital Education Department.
5. Knowledge of emergency care and procedures as provided in the EMT -A
courses or other qualified training.
6. Maintain a current Chauffeur's License and Ambulance License for
Cedar Rapids and Marion.
7. Must meet physical demands of:
a. Good mental and physical health.
b. Eye, hand and foot coordination.
c. Color vision and depth perception.
d. Ability to stoop, lift and carry patients and
equipment.
8. Must display knowledge, tact, and efficiency in caring for all
patients.
9. Possess knowledge of safety and traffic regulations.
Responsible To
Ambulance Supervisor
September 21, 1979
Examples of Emergency Rates if Transfer Rate Remains the Same
100% _($240,240) 80% ($193,040)
4) Transfer
Emergency
$ 35
135
$ 56,805
185,895
$ 35
100
$ 56,805
137,700
$242,700 $194,505
100% ($361 , 460) 80% ($289,200)
5) Transfer $ 35 $ 56,805
Emergency $220 302,940
$ 35
170
$ 56,805
234,090
$359,745 $290,895
100% ($274,485) 80% ($220,260)
7a) Transfer $ 35 $ 56,805
Emergency 160 220,320 '
$ 35
120
$ 56,805
165,240
$277,125 $220,045
100% ($239,550) 80% ($190,950)
7b) Transfer $ 35 $ 56,805
Emergency 135 185,895
$ 35
100
$ 56,805
137,700
$242,700 $194,505
September 21, 1979
7) Establish pool (15-18) of Fire Fighter/Ambulance Driver/Attendant positions
within Fire Department to provide ambulance service.
Provide 1 ALS ambulance with no firefighter duties.
Provide back-up ALS ambulance from trained personnel assigned to fire
fighting duties.
Personnel would rotate between assignments to Medic 11 and Medic 12.
7a) Without transfer duties.
7b) With transfer duties (Medic 11).
7a) $182,500 + 32,000 transfer expense + $30,000 + 30,500 Noncollectible =
$275,000
Basic Care
Intermediate Care
Advanced Care
$ 85
125
150
100% 80% ($220,000)
$217,260
46,875
10,350
$ 70
90
110
$178,920
33,750
7,590
$274,485 $220,260
7b) $182,500 + 30,000 + 26,000 Noncollectible = $239,000
100% 80% ($191,200)
Basic Care $ 75 $191,700 $ 60 $153,360
Intermediate Care 100 37,500 80 30,000
Advanced Care 150 10,350 110 7,590
$239,550 $190,950
September 21, 1979
4) Transfer
Emergency
Examples of Two Rate Structure
100% (240 , 240) 80% ($193 , 040)
$ 55
110
$ 89,265
151,470
$ 55
75
$ 89,265
103,275
$240,735 $192,540
100% ($361,460) 80% ($289,200)
5) Transfer $ 55 $ 89,265 $ 55 $ 89,265
Emergency 200 275,400 145 199,665
$364,665 $288,930
100% ($274,485) 80% ($220,260)
7a) Transfer $ 55 $ 89,265 $ 55 $ 89,265
Emergency 135 185,895 95 130,815
$275,160 $220,080
100% (239,550) 80% ($190,950)
7b) Transfer $ 55 $ 89,265 $ 55 $ 89,265
Emergency 110 151,470 75 103,275
$240,735 ' $192,540
Meeting No. 11
Members Present:
Others Present:
AMBULANCE STUDY TASK FORCE
September 28, 1979
3:00 p.m. , Mercy Health Center
R.N. Dunphy
Arthur Roth, Jr.
Rick Kreiman
Phyllis Anger
Don Allendorf
Ken Sargent
Ann Sweeney
Ken Gearhart, City Manager
Don Bradley, R.N.
Pat Kutsch, Amb. Dr./Att.
B.J. Sisson, Americana Healthcare
Gary Rieniets
Craig Rose
Pat Gabrielson
Bob Freund, T,H.
Joe Jordan, KDUB-TV
Art Hackett, WMT
Ken Sargent reported on discussions with hospital administration relative to the feasibility
of hospital based ambulance service. He indicated that each of the three Dubuque hospitals
would be submitting proposals for the service to the Task Force. He further indicated that
a city owned service would be considered with a service contract similar to that used in
the Cedar Rapids program. Three assumptions would also be made of the hospital based
service: 1) the service would be reconstituted; 2) a favorable Certificate of Need review
would be obtained from the state; 3) a favorable review by the Tri Hospital Coordinating
Committee would be obtained.
It was suggested that the hospital representatives form a subcommittee to attempt to
develop some reasonable basis on which the ambulance service might be constituted as a
hospital service. Certain elements of the ambulance service must be determined by the
Task Force before the individual hospitals can develop proposals. First, the Task Force
must decide upon the level of care desired. It was suggested that a time line be set for
the advancement of personnel. Several members questioned whether or not an EMT -
Paramedic could remain proficient in his field with the workload of a city the size of Dubuque.
It was also pointed out that if the service is based at a hospital, the EMT-P would be
using his skills in the emergency room as well as out on calls and would therefore remain
more proficient than if based elsewhere. It was noted that while the EMT-P may not be
able to maintain his level of expertise in Dubuque, certainly the EMT-2 is the very least
that should be expected. It was the concensus of the Task Force that a minimum of EMT-2
be required with the option of paramedic training. It was further stressed that the staffing
pattern should go to the paramedic level within a certain period of time and also set the
goal of at least one paramedic per unit at some future date. This would reflect a greater
commitment to the future improvement of the service. The Task Force agreed on these goals.
It was noted that the hospitals would need to investigate the availability of personnel in
this field in order to set realistic time frames for these goals.
Ken Sargent discussed the fact that the ambulance service would be regarded as a new
service in any of the hospitals. In such a case, the hospital would be required to obtain a
Certificate of Need through a regulating system prior to actually providing that service.
Although difficulty in obtaining the necessary approval is not anticipated, the hospitals do
expect the process to take at least three months, and the Task Force should be aware of
this time element. It was suggested that perhaps the plan should be put before the Tri
Hospital Coordinating Committee first, however, it was not determined whether this would
be successful in avoiding any delays.
The Task Force discussed the number of vehicles needed for the service. It was noted
that the appropriate number of vehicles might vary for a hospital based service versus a
city based service. The concensus was that two ACLS ambulances 24 hours a day would
be necessary.
Communications were also discussed. It was noted that the city was hoping to go to the
"911 " number sometime in the future and that the police and fire dispatching system is
already set up. Therefore, it would perhaps be beneficial to have all calls received by
the city. There was some discussion on dispatcher's time being considered a subsidy by
the city.
The Task Force reviewed the charges by the City Council. In relation to the scope of
service, it was felt that the transfers should be continued for economic reasons. It was
also felt that as long as two ACLS ambulance would be provided, that the same boundaries
could be maintained. There was also the consideration that many times the ambulances
goes outside Dubuque's city limits but is responding to an emergency involving a city
resident. It was further noted that a good working relationship should be maintained with
the neighboring volunteer ambulance services.
The Task Force feels that they must wait for another progress report from the subcommittee
before proceeding further.
Next meeting is scheduled for Thursday, October 11, 3:00 p.m., Mercy Health Center.
THE CITY OF
'' 5313 uQuE
R. N. DUNPHY, Chief
September 26, 1979
1, NC ETA
- , p FIRE DEPARTMENT
,- \ m 9TH & CENTRAL
v,:
�. DUE3UQUE, IOWA 52001
.*co 1$ Telephone 319 582.2577
'fMUtitr<V.
Mr. W. Kenneth Gearhart
City Manager
Dubuque, Iowa 52001
Dear Sir:
Following is a report of the Operations of the City Ambulances for the
month of August, 1979:
MEDIC 11 MEDIC 12
Emergency/Sick 67 $ 2,476.00 5 $ 175.00
Emergency/Accident 23 805.00 3 130.00
Vehicular Accident 38 1,454.00 1 35.00
Transfer 119 4,205.00 - -
Unnecessary 11 - 7 -
Other 15 525.00 -
Totals 273 $ 9,465.00 16 $ 340.00
GRAND TOTALS CALLS----289 COST----$9.805.00
Amount Charged $ 9,465.00 $ 340.00
Time worked on calls 173:10 7:45
Man hours worked on calls 346:20 15:30
Time spent on recordkeeping 30:10 4:00
Time spent on medical equipment Maint. 15:30 6:00
Time spent on vehicle maint. 15:30 6:00
Out of service for repairs 29:00 0
Miles traveled 1,731.2 367
Gasoline used (gallons) 172 60
Respectfµlly_submitted,
R. N. Dunphy
Chief
jf
Meeting No. 12
AMBULANCE STUDY TASK FORCE
October 11, 1979
3:00 p.m. , Mercy Health Center
Members Present: Gary Rieniets
Art Roth
Don Allendorf
Robert Dunphy
Others Present:
Don Bradley
Ken Gearhart
B.J. Sisson
Rudy
Ric Jones
jack Schaefer
Ann Sweeney
Pat Gabrielson
John Hutchcroft
John Chapman, M.D.
Deb Bulgarell
Carol Beaves
Emmy Miller
Phyllis Anger
Rick Kreiman
Ken Sargent
Bob Freund
Joe Jordan
Shawn Barry
Dr. John Chapman, Dubuque County Medical Society, (also advisor to the present
ambulance service) was present to represent the feelings of Dubuque physicians regarding
the ambulance service. If a hospital should take over the service, Dr. Chapman indicated
that the majority of doctors feel it would be unwise for only one hospital to be involved.
He stressed the need for a central location indicating that none of Dubuque's three hospitals
would fit this description. It was suggested that a Tri-hospital effort be explored. Also
suggested was the development of a commission for the ambulance service (much like the
Dock Commission) to have organizational structure. Dr. Chapman stressed that the present
service is a very good one and perhaps should not be changed, suggesting that the Task
Force look at other alternatives to cover the expenses involved while still under the admini-
stration of the city of Dubuque. It was noted by Task Force members that many of these
areas had been investigated.
The suggestion of a rotating service among the hospitals was also brought up. The Task
Force indicated that they had explored this possibility before (using Sioux City as an
example) and had rejected the idea.
The question was raised, if the ambulance service became hospital based, would the Fire
Department engine company still respond to calls in order to provide immediate CPR if
necessary. The city felt that this would still continue, along with the city providing dis-
patching duties. Rick Kreiman stressed the existence of a good working relationship be-
tween the engine company and ambulance crew. He pointed out that with the present sys-
tem, the two crews work together routinely and are aware of follow up on cases in which the
engine company assists. He stated that if the ambulance service moves out of the Fire
Department, this efficient routine working relationship might be lost. It was also noted
that as a professional firefighter, city personnel would be expected to act efficiently and
skillfully whether they were assisting an ambulance crew administered by the city or a
hospital.
The hospital representatives reported on their study. They presented a list of assumptions
which will be the basis for proposals to be submitted to the Task Force from each of the
three hospitals. The list was distributed to the Task Force members for their review and
questions.
It was felt that the reference to "bid" in the assumptions was inappropriate. It was agreed
that the word would be changed to "proposal."
The wording "exclusive contract" on item 2 was discussed. The hospital representatives
indicated that this means that only one hospital would administer the ambulance service in
Dubuque. It would further eliminate the possibility of a private company operating any part
of the service (for example, transfers) . It was stressed that all facets of the ambulance
service (including transfers) were needed to support the program. Without the guarantee of
an exclusive contract, the hospital could not budget their program.
There was discussion as to how long it would take to obtain the necessary level of personnel
required for the type of ambulance service Dubuque wishes to provide. It was felt that the
maximum time required (that is, training an employee with no prior education/experience in
this field) would be nine months to one year. It was noted by hospital representatives,
however, that the ambulance attendant positions will most certainly draw applicants already
experienced in the medical field (R.N., LPN, etc.) Each hospital will provide an effective
date in their proposals. This requirement will be added to the assumptions as item 7.
There was some discussion regarding the life of vehicles. Chief Dunphy estimated that the
life of the modular would be six years, the life of the vehicle (chassis) would be three years.
The question was raised, would the exclusive contract be to the detriment of the other two
hospitals? Ken Sargent explained that specific procedures would be appropriate to determine
which hospital a patient is taken to. He suggested a procedure of patient preference, and
if the patient or relative is unable to give a preference, geographical location be the
determining factor. However, he indicated that studies have shown that over a period of
time, the public begins to consider the hospital administering the ambulance service to be
the better emergency facility and will therefore request to be taken there. Figures from the
Cedar Rapids ambulance service were presented to back up this hypothesis.
The matter of central location and the possibility of more than one location of ambulances
was brought up. Task Force members pointed out that under this proposal, although only
one hospital would have administration of the program, nothing would preclude that hospital
from locating ambulances in more than one hospital.
The question of hospital's ability to adjust rates was raised. It was indicated that being
a city owned service, the city would have to give permission to raise rates. This matter
will be investigated further.
Malpractice insurance questions were also raised. City Manager will investigate the
requirements.
It was decided that noon, November 5, would be the deadline for proposals to be submitted
to the City Manager's Office, City Hall. Copies of the proposals will then be made and
distributed to members for their review. The task Force will meet November 8, 3:00 p.m. ,
Mercy Health Center to discuss the proposals.
It was decided that the Task Force would meet on October 25, 3:00 p.m. to discuss how
the proposals will be evaluated, as well as to discuss any other items members wish to
bring up at that time.
ASSUMPTIONS AS REVISED PER DISCUSSIONS AT MEETING NO, 12
three hospitals will utilize these assumptions for submitting proposals:
1. The service will be run on a break-even basis, i . e , , no
hospital will subsidize the operation of the ambulance service.
However, proposals will include the projected cost of service.
2. The City will continue to own the service and contract with one
of the hospitals to operate it. It is mutually understood that this
is an exclusive contract.
3. All proposals will be based on the following service level:
a. Operation of at least two fully equipped ALS ambulances.
b. Staffing levels of 1 EMT ii and 1 EMTP within one year of
beginning operations. All staff will be employees of the
contracting hospital.
4. Projected cost of operating the service will include depreciation
expense on all capital equipment involved.
5. Review of operations and policy making for the operation of the
service will be accomplished by a committee composed of rep-
resentatives of each of the three hospitals and the City.
6. Term of the contract should be three years, with provisions for
renewal.
7. Specify effective date.
8. City will continue to provide dispatch.
Meeting No. 13
AMBULANCE STUDY TASK FORCE
October 25, 1979
3:00 p.m., Mercy Health Center
Members Present: Pat Gabrielson
Gary Rieniets
Ann Sweeney
Rick Kreiman
Don Allendorf
Robert Dunphy
Art Roth
Craig Rose
Others Present: W. Kenneth Gearhart, City Manager Deb Bulgarelli, R.N.
John Hutchcroft, Ambulance Driver/Att. Carol Bea ves, R.N.
Don Allendorf indicated that certain subjects needed to be discussed and resolved regard-
less of the outcome of the proposals to be submitted by hospitals. Topics included the
following.
Nursing Home Transfers - Discussion of problems associated with transferring
patients from bed to bed. It was felt that if the service consisted of two ACLS
ambulances, this would not be so great an issue. It was also suggested that
each home purchase a cot. However, the issue of having to leave a patient
unattended at the door still would exist. It was felt that improved communica-
tions as to time of ambulance arrival could solve a lot of this problem.
Rate Charges - It was pointed out that hospital proposals would contain rate
structures and that the Task Force will look at rate structures as a part of
their evaluation of proposals. It was also noted that if the service does become
hospital based, rates will most likely be set through contract; whereas, if the
service stays with the city, rates will most likely be set through ordinance.
Area of Service - It was indicated that the geographical area served would
remain the same and that this information had been given to the proposers.
Surcharge - It was noted that the hospitals would present proposals based
on a break even basis. Several Task Force members felt that nonresidents
of the city of Dubuque should be required to pay a higher fee for the service.
One reason cited was the fact that nonresidents are not contributors to the
tax funds which would be used to make up any loss, should one occur. It
was decided that this issue could be addressed at a later point, after proposals
are submitted.
Insurance Protection - Ken Gearhart indicated that Romolo Russo, Corporate
Counsel, had replied to questions on this matter. However, Ken also indicated
that more information would be necessary. Ken will be contacting Mr. Russo
for further information.
Chief Dunphy reported on his trip to LaCrosse, Wisconsin where the ambulance service
is under private ownership and operation. The service is basic EMT only and covers
LaCrosse, as well as the surrounding areas. Charge for the service is $55 plus $1.60
per load mile plus charge of any equipment used, except the cot. The service employs
17 people with 8, 12 and 24 hour shifts. Chief Dunphy indicated that although the
service is considering advancement of level, they are not interested in offering ACLS
service at this time. The operator of this service is willing to speak to the Task Force
regarding a proposal; however, the consensus feels that since it cannot accept a level
of care lower than ACLS, they are not interested in entertaining a proposal from him.
The Task Force felt it necessary to develop some criterion on which to base their
evaluations of the hospital proposals to be submitted November 5.
1. How soon will the hospital be prepared to take over the service?
2. Is the hospital service offering the level of care described in item 3 of the Assumptions?
3. Look at the fee schedule and expense budget to determine whether or not the proposed
service is budgeted as close to break even as possible.
The subject of hospital zones was discussed. It was felt that the establishment of
zones was not a burden of the proposers and could be addressed at a later date.
The Task Force discussed item 6 of the Assumptions with regard to the wording, "with
provision for renewal." It was felt that the intention of this language was to provide an
opportunity for all hospitals to again offer proposals at the end of the contract period.
Several members felt that if a proposal procedure was to be initiated at the end of each
contract period, that period should be longer than three years. It was stressed that
whatever decision was reached in this regard, all three hospitals should be aware so that
all proposals can be based upon the same assumptions.
4. Response time - It was pointed out that response time was twofold --time for the
ambulance driver/attendant to leave his duty station to reach ambulance; and driving
time to arrive at scene. The Task Force may want to look at what type of work the
attendants will be performing in the hospital and how this relates to their availability
to respond to a call. Also included in evaluation of response time is where the
ambulances are housed.
5. Plans for recruitment and training should be considered. This also ties into the
effective date.
Gari Rieniets indicated that hospitals may encounter a problem in compiling complete
proposals by November 5; however, the Task Force did not move to change the deadline
at this time.
Next meeting will be held November 8, 1979 , 3:00 p.m. , West Education Room, Mercy
Health Center. Please note change in room location for this meeting.
r\leeting No. 14
AMBULANCE STUDY TASK FORCE
November 9, 1979
3 : 00 p.m., Mercy Health Center
Members Present: Gary Rieniets
Craig Rose
Robert Dunphy
Others Present:
Ken Sargent
Don Allendorf
Rick Kreiman
W. Kenneth Gearhart, City Manager
Don Bradley, R.N.
K. Steiner, Finley Hospital
j. Murray, Finley Hospital
L. Colin, Finley Hospital
Melvin Graves, Finley Hospital
Rick Bankson, Amb. Dr./Att.
Ric Jones, Amb. Dr./Att.
John Hutchcroft, Amb. Dr./Att.
Ron Theisen, Amb. Dr./Att.
Rudy Vera , Amb. Dr./Att.
Phyllis Anger
Ann Sweeney
Joe Hubei, Xavier Hospital.
Gary Nielsen, Xavier Hospital
B. Sisson, Americana Healthcare
Emmy Miller, R.N.
Carol Beaves, R.N.
Bob Freund, T.H.
Joe Jordan, KDUB-TV
Timothy Berry, KDTH
Art Hackett, WMT
Correction - Please note a correction in the minutes of the last meeting. The minutes
indicate that the meeting was held on October 26, 1979. In fact, that meeting was held
on October 25, 1979.
All Task Force members have received copies of the three hospital proposals. Each
hospital representative presented their proposals verbally and responded to questions.
Xavier Hospital - Gary Rieniets
This proposal provides for two ACLS ambulances, one housed at Xavier Hospital and one
at one of the other two hospitals. It was noted that no final decision or arrangements had
been made in regard to the second location and corresponding expenses had not been
reflected in the rate projections. Transfers would also be handled by these two vehicles.
It was noted that Xavier had difficulty in determining the availability of trained personnel
in the area. The staffing pattern proposed includes two people each 24 hour shift at two
locations. Both full and part time employees will be utilized. It was also noted that
Xavier Hospital did not feel they could identify an actual offset in other expenses due to
the use of ambulance attendants throughout the hospital. It was noted that training of
employees will be necessary and that this proposal indicates a subsidy from an
unspecified source to cover the salaries during this training period.
Budget explanations raised the question of indirect costs. It was explained that indirect
costs are those expenses which are not revenue producing . Xavier Hospital has used
10% to reflect this cost in their figures. It was also noted that total operating costs
of the service would be allocated solely to the service. In discussing rate structure,
it was pointed out that this was an example of a rate structure which would cover the
cost of the service. However, it was noted that other rate structures were possible and
perhaps this is a question to be left to the Task Force.
2
The question of insurance was discussed. Currently the city carries liability insurance
on the ambulances and malpractice insurance on the driver/attendants. Xavier Hospital
was under the impression that the ambulances would remain city property and therefore
be insured by the city. If, in fact, the hospital would be required to carry this expense,
it would have to be reflected in the rate structure.
In conclusion, it was stressed that there are still many unknown factors which would
have a direct result on the cost and therefore the rates of the service. In light of this,
these cost projections and rates cannot be considered binding. Xavier indicated that
considering all unknown factors, the effective date of operation would be a minimum of
6-9 months.
Mercy Hospital - Ken Sargent
Mercy indicated that their proposal provided two ACLS ambulances and one transfer
vehicle with housing at both Mercy Hospital and Xavier Hospital, although it was noted
that no final arrangements had been made in regard to housing an ambulance at Xavier and
the costs involved.
The staffing proposal indicated that registered nurses would be hired in the beginning
and would "qualify under the law as EMT-P prior to initiation of the service so that
service will continue to qualify as Advanced Level under state law." Education will
then be provided to move toward certification as EMT II within one year. Rick Kreiman
expressed concern over registered nurses being used in this capacity. It was noted by
Ken Sargent that the nurses would go through training prior to the March 1 suggested
start date in order that they are prepared for work in this environment. Further staffing
information indicated 12 hour shifts being utilized. Discussion also included the
activities of the driver/attendants while not on a call as indicated in their proposal.
Budget implications were provided for four options:
1. Two vehicles based at Mercy Hospital and one based at Xavier.
2. Three vehicles based at Mercy Hospital
3. One vehicle based at Mercy Hospital and two at Xavier.
4. One vehicle based at Mercy Hospital and one at Xavier.
Questions regarding indirect costs led to a discussion on this subject as well as nursing
administration costs and general administration costs. It was noted that all costs of the
service would be borne by that service. It was also noted that all capital expenses in-
volved in the service would be carried by Mercy Hospital as its investment in the service
It was noted that Option 4 was most similar to the proposal of Xavier Hospital. After
attempting to compare the two, it was noted that until specific bid specifications are drawn
up, there will continually be discrepencies in comparison of proposals.
Finley Hospital - Phyllis Anger
Finley's proposal provides for at least two ACLS ambulances with the service being
started six months after approval of Certificate of Need. Finley also points out that
they have made application to become a certified training center. This application is
now going through its natural process.
3
It was noted by the Task Force that Finley Hospital has not submitted any budget figures
or rate structures. Representatives of Finley Hospital stated that until all "unknowns"
are brought out and answered, an accurate budget and rate structure cannot be drawn up.
They cited two problems: unsure of scope of service and the need to make assumptions
in order to cost and deal with indirect costs. It was indicated that the time necessary
to deal with these factors was not available to the hospitals. Members of the Task
Force responded that scope of the service had been identified and communicated to all
hospital representatives. Further, it was felt that the provision of service could be
negotiated rather than bid.
The question was put to the Task Force as to how to respond to the lack of information
from Finley Hospital. Several members feel a decision cannot be reached until Finley
presents the budget and rate figures. This response brings up the concern of fairness
to Mercy and Xavier if Finley is given an opportunity to present the information at this
point. Several Task Force members pointed out that none of the information presented
by any of the three hospitals is considered final or binding and therefore, Finley
would not become a threat to Mercy or Xavier by presenting figures after the fact.
Concern was expressed over the fact that none of the proposals were similar enough to
actually be compared completely. It was pointed out that without actual bid specifica-
tions, this result may never be accomplished. The question was raised as to whether
the Task Force wished to look at the three proposals, and then proceed to draw up
specifications based on the information proposed. However, it was also pointed out that
it may be inappropriate for the Task Force to dictate how a hospital may operate their
ambulance service. The question of comparing the hospital proposals to city cost
figures was also raised.
It was decided that the Task Force should meet again to discuss the proposals further.
The meeting will be held Tuesday, November 13, 1979, 3:00 p.m., West Education Room,
Mercy Hospital.
Meeting No. 15
AMBULANCE STUDY TASK FORCE
November 13, 1979
3:00 p.m. , Mercy Health Center
Members Present: Gary Rieniets
Craig Rose
Robert Dunphy
Pat Gabrielson
Ken Sargent
Don Allendorf
Rick Kreiman
Others Present: W. Kenneth Gearhart, City Manager
Don Bradley, R.N.
Melvin Graves, Finley Hospital
Ric Jones, Amb. Dr ./Att.
Phyllis Anger
Ann Sweeney
Art Roth
Emmy Miller, R.N.
Carol Beaves, R.N.
Joe Jordan, KDUB-TV
Art Hackett, WMT
Dr. Rose addressed the issue of ambulance service fees for clarification purposes. It was
pointed out that the current ambulance fee is totally out of line with today's costs. It was
noted that no matter what agency (hospital, city, private, etc.) offers the service, fees
will have to be raised 100% or more in order to become a self supporting service. This
explanation was an effort to correct any misconceptions of prices rising due solely to the
service being hospital based.
Revised information was presented by the three hospitals:
Xavier Hospital made several revisions to their proposed budget and rate structure reflecting
training and insurance costs and based on 3,000 calls rather than 3,300. Xavier still re-
flects no offset in their figures.
Finley Hospital distributed an appendix to their original proposal outlining a proposed budget
and rate structure for two options. Option 1 provides one ACLS ambulance and one transfer
vehicle. Option 2 provides two ACLS ambulances. Salaries indicated in the proposals do
reflect an offset. The proposal does not reflect any start up costs or capital investments
which may be involved, as well as salaries of employees in training. It was also noted
that Finley's Option 1 does not meet the minimum level of care set forth by the Task Force.
Clarification was requested on the breakdown of the rate structure. Transfers are on a
completely scheduled basis. Emergency sick is differentiated from emergency accident
with emergency accident reflecting the higher supply usages in its higher rate.
Mercy Hospital also submitted revised figures reflecting an increased offset. The revised
figures also eliminate some indirect expenses with the service reporting directly to
administration resulting in lower salary figures.
With the completed information submitted from each hospital, the Task Force looked at how
to proceed with the decision making process. It was noted that hospital based service was
only one of several options, and now all options must be considered.
The question was raised as to the validity of the city figures presented several months
ago. It was pointed out that the city cost figures do not include indirect or "overhead"
costs. This may create a discrepancy for purposes of comparison with hospital proposals.
In budgeting a city ambulance service, it is considered that overhead costs will exist
whether or not the service is offered. Therefore, Council would not consider the over-
head costs as an expense of that service. The Task Force felt that they could look at
cost figures of the city, keeping the fact in mind that overhead expenses are not reflected.
The Task Force would like to look closer at the city's Option 5 and 7 presented at previous
meetings.
The Task Force feels that all options should be considered at the next meeting in order to
come to a final recommendation for City Council. That meeting will be held on Saturday,
November 17, 8:00 a.m., West Education Room, Mercy Health Center.
Meeting No. 16
AMBULANCE STUDY TASK FORCE
November 17, 1979
8:00 a .m. , Mercy Health Center
Members Present: Gary Rieniets
Craig Rose
Robert Dunphy
Pat Gabrielson
Others Present:
Ken Sargent
Don Allendorf
Rock Kreiman
Jack Schaefer
Ken Gearhart, City Manager
Mel Graves, Finley Hospital
John Muenster, Finley Hospital
Ron Jaeger, Finley Hospital
Nancy Ertl, Mercy Hospital
Don Bradley, Mercy Hospital
Paul Kluseman, Mercy Hospital
Art Hackett, WMT-TV
Phyllis Anger
Ann Sweeney
Art Roth
Ric Jones, Ambulance Dr./Att.
Rudy Vera, Ambulance Dr./Att.
Ron Theisen, Ambulance Dr./Att.
John Hutchcroft, Amb. Dr./Att.
Bill Hammel
Emmy Miller, R.N.
Carol Beaves, citizen
Joe Jordan, KDUB-TV
Preston Lerrey, T.H.
The City presented cost figures for its previously discussed Options 5 and 7. Option 5
provides two ALS ambulances with transfer duties with back up and fill-in by fire
personnel. Option 7 provides one ALS ambulance with no firefighting duties and one back-
up ambulance staffed by on -duty firefighters. It is noted that Option 7 is the only way
the City can identify any offset. Discussion of response time in Option 7 indicated that
this would only be affe cted if the second ambulance crew were involved in a major
(multi -story) fire. This is a minimal occurrence and could be alleviated by keeping these
crew members on the outer parimeters of the fire.
A handout was distributed showing a comparison of an option from each of the three
hospitals and city option 7. Another handout was distributed showing a comparison of
the different rates set up by these proposals. It was noted that rates can be set in a
number of ways and it was felt that this should be accomplished by the Task Force as
a group. Some concern was expressed over the rate structure necessary to support the
proposed service. However, it was also noted that these rates were not unlike the rates
in most other areas offering this type of service.
The question was raised that if transfer rates are raised drastically, how many transfer
calls may be lost. After some discussion, it was felt that only 10-15 percent of the
present transfer calls would have the potential of being lost due to the higher fees.
In discussing the hospital proposals, it was noted that for comparison purposes, Mercy's
Option 3 was most similar to the other hospital options. However, it was noted that
Mercy's Option 2 provided a more extensive service with less cost (due to offset ability)
It was pointed out that three concerns should be addressed in the decision making
process --risk, cost and level of care. Although Mercy's Option 2 did serve best for com-
parison purposes, perhaps the Task Force should give consideration to the option
providing the better service at less cost.
Before taking a vote on the most acceptable hospital option, the Task Force members
were asked to discuss their general feelings on the options presented. Several members
felt that there were advantages to ambulance driver/attendants being based in a medical
2
environment where their skills can be used more often and therefore expertise can
be maintained. It was questioned whether the salaries offered by the hospitals were
competitive and could provide incentive for employees to remain. The hospitals in-
dicated that they had assigned what they felt were appropriate and competitive salaries
to the positions. Mercy's proposal to use registered nurses was also discussed.
Phyllis Anger stressed that although R.N.'s are certainly best equipped to give medical
care, they may not have the physical strength or stamina to handle situations encountered
in emergency medical service.
The Task Force called for a vote on the most acceptable hospital proposal. It was felt
that Mercy's Option 2 should be considered for the vote because it meets the minimum
requirements set forth by the Task Force and provides for additional service at a lesser
cost. Had such an option been available from either of the other two proposers, such
options would also have been considered. Results of the vote are as follows:
Mercy Option 2 - 6
Finley Option 2 - 4
Xavier Option - 1
11 members
Dr. Rose indicated that he had talked to Dr. Chapman, head of the Dubuque County
Medical Society. Dr. Chapman had indicated that the Medical Society requests that
the ambulance service remain with the City if at all possible because they did not want
anything to occur that would be political or contribute to the deterioration of the present
service. It was noted that this communication was for informational purposes only and
did not represent any mandate for any voting. The Task Force felt that the political
issues had been adequately addressed. It was recognized that Dr. Chapman's state-
ment is certainly worthy of consideration.
Chief Dunphy provided some informational background on the "enabling" law and the
requirements which would have to be met before January 5 in order to maintain the present
level of service. January 5 is the deadline for personnel to challenge the test. After
that date, the law is quite specific in exactly what must be accomplished to obtain the
certification. It was noted that such a challenge test was scheduled in Dubuque on
December 7. It was also noted that if the service does remain with the City, the hospitals
will be relied upon heavily (as in the past) for necessary training in order to maintain
skills and certification.
The Task Force turned its attention to the two city options presented today. It was
felt by some members that Option 7 did not offer the minimum level of service required
of the hospital proposers. It was also felt that Option 7 did not offer much resolution
to the transfer scheduling problem. Although Option 5 would better solve the nursing
home problem, it also provides for higher fees. Are the nursing homes willing to pay
the fees necessitated by Option 5 in order to obtain a better transfer schedule?
Ken Gearhart indicated that the Task Force should recommend the option they feel most
acceptable. However, he feels an obligation to inform the Task Force that, due to
budget implications and non -revenue producing time involved in Option 5, he would be
3
unable to recommend it to Council should such a recommendation be requested of him.
Rick Kreiman stresses that although the Task Force should be aware of Ken's position,
they must also consider what is best for the community and avoid making a recommenda-
tion to Council based solely on the fact that it is a recommendation that can be approved
by Council.
Ken Gearhart called a brief caucus with city representatives.
Ken Gearhart suggested the Task Force reconsider Option 7b. This option provides for
a pool of personnel cross trained as firefighters and ambulance driver/attendants. They
would be assigned to primary ambulance, back-up ambulance or firefighting on a rotating
basis. The mechanics of this option were discussed.
Several Task Force members express the concern that this group has spent a great deal
of time in determining a level of care which they would support. It is the opinion of
several members that only Option 5 of the City meets this minimum level of care. The
Task Force called for a vote on the most acceptable City option. Results are as follows:
City Option 5 - 8
City Option 7 - 3
11 members
The question was raised whether the Task Force can present to Council the alternatives
arrived at --most acceptable hospital and most acceptable city proposals. It was felt
that a single recommendation should presented. It was noted that a report will accompany
the recommendation allowing for sufficient discussion of the alternatives at the Council
table. In voting on the recommendation to give to Council, it was stressed that Task
Force members base their decision not on cost figures alone, but on all other aspects
of the proposals as well. Results of the vote are as follows:
City Option 5 - 4
Mercy Option 2 - 7
11 members
It is stressed by the Task Force that this is a recommendation only and that City Council
will make the final determination based on this recommendation. Rick Kreiman stressed
a concern that the vote tallies be indicated in the minutes. The question of minority
reports was also raised. It was felt that each party interested in submitting a minority
report should be solely responsible for doing so.
There are other items which need to be addressed by the Task Force. Ken Gearhart will
discuss the matter of Council deadline and report back at the next meeting. The next
meeting will be Tuesday, November 20, 1979, 1:00 p.m., Mercy Health Center Auditorium.
November 16, 1979
Option 5 - Two ALS Ambulances, with Transfer Duties
Add 6 Ambulance Driver/Attendant positions
Provide 2 ALS ambulances with transfer duties
Provide backup and fill-in from Fire Department on -duty personnel
FY 1980-81 Costs
Current Second
Arrangement ALS Fill -In
(1 ALS Amb .) Ambulance Expense Total
Salaries $110,800 $110,000
Benefits 49,200 49,200
Total Employee Expense $160 , 000
$ 11,000 $231,800
4,800 103,200
$159,200 $ 15,800 $335,000
Supplies $ 5,500 $ 1,000 $ 6,500
Training 2,500 2,500 5,000
Services 3,500 500 4,000
Total $ 11,500 $ 4,000 $ 15,500
Depreciation $ 7,500 $ 7,500 $ 15,000
Equipment 500 500 1,000
Total $ 8,000 $ 8,000 $ 16,000
Billing Salaries (30%) $ 4,300 $ - $ 4,300
TOTAL $183,800 $171,200 $ 15,800 $370,800
November 13, 1979
,Tevised November 16, 1979
Option 7-1 Full -Time ALS Ambulance with no fire fighting duties, 1 Back -Up ALS
Ambulance staffed by on -duty Fire Department personnel
Personnel would rotate between assignments to Medic 11 & Medic 12.
FY 1980-81 Costs Current Second
Arrangement ALS
(1 ALS Amb.) Ambulance Total
Payroll $110,800 $ 10,343 $121,143
Benefits 49,200 4,593 53,793
Total, Employee Costs $160,000
$ 14,936 $174,936
Supplies $ 5,500 $ 1,000 $ 6,500
Training 2,500 2,500 5,000
Services 3,500 500 4,000
Total $ 11,500 $ 4,000 $ 15,500
Depreciation $ 7,500 $ 7,500 $ 15,000
Equipment 500 500 1,000
Total
Billing Salaries
TOTAL
$ 8,000
$ 4,300
$183,800
$ 8,000 $ 16,000
$ - $ 4,300
$ 26,936 $210,736
:November 16, 1979
Direct Expense
Salaries
Med. Specialist Fees .
Fuel & Oil
Veh. Maint. & Repair
Equip. Maint. & Repair
Supplies
Miscellaneous
Training
Total, Direct
Indirect Expense
Bldg. Dep, Int, Ins
Dep - Equipment
Fringe Benefits
Admin. & General
Plant Maint. & Op.
Laundry
Nursing Adm.
Total, Indirect
Total
TWO ALS AMBULANCE COMPARISON
Finley
Mercy
$218,653. $184,200
5,000 -
4,620 4,800
1,000 1,200
1,400 1,200
13,690 -
2,000 900
Xavier
$229,953
5,000
4,000
33,333
City
$231,800
6,500
1,024
5,000
$246,363 $192,300 $272,286 $244,324
$ 3,640
8,000
28,622
36,472
4,585
3,256
21,592
$ 5,600
9,500
22,800
31,900
13,300
2,300
$ 19,899
11,540
32,193
31,030
2,700
15,000
$106,167 $ 85,400 $112,362
$352,530 $277,700 $384,648
+ 74,830
+ 27%
+106,948
+ 38%
$ 2,976
16,000
103,200
4,300
$126,476
$370,800
$ 93,100
34%
November 16, 1979
Total Budget
Plus 10% on Ca-1-1
TOTAL
RATE COMPARISON
Finley
$352,530
35,253
Mercy Xavier
$277,700
27,770
$387,783 $305,470
PROPOSED RATES
$384,648
38,465
City
$370,800
37,080
$423,113 $407,880
Transfer Rate $ 30 $ 86 $ 92 $ 85
Basic - 86 192 i7t
Emergency Sick 180 - 192
Emergency Accident 220 - 192
Intermediate - 190 192 ,2Sc
Code 270 260 192 c
ALTERNATE RATES
Transfer 60 $ 97,380 60 $ 97,380 60 $ 97,38D 60 $ 97,380
Fm ergency 211 290,547 151 207,927 237 326,349 225 309,825
Total $387,927 $305,307 $423,729 $407,205
Transfers 60 $ 97,380 60 60 60
Basic 190 177,270 105 210 195,930 !Vc
Advanced 250 111,000 250 260 ,WS-S
Transfer 85 $137,955 7,C ' *,r
Basic 150 139,950 /" /7c
Advanced 250 111,000 /"- g- '
Meeting No. 1
AMBULANCE STUDY TASK FORCE
November 20, 1979
1:00 p.m., Mercy Health Center
Members Present: Rick Kreiman
Pat Gabrielson
Robert Dunphy
Others Present:
Craig Rose
Gary Rieniets
Ken Sargent
Ken Gearhart, City Manager
Emmy Miller, R.N.
Don Bradley, Mercy Hospital
Nancy Ertl, Mercy Hospital
Gary Nielsen, Xavier Hospital
L. Colin, Finley Hospital
Art Roth
Don Allendort
Phyllis Anger
Melvin Graves, Finley Hospital
R. Jaeger, Finley Hospital
Lania McClain
Timothy Berry, KDTH
Dave Lawrance, WDBQ
Preston Leiner, T.H.
Art Roth reported that the Tri-Hospital Committee has requested the Task Force to sub-
mit its recommendation to them prior to submitting it to Council in order to afford Tri-
Hospital an opportunity for input.
The Task Force set the following agenda items: Rates, Ambulance Commission,
Agreement Language, Dispatching, Training, Outline of Final Report, Nursing Home
Cots, City Subsidy, Effective Date.
Rates
Discussion on how many divisions should be represented in the rate structure. Three
categories were suggested --Basic, ALS and Code. Mercy's accepted proposal called for
the following rate structure: Basic-$76; ALS-$181; Code-$245. Dr. Rose felt that
concern should be given to the user who will have the most difficulty in paying the fee.
The suggestion was made to lower the basic rate to approximately $65. A fourth rate
was also proposed to allow for this lower basic rate, resulting in the following four
tiered structure: Transfer-$60; Basic-$110; ALS-$160; Code-$300.
Rick Kreiman stressed his concern that there be as few categories as possible and as
little spread between categories as possible. He pointed out that in certain instances
the ambulance driver/attendant may feel the use of certain equipment is warranted, but
the patient will view the use of such equipment as merely a method of producing revenue.
Rick suggested a two tiered structure: Basic-$88, Code-$300.
Mileage was discussed. Presently, mileage is charged to calls outside the city limits
and is based on total round trip mileage (not mileage from city limits) . Chief Dunphy
pointed out that mileage revenue represented a rather insignificant figure. Ken Sargent
suggested it may be such an insignificant figure as to not warrant considering its use in
this rate structure.
Rick Kreiman moved that the Task Force vote on acceptance of the proposed two tiered
rate structure: Basic-$88; Code-$300. No second. The question was raised whether
or not a particular fee would be assigned to the transfer vehicle alone.
Ken Sargent moved the Task Force adopt the four tiered structure: Transfer-$60; Basic-$110;
ALS-$160; Code-$300. Seconded by Art Roth. Discussion included the transfer veh icle
2
provided in Mercy's accepted proposal. The problem of a transfer turning into an
emergency enroute was addressed along with the question of whether or not this vehicle
should be equipped to handle such a situation. Rick Kreiman identified a concern that
the crew assigned to the transfer vehicle be prepared to handle an ALS call should a
transfer turn into such an ALS call. Ken Sargent indicated that this transfer vehicle could
be so equipped and staffed if the Task Force felt it necessary. It was reported that
this upgrading of Mercy's proposal would cost approximately $3800.
Craig Rose moved that the Task Force amend its decision of the last meeting to increase
the budget of the accepted proposal by $3800 in order to staff the transfer vehicle with
an R.N. and a basic EMT during the first year of operation. Seconded by Pat Gabrielson.
Call for vote: 8 in favor.
The question was raised whether or not this would affect the indirect costs involved.
Although the indirect costs will be raised with this action, the amount is less than $500
and will most likely be absorbed through the rate structure.
Ken Sargent moved that the Task Force adopt the four tiered rate structure with modifica-
tions to compensate for the $3800 increase: Transfer-$63; Basic-$110; ALS-$160; Code-
$300. Seconded by Don Allendorf. Call for vote: 7 in favor.
The Task Force identified the need for written definitions for each category. Ken Sargent
will formulate those definitions and present them to the Task Force.
Several Task Force members identified the fact that with the changes made to the transfer
vehicle, this service is now a three ALS ambulance service and perhaps Finley and
Xavier Hospital should be allowed to present figures on a three ALS ambulance service.
It was further pointed out that Mercy's accepted proposal met all of the criteria es-
tablished by the Task Force in their set of "assumptions." The fact that it went beyond
that criteria and gave more service was an added plus but should not invalidate the
Task Force's acceptance of this proposal at the last meeting. Based on this fact, several
Task Force members did not feel it was appropriate to allow the other two hospitals to
resubmit figures at this point.
Rick Kreiman moved that the. Task Force reconsider the vote taken at the last meeting
in which Mercy's proposal was accepted as the recommendation to Council. It was
questioned whether or not this motion was in order. It was pointed out that it is the
level of service being challenged. Based on this fact, if Mercy's accepted proposal
is considered invalid because it goes beyond that minimum level of service, then the
correct procedure would be to reconsider Mercy's Option 3 along with Xavier and Finley
Option 2 rather than entertain new cost figures.
Ken Sargent moved that the Task Force return to the agenda. Seconded by Pat Gabrielson.
Discussion indicated that a second had not been offered on Rick Kreiman's previous
motion to reconsider the vote of last meeting. Several Task Force members indicated
they had not hear a call for the second. After further discussion, Rick Kreiman moved
that action to reconsider the last meeting's vote be tabled until such time when all
Task Force members can be present. Seconded by Phyllis Anger.
Next meeting will be Tuesday, November 27, 3:00 p.m., Mercy Health Center.
Jtxbnxxqur Cnnnntg
Mr. Kenneth Gearhart
City Manager
City Hall
Dubuque, Iowa 52001
Dear Mr. Gearhart:
edtrl .artrtj
DUBUQUE. IOWA
November 16, 1979
At the last regular monthly meeting of the Dubuque County Medical Society,
which took place on November 14, 1979, the city ambulance situation was
discussed. The doctors at the meeting expressed satisfaction with the present
ambulance service although they agree that it could be improved upon. They
expressed some fears that the ambulance service might become politicized and
they felt that this might be especially true if the hospitals compete for the
service. A motion was made, seconded, and passed unanimously that the ambulance
service remain within the Fire Department.
The doctors do have the suggestion that a medical coordinator be employed, at
least part time, to supervise the medical activities, coordinate the training,
etc. Mr. Don Bradley at Mercy appears to have unique qualifications for this
task. He is currently in the employ of Mercy Hospital and Mercy is allowing
him to devote a certain number of hours each week to the ambulance service Mr.
Bradley would be interested in devoting more hours and perhaps he could be
compensated by the three hospitals for these duties.
The doctors also agreed that the fees need to be reassessed although the basic
fee at present should be adequate for simple transportation hauls. The more
complex services such as cardiac defibrillation, insertion of intravenous lines,
monitoring, etc. could be itemized and the charges could be made comparable to
those charged by the hospital for similar services.
Thank you for your consideration of the doctors' views regarding ambulance
service. We are most appreciative of the improvement in the service and hope
that it will continue at a high level and will continue to improve in its
services to the citizens of this community.
Sincerely yours,
John'S. Chapman, M. D.
JSC:kb
yo
1
Placement of Vehicles for the Ambulance Service for the City of Dubuque and
Surrounding Area
It is my personal opinion that to optimize on the indirect costs and direct costs and
training and utilization of personnel during their time not actually involved in ambulance
service and to completely lead to a more cohesive organization, I firmly believe that
all the ambulance vehicles shall be based and shall return to and be housed at Mercy
Hospital in Dubuque.
Ordinances Governing any Rules and Regulations I believe Should be Included in
the Contract with Mercy that 1) they shall maintain a minimum of three vehicles, one
transfer ambulance and two ALS ambulances , and secondly, that they should, in fact,
be directed by their contract to respond to the now presently existing areas that the
known Dubuque Fire Department ambulance responds to, including the city of East
Dubuque. I should also like to directly state in the contract that the ambulance
service rates shall be set as to be reviewed the first six months of its operation as
regarding profit or loss and then after that at the end of the first year's operation and
then after each year's operation in order to maintain an equitable rate structure for the
citizens, for the hospital and also to prevent the City of Dubuque fromencumbering any
additianal subsidies.
Training of Personnel
I am sure it would behoove the other two hospitals to continue to volunteer training
assistance to the ambulance team although they may not wish to do so. It would, of
course, be of an informative nature to completely involve the existing ambulance crews
which would be employed by Mercy Hospital to know what is available and what is
happening in the other two institutions.
Rates
I believe that a basic transportation rate should be established, of course. I also believe
that a subrate should be established to take care of the intrahospital round trip and the
intra nursing home round trip where in fact, many of these patients do remain on the cot
and do not need additional changes of linen, etc. , nor do they need a advanced type of
care. I would like to see a basic transfer rate on a one-way basis and a basic transfer
rate on a round trip basis. In regards to a second rate structure, possibly titled basic,
I would like that to be known that I feel there is a standard transfer, then the next step
should be an intermediate care rate. Intermediate care rate can possibly be anything
needing the additional training and staffing of EMT -I or EMT -II or EMT-P, whichever
training level may be reached at that time. I would like a next rate to be, if possible,
labeled emergency sick and emergency accident and a final rate to be known as a code
or cardiac arrest or something of that nature where the extreme highest level of care
training and equipment is being brought into effect.
2
Nursing Home Exchange Cots or Carts
I feel that every nursing home expecting ambulance service from Mercy Hospital be re-
quired to provide an exchange cot for the ambulances which shall conform to the existing
specifications that Mercy would set out. My recommendation for those specifications also
include that this cot be a comparable and acceptable one man cot which can be loaded by
one man, male/female staff, female/female staff. The ability to get this patient into the
back of the ambulance would be much aided by the opportunity to use a one man cot. I
also recommend that the existing cots be transferred over to that same one man cot status
sooner or later. It is my feeling that the ambulance crew providing the transfer service
should not be required to take patients to and from their beds in the nursing home other
than in severe incidents where a fall has occurred and the patien'i is in need of special
devices to place him on the cot. That can be considered something other than a standard
transfer call and an ACLS ambulance can be provided to treat that case as an emergency
sick or emergency accident case because of the necessary appliances that may be needed.
Equipment
It is my feeling that the present equipment in the ambulance service for the citizens of
Dubuque and the tri-state area shall be known as "existing equipment" and that equipment
shall be given to Mercy Hospital for them to provide total maintenance, replacement and
continual repair and upgrading to meet the specifications for an ACLS ambulance service.
I feel it should be ordained by the City Council that Mercy Hospital be required to maintain
this equipment in a manner which meets the approval of the City Health Department and that
Department shall have the right to inspect that service at any reasonable time to assure the
citizens of Dubuque that the equipment is being maintained. I would also like to have it
ordained that should the Mercy Hospital decide that it no longer wishes to provide the
ambulance service at the termination of their contract, the equipment remaining in their
hands be in equal shape and of equal inventory as they now receive it from the City so that
if another organization takes over the service it does not receive inadequate equipment and
supplies. I believe that the determining factor in assessing the value or condition of the
equipment shall be borne by an independent ambulance commission drafted by this Task
Force with the possibility of evaluating that equipment and making a written communication
as to their feelings on the status of the equipment.
Independent Ambulance Review Commission to Review Financial "Books" of the Ambulance
Service and to Determine Whether Rate Adjustments are to be Needed at the end of the
First Six Months of Operation, at the end of the First Twelve Months of Operation and
Thereafter after each Twelve Months of Operation
I feel this Commission should be represented by one person from the City of Dubuque
Government, one person from Finley and one person from Xavier, one representatave of
the nursing homes, one representatives from East Dubuque, one representatives from the
c itizens of Dubuque and surrounding area for a total of seven representatives on the
commission. Also acting in a nonvoting capacity on the Commission shall be the coordinator
of the ambulance service from Mercy to explain any necessary questions that would be
raised. He/she would be required to attend any and all meetings of that commission.
I think that at least one citizen without any vested interest in the service should be a per-
son with qualifications necessary to understand not only the service, but the needs of the
public. That Commission member should be a former paramedic or someone in the ME
medical field oher than an employee of one of the three hospitals.
3
Housing of the Ambulances
I feel it should be ordained by the City Council that the ambulance shall be housed
in a heated garage when the temperature at night reaches a low of 40 degrees F or
less.
Training
It is my feeling that any person in Mercy Hospital Organization involved in the training
of the ambulance service should, in fact, also be directed by the Commission and/or
all ordinances of the City Council to maintain a direct and personal commitment to the
Fire Department of Dubuque, to act as a liaison in aiding their training officer in the
continual update and maintenance of training with the individual fire companies so that
the fire companies can, in fact, maintain proficiency and training and response to a
situation which is now commonly known as a resuscitator call or a code to insure that
the initial CPR can be established prior to the arrival of the ambulance crew. It should
also be a directive of the Commission and/or ordinance that this training person with
Mercy Hospital shall coordinate with the Civil Defense Director to insure that all personnel
are versed in the training and problems of extrication and to work with the Coun'y Civil.
Defense Director in coordinating a continual and necessary utilization of the County
Civil Defense extrication equipment now housed at the main fire station at 9th & Central..
Dispatcher
It is my feeling that the dispatch system as it now exists should be utilized to the
greatest extent. The training and experience of the present dispatchers on the Fire
Department as it exists today is invaluable. I feel it should be ordained that any
contracting body that is providing ambulance service should maintain a direct portable
and stationary communication at all times with the dispatcher in the Fire Headquarters
and that communication system shall be tested daily at 8:00 a .m. and 8:00 p.m., seven
days a week, 365 days a year. I don't think that specifics need to be addressed at this
time as to the type of communication, ,only that it should be a two way communication
so the dispatcher in the Fire Headquarters may receive an acknowledgement from that
group of individuals who is maintaining the ambulance vehicles during any period of time
and that that communication structure should also include a direct communication line
to any area in which personnel will be allowed to sleep in any location while on duty.
Employees of the Ambulance Service
It is my feeling that employees of the ambulance service should be of the best moral
character and that person should qualify in regard to not having been convicted of a
felony and he should have a valid chauffeurs license to drive the ambulance if needed
at any time. Each and every member of the ambulance squad shall be of the same
caliber and also be able to provide a chauffeurs license in case any or all three or two
whichever the case may be, members shall be needed to drive. The employees should
be with all possible due regard, be placed in a service area of the hospital which will
provide them with the quickest response to that ambulance that is possible bearing in
mind the fact that these restrictions should not govern the employment of that individual
throughout the hospital and the hospital shall have some latitude in how it compensates
4
for the time that that employee is not operating the ambulance service. My only
concern is the response time will be minimum amount to that vehicle in order to get it
on the street as quickly as possible.
Final Review
I feel that by placing the ambulance in the medical environment, it was a very fine
choice of this Commission and I hope the Council will take this recommendation and pass
on it. I feel that the decision of this Task Force is not a vote of no faith or dissatisfactic
with the City Fire Department ambulance service, it is my feeling that with the new
requirements and certification that the service can best be rendered by personnel in a
medical environment rather than in a lay environment as it exists today.
jack Schaefer
Meeting No. 18
AMBULANCE STUDY TASK FORCE
November 27, 1979
3:00 p.m. , Mercy Health Center
Members Present: Rick Kreiman
Pat Gabrielson
Robert Dunphy
Ann Sweeney
Others Present:
Ken Gearhart, City Manager
Paul Kluseman, MHC
Don Bradley, MHC
Carol Reimer, MHC
Nancy Ertl, MHC
Bev Patty, MHC
Julie Woodyard, MHC
Bob McFadden, MHC
Kimberly Steiner, Finley
L. Colin, Finley
Mel Graves, Finley
Ron Jaeger, Finley
John Muenster, Finley
Craig Rose
Gary Rieniets
Ken Sargent
jack Schaefer
Art Roth
Don Allendorf
Phyllis Anger
Gary Nielson, Xavier
Joe Hiebel, Xavier
Pat Dillon, Local 94, UAW
Edna Thompson, Rep. , Supervisors
Tania McClain
Carol Beaves
Emmy Miller, R.N.
Joe Jordan, KDUB-TV
Art Hackett, WMT-TV
Preston Lerner, T.H.
Dave Lawrance, WDBQ
Timothy Berry, KDTH
Ken Sargent presented definitions of the four categories in the rate structure --Transfer,
Basic, Intermediate and Advanced. Most of the discussion was concerned with the transfer
rate and what types of calls could be included in this category. It was felt that the transfer
call would be determined more on the basis of something,. scheduled, rather than on day, time
or vehicle used. It was noted that,as the service becomes operational, many of these
questions would be more clearly addressed.
Rick Kreiman felt that since two ALS ambulances were provided by this service, they would
be better used for transfer calls that back up rather than sitting idle. Other members felt
that the purpose of the additional ALS vehicle would better be served by keeping these
vehicles "standing by" for emergencies rather than running transfers. Rick pointed out that
an ALS ambulance could "get out of a transfer in 5-10 minutes." He further stated that if
the ALS ambulances are not used to assist in the transfers, then the service provided by
Mercy is no better than the present service. Ken Sargent pointed out that there is, in fact,
a definite upgrading in the proposed service because of the additional vehicle devoted solely
to transfers, rather than the present system of handling transfers and emergencies with the
same vehicle. It was further pointed out that this Task Force had established that it wanted
the highest rate of coverage possible --that is an ALS ambulance standing by to answer an
emergency call at the highest percentage of the time possible. In order to accomplish this
percentage of coverage, the ALS ambulances cannot be used for transfer duties.
Jack Schaefer presented the idea of a round trip rate to alleviate the high fee charged on
intra-hospital and similar calls. Several Task Force members felt that in order to give
active consideration to this suggestion, statistics on how many of these cases occur would
have to be obtained. Chief Dunphy reported that the information could be obtained only by
going through the bills manually or by starting a survey of future calls. The Task Force
decided to take the suggestion under advisement at this time. This may be a matter for the
proposed Ambulance Commission to review.
The Task Force addressed the tabled motion of the last meeting to reconsider the vote of
Saturday, November 17, in which Mercy Option 2 was selected as the Task Force's recom-
mendation to City Council. The results of this vote were as follows:
Those in favor of reconsidering the vote of November 17 - 3
Those opposed to reconsidering the vote of November 17 - 8
11 total members
The motion was defeated and the vote of November 17 resulting in the selection of Mercy
Option 2 as the Task Force recommendation to City Council stands.
The Task Force identified the need for an Ambulance Commission to be established with the
following proposed purposes:
1. To enforce the policy that the ambulance service in one hospital not adversely affect
service to any of the other hospitals. This calls for insurance of patient choice as
well as geographic division of the city.
2. To set and review rates. Included should be some sort of penalty clause to ensure that
the agreement is lived up to.
3. To oversee the continuing education of ambulance driver/attendants in order to achieve
and maintain the level of care called for.
4. To cause protocol to be reviewed and approved by the appropriate medical personnel at
the appropriate time intervals.
5. To address complaints, perhaps through a hearing procedure, both within and outside
the service.
It was suggested that the Commission meet on a monthly basis with the option to meet less
if deemed appropriate.
The following membership guidelines were suggested:
3 consumers
2 representatives each hospital
1 city representative
1 Medical Director
11 members
1 representative each hospital
1 resident of Dubuque
1 resident of service area, not Dubuque
1 nursing home representative
1 Dubuque city government representative
1 ambulance employee
1 physician not affiliated directly with a hospital
9 members
Discussion showed a concern that each hospital be allowed more than one representative to
provide for someone from other than the medical field (such as accounting). The need for
at least three consumers was also expressed. The Task Force proposed the following
membership list:
3
2 representatives from each hospital
2 consumers residing within Dubuque city limits
1 ambulance employee
1 consumer residing in ambulance service area outside Dubuque city limits
1 nursing home representative
1 Dubuque city government representative
1 physicia l - Dubuque Medical Society
13 members
Pat Gabrielson moved that the Task Force vote on acceptance of this membership list.
Seconded by Ann Sweeney. Discussion pointed to the fact that the ambulance employee would
be a representative of Mercy which would allow that hospital one more representative than
Finley and Xavier. Ken Sargent indicated that he could accept the elimination of this
representative. In order to maintain an odd number of members, it was suggested that this
vacancy go to a representative of East Dubuque. Pat Gabrielson amended her motion to re-
flect this change. Seconded by Ann Sweeney. Voting results showed 11 in favor of the
following membership list:
2 representatives from each hospital
2 consumers,residents of. Dubuque
1 consumer,resident of East Dubuque _
1 consumer, resident of ambulance service area, not Dubuque or East Dubuque
1 nursing home representative
1 Dubuque city government representative
1 physician - Dubuque Medical Society
13 members
Ken Sargent expressed concern that the Task Force set an effective date so that Mercy
can make necessary preparations. It was noted that there is much public controversy over
the recommendations of this Task Force. The longer the Task Force deliberates on decisions,
the stronger the public controversy will become. Ken stressed that the Task Force act
expediently to resolve the issues still at hand so that the recommendation can go to Council
as soon as possible. Ken Gearhart indicated that the following items remain to be addressed:
dispatching, nursing home cots, housing of ambulance, city subsidy, effective date, outline
of contract elements and final report to Council. The question of input from other agencies
on this recommendation prior to submission to Council was raised. Ken Gearhart expressed
his obligation,as he sees it, to bring this recommendation to Council and asks Ken Sargent
to present a sequence of events, as he sees it, at the next meeting.
The next meeting will be held Tuesday, December 4, 3:00 p.m. , Mercy Hea lth Center.
'._CATEGORY
FEE
DEFINITION
EXAMPLES OF CARE/REMARKS
I. Transfer
II. Basic
III. Intezmediate
$63
$110
$160
This category refers to scheduled transportation
of a patient from:
1) An extended -care facility to a hospital
2) A hospital to an extended -care facility
3) Intra-hospital transfers
Ftcm nr;✓4 zte re5,'dc r,ee el ell? h,1)�&;c:3 s
t 4erec7
This category refers to any treatment which may
be performed by a Basic EMT at the scene of
an accident or illness.
This category refers to any treatment which
requires the expertise and medical intervention
of an Advanced EMT at the scene of an accident.
or illness.
This "transfer rate" will be
effective during the hours of
0700-1600 on Monday through
Friday,, while the designated
transport vehicle is operational.
This category will affect only
those patients whose condition
will not be adversely affected by
a delay in transport and does not
require advanced emergency medical
care as defined by recent legisla-
tion.
Again, the condition of this type
of patient does not require ad-
vanced emergency medical care as
defined by recent legislation.
Types of care include:
1) Bandaging
2) Splinting
3) Control of bleeding
4) Extrication
Types of medical care includes:
1) I V cannulation
2) Cardiac monitoring and
dysrhythmia recognition.
3) The administration of
medication, either IV,
IM or sub Q
4) MAST application
5) Advanced methods of main-
taining a patient airway
(i.e. assisted ventilation,
nasal or esopharyngeal
airway, etc.)
CATEGORY
FEE
DEFINITION
EXAMPLES OF CARE/REMARKS
I�. Advanced
$300
This category pertains to the level of care
rendered to a critically ill patient in cases
of unexpected cessation of vital signs (i.e.
cardiac or respiratory arrest).
Types of medical intervention
include:
1) Initiation of BLS techniques
(CPR)
2) Initiation of ACLS techniques
a) Monitoring and/or defibril-
lation
b) Esophageal or endotracheal
intubation
c) The administration of
cardiac drugs
Meeting No. 19
Members Present:
Others Present:
AMBULANCE STUDY TASK FORCE
• December 4, 1979
3:00 p.m. , Mercy Health Center
Kenneth Sargent
Robert Dunphy
Craig Rose
Ann Sweeney
Phyllis Anger
Art Roth
Pat Gabrielson
Ken Gearhart, City Manager
Don Bradley, MHC
N. Ertl, MCH
C. Reimer, MHC
Pat Fley, MHC
John Hutchcroft, Amb. dr./att.
Carol Beeves
Tania McClain
Emmy Miller
Timothy Barry, KDTH
Gary Rieniets
Rick Kreiman
Don Allendorf
Lorene Colin, Finley
L. Steiner, Finley
Mel Graves, Finley
Joe Hiebel, Xavier
Gary Nielson, Xavier
Jere Murray, Finley
Joe Jordan, KDUB-TV
Ron Bock, KDUB-TV
Dave Lawrance, WDBQ
Art Hackett, WMT-TV
Dr. Rose indicated that at the last meeting the Task Force, in discussing the position of
Medical Director of the service, did not address directly the fact that the Medical Director
would be appointed by the Medical Society. For clarification purposes, the minutes should
reflect that, according to law, the Medical Director will be appointed by the Dubuque
County Medical Society.
Ken Sargent distributed a sheet of revised examples of care at different rate levels as per
discussions of last meeting.
2. Time Table for Implementation - Ken Sargent distributed a handout outlining this timetable.
As per the request of the Tri Hospital Planning Conference to review the Task Force
recommendation before submission to the City Council, such review has been set for December
12, 1979. As it will be impossible to have the final report ready by this date, Ken Sargent
suggested that he put together a fact sheet indicating that this is not the final report, but
only a summary of the actions as seen by him. Ken feels it is important that the review take
place at the December meeting rather than wait until January and therefore he suggested this
course of action.
Ken pointed out that it is possible to conduct the HSA Process concurrently with the City
Council review, but questions the wisdom of this course of action. He further pointed out
that if City Council approval is received, the HSA process can begin along with recruiting
and training of ambulance personnel. He noted that the HSA Process can take a maximum of
120 days depending on the amount of support received from Tri Hospital and Dubuque City
Council. For purposes of the final report, the time to obtain HSA approval (maximum 120
days) would reflect the effective date. The question was raised regarding the risk involved
with recruiting and training of personnel prior to HSA approval. Ken Sargent indicated that
this is an acceptable risk to Mercy Health Center.
3. Dispatching - Discussion of 911 emergency number to be implemented in Dubuque. The
city will continue to pay for staff telephone lines in place currently. Any additional tele-
phones within the hospitals would be the hospital's responsibility.
2
4. Nursing Home Cots - Pat Gabrielson indicated that there are several. problems associated
with the possible requirement that each nursing home furnish an ambulance cot. She pointed
out that the nursing home is actually the home of the patient and as such, the only place for
a patient to await the ambulance may be in the living room or dining room of the home. She
also indicated that three of the eight nursing homes do not have space to store such a cot.
She pointed out that the current problems associated with the time factor will no longer be a
significant problem if one ambulance is designated solely for transfers. Further, there
exists the problem of personnel to wait for the ambulance with the patient. Pat believes
the suggested requirements would be detrimental to the mental well being of these elderly
people. It is noted that on return runs to the nursing home, it would not be a problem for
personnel to meet the party at the door. The Task Force feels that this matter may be better
addressed after the service is in process and should perhaps be a matter for the Ambulance
Commission to take up. Phyllis Anger believes that the expense for the cots should be
addressed by this Task Force and such expenses figured into the bottom line. The point was
also raised that a special rate has been established for the nursing home transfers, and, in
reciprocity, cots maybe an expense covered by the nursing homes. Ken Sargent points out
that without knowledge of cost of cots, depreciation rates, life estimates, etc., it is
impossible for the Task Force to make a judgment in this area. Phyllis Anger will obtain this
information and report back to the Task Force.
5. Housing the Ambulance - Mercy Health Center intends to build a garage to house the
ambulances year round. Ken Sargent believes that such construction will take approximately
three to four months but will report back with more specific information on this matter. He
further reported that currently space is available to house the ambulances pending completion
of the garage.
6. City Subsidy - The purpose of this agenda item is to test the sense of the Task Force
pertaining to city subsidy. Several members indicated that they are hearing much public
comment that this service should be subsidized. The question was raised whether this was
a matter for the Task Force or City Council. It was felt that although the ultimate decision
is up to City Council, it would be appropriate for the Task Force to make a recommendation.
Several Task Force members feel it imperative that the Task Force look again at the rate
structure in an attempt to get the rates as low as possible. The point was made that much
public misunderstanding has taken place regarding city subsidy. The public comment seems
to be in favor of city subsidy, but the thinking is that a city subsidy can exist only if the
service is city operated. In fact, a city subsidy can exist regardless of who operates the
service.
Ken Gearhart presented a revised rate structure for review. Transfer still $63; Basic still
$110; combine third and fourth tiers into one category at $170. After some review of this
revision, Craig Rose moved that the third and fourth categories of the rate structure be
combined in all ways, including fees, so that a new third category will be created at a
fee of $170. Seconded by Pat Gabrielson. Discussion reflected that this new rate structure
still assumes no city subsidy as compared to the present service which does operate with
city subsidy. Vote: in favor-10; opposed-O. The rate structure is so revised.
3
The Task Force was questioned as to the amount of city subsidy, if any, they feel would be
appropriate. Rick Kreiman opposed reopening the issue of city subsidy indicating that the
Task Force had decided previously that no city subsidy would be involved. Other members
indicated that although the Task Force did make this decision previously, public opinion is
showing that a city subsidized service is favored, and therefore, the Task Force may be
obliged to look at this issue again. It was suggested that if the city subsidized is meant
to lower the rates, we may recommend the current level of subsidy of $60 , 000 or perhaps a
lower figure of $40, 000-$45 , 000 . It was also suggested that the subsidy be based on any
unforseen loss by Mercy Health Center rather than a flat figure. This, however, would not
serve to lower the present rate structure. It was felt that the Task Force could perhaps
recommend that the City Council look at city subsidy without specifying a particular amount.
Craig Rose moved that the Task Force strongly suggest to the City Council that a subsidy be
considered in that it would lower the proposedrate structure. Seconded by Ann Sweeney. No
discussion. Vote: in favor-6; opposed-4. This motion carries.
The question of subsidy from other user groups was also raised. It was felt that this is an
area outside the jurisdiction of the Dubuque City Council appointed task force and is something
to be addressed by the Dubuque City Council.
7. Effective Date - According to Ken Sargent's timetable, the effective date will be a maximum
of 120 days from City Council approval.
8. Outline of Contract Elements - Ken Gearhart asked the Task Force to review this ma tter
and present their thoughts to him at a later date.
9. Final Report to Council - Ken Gearhart indicated that he sees the final report as a type of
summary or outline form. Ann Sweeney and Don Allendorf will assist Ken Gearhart in prepara-
tion of a draft to be reviewed by the Task Force at the next meeting. All minority reports are
the sole responsibility of the individual submitting such a report. The Task Force does not
feel a need to review any of the minority reports.
10. Public Education - Ken Sargent distributed a handout of questions and answers regarding
facts about the Ambulance Task Force investigations. Ken feels there has been a great deal
of public misunderstanding regarding the decisions of the11Task Force. He further indicated
that were this issue to come before the City Council at this point in time, that the level of
public feeling based on misunderstanding and lack of data would greatly hinder the acceptance
of this Task Force recommendation. It was stressed that if the City Council rejects the
Task Force recommendation based on an understanding of all the alternatives, this is acceptable
However, it is imperative that a decision to reject the recommendation not be made based on
misunderstanding or lack of data. Rick Kreiman and Phyllis Anger agree with Ken that public
education is necessary. They feel that the public should be educated both on the service
Dubuque presently has and the proposed service. The Task Force decided that each member
will look at the issue of public education, formulate ideas and bring their ideas back for
discussion at the next meeting.
11. East Dubuque Representation - It was noted that East Dubuque City Council expressed
dissatisfaction with representation on the Task Force. Ken Gearhart stressed that the 11
member Task Force was established by the Dubuque City Council, who received applications
and selected three at large members from those applications. It was again stressed that this
action was by Dubuque City Council resolution.
Next meeting will be held Frid?v. T?ecemhar 'a q•nn ,,, raP,-,.t, rn.,+,.1,-
CATEGORY
FEE
DEFINITION
EXAMPLES OF CARE/REMARKS
I. Transfer
II. Basic
III. Intermed-
iate
IV. Advanced
$63
$110
$160
$300
This category refers to scheduled trans-
portation of a patient from:
1) An extended -care facility to a
hospital.
2) A hospital to an extended -care
facility.
3) Inter -hospital transfers.
4) From or to a private home or any
combination of the above.
This category refers to any treatment
which may be performed by a Basic EMT
at the scene of an accident or illness.
This category refers to any treatment
which requires the expertise and medical,
intervention of an Advanced EMT at the
scene of an accident or illness.
This category pertains to the level of
care rendered to a critically ill patient
in cases of unexpected cessation of vital
signs (i.e. cardiac or respiratory arrest)
This category will affect only those patients
whose condition will not be adversely affected
by a delay in transport and does not require
advanced emergency medical care as defined by
recent legislation. When questions arise the
coordinator of the service will be consulted.
Again, the condition of this type of patient does
not require advanced emergency medical care as
defined by recent legislation. Types of care
include:
1) Bandaging 3) Control of bleeding
2) Splinting 4) Extrication
Types of medical care include:
1) I V cannulation
2) Cardiac monitoring and dysrhythmia recognitiol
3) The administration of medication, either I V,
I M or sub Q.
4) MAST application
5) Advanced methods of maintaining a patent
airway (i.e. assisted ventilation, nasal or
esopharyngeal airway, etc.)
Types of medical intervention include:
1) Initiation of BLS techniques (CPR)
2) Initiation of ACLS techniques
a) Monitoring and/or defibrillation
b) Esophageal or endotracheal intubation
c) The administration of cardiac drugs
'TIMETABLE FOR IMPLEMENTATION
I. Tri Hospital Review: 12/12/79
II. City Council Review
III. H.S.A. Process: Approximately 120 days
A.) Submit a Letter of Intent to the Office of Health Planning,
Iowa State Department of Health: 60 day waiting period.
B.) 60 days later, MHC wil receive a letter from the Iowa State
Department of Health, requesting that an application be
filed. Appropriate forms will accompany the letter.
C.) The application is prepared and submitted.
D.) The review process then begins: 50-60 days
1. Community informational meeting
2. Project review
3. Sub -area review
4. Board review
5. CON council
* A non-substantative review is an option if the Task Force's
recommendation is supported by Tri Hospital and the Dubuque
City Council: Approximately 30 days.
Pending H.S.A. approval, MHC will begin recruiting and training
ambulance personnel. Members of the Dubuque Ambulance Commission
will be appointed and organizational meetings will be scheduled
during this time.
December 4, 1979
WHY THE AMBULANCE STUDY TASK FORCE WAS FORMED
The task force was formed at the request of the City Council to examine ways
of providing Dubuquers with continued high quality ambulance service.
GOAL OF THE AMBULANCE STUDY TASK FORCE
To provide the citizens of Dubuque with the high level of ambulance service
required by law at the lowest possible cost, by examining all of the
alternatives and resources available in the City of Dubuque.
STATEMENT OF WHERE THE TASK FORCE IS IN ITS PROCESS
It has examined proposals from The Finley Hospital
Xavier Hospital
Mercy Health Center
City of Dubuque
and selected the Mercy Health Center plan as the one which would best meet
the goals of the committee.
Mercy's proposal was compared with the City's and this task force came to
the conclusion that Mercy's proposal would best suit the needs of the
citizens of Dubuque.
WHAT WAS THE COST COMPARISON PROJECTED TO BE FOR 1980 BETWEEN THE CITY
OF DUBUQUE PROPOSAL AND THE MERCY HEALTH CENTER PROPOSAL ACCEPTED BY THE
TASK FORCE?
The City of Dubuque projected that ambulance service would cost the City
$370,800 in 1980.
Mercy Health Center projected a cost of operating the ambulance service
for the same period of time at $277,700.
WHY IS THE CITY'S COST $93,100 HIGHER THAN MERCY'S?
The hospital had the advantage of utilizing an offset.
WHY ARE THE CITY'S EXISTING RATES SO MUCH LOWER THAN MERCY'S PROJECTED
RATES FOR USING THE SERVICE?
The City's rates are currently subsidized by tax dollars...Mercy's
projected rates are not.
COULD MERCY'S RATE STRUCTURE ALSO BE SUBSIDIZED BY TAX DOLLARS?
Yes.
-2- December 4, 1979
COULD THIS SUBSIDY MEAN AN EVEN LOWER RATE STRUCTURE THAN THE CITY
COULD OFFER UNDER THEIR PROPOSAL?
Yes.
WOULD THE CITY'S RATES BE HIGHER THAN MERCY'S IF NOT SUBSIDIZED BY
TAX DOLLARS?
Yes!!!
IF THE AMBULANCE SERVICE WOULD BECOME HOSPITAL -BASED, WOULD THE CONSUMER
STILL HAVE HIS CHOICE OF HOSPITALS?
Yes, however there would be some life and death situations where a patient
would be taken to the NEAREST HOSPITAL, or the hospital which had the
SPECIFIC diagnostic or life-saving equipment needed by the patient. After
being stabilized, choice of hospital would still belong to the patient.
Meeting No. 20
Members Present:
Others Present:
Public Education
AMBULANCE STUDY TASK FORCE
December 14, 1979
9:00 a.m., Mercy Health Center
Robert Dunphy
Gary Rieniets
Pat Gabrielson
Rick Kreiman
Art Roth
Craig Rose
Don Allendorf
Ken Gearhart, City Manager
C. Calin, Finley
Tania McClain
Gary Nielson, Xavier
William Hammel
Art Hackett, WMT-TV
Phyllis Anger
Ken Sargent
Ann Sweeney
Emmie Miller, MHC
Nancy Ertl, MHC
Don Bradley, MHC
Pat Fleming, MHC
Rudy Vera, Dubuque Ambulance
Ron Theisen, Dubuque Ambulance
The purpose of this presentation would be an effort to inform the public about why the
Task Force was established and what its findings have been. In discussion of the format
of the presentation, it was felt that this should not take the form of debate or public hearing,
but rather it was suggested that information be presented by the Task Force and written
questions be accepted from the audience in writing. Perhaps the written questions could
be submitted to the chairperson and he could choose to answer or appoint a Task Force
member to respond. It was also stressed, however, that through this method, it may
appear that the Task Force is only willing to address a selected group of inquiries.
The question of Task Force members expressing minority opinions was raised by Rick
Kreiman. Dr. Rose responded that he felt this type of personal opinion to be inappropriate
for this type of presentation.
It was stressed that ground rules for the format should be established prior to the presenta-
tion and made known to the public so they would know what to expect.
Phyllis Anger raised the question of whether it was in the realm of the Task Force to hold
such a public education presentation. She felt that because the Council had not
specifically asked the Task Force to go to the public in this manner, it may not be
appropriate. Several Task Force members responded that they felt the Council would be
appreciative of any efforts on the part of the Task Force to inform the public so that any
opinions expressed at a public hearing or to the Council members would be opinion based
upon correct and adequate information. It was felt that presently much public opinion
was based on misinformation or lack of information. The public education presentation
would be an effort to see that public opinion expressed, whether in favor or against the
Task Force recommendation, would be opinion based on accurate and adequate information.
Several members felt that if the Council did not approve of such action, they would
certainly inform the Task Force through Ken Gearhart. After discussion, the concensus
of the group was to direct Ken Gearhart to request the Council's feelings on this public
education presentation before going ahead with any concrete plans.
2
Tri-Hospital Report
The Tri-Hospital Planning Conference directed a letter to the Task Force indicating a
motion passed at their last meeting as follows:
That a letter be sent to the Task Force and the City of Dubuque asking that:
(1) The Task Force ensure that they have investigated every avenue for providing
the service, (2) that the City investigate other potential areas of revenue for the
service (such as appropriate contributions from other governmental bodies in the
service area) and (3) That other concerned bodies such as the County Medical
Society and the Tri-Hospital Conference have an opportunity to give input to the
Council and the Task Force.
In an effort to accommodate input from the County Medical Society and the Tri-Hospital
Conference, it was moved by Don Allendorf that a representative from the Dubuque
County Medical Society and the Tri-Hospital Conference be invited to participate at the
next Task Force meeting. Seconded by Art Roth. Motion passed unanimously. Ken
Sargent and Art Roth will be responsible for extending this invitation to the Tri-Hospital
Conference, and Dr. Rose will contact the Dubuque County Medical Society.
Nursing Home Cot Cost Data
Phyllis Anger reported that the two -man stretcher with restraint straps and mattress costs
$531.95. The one-man cot: costs $633.15. She noted that these prices were guaranteed
for 30 days only. It was also noted that if these cots were put out for bid, a more
competitive price could probably be secured. Pat Gabrielson indicated that this would be
considered a major expense for the nursing homes and could not be handled by all of them.
The Task Force took no further action on this matter at this time.
Contract Outline
The Task Force deferred this subject until a draft of the report to Council is presented
at the next meeting.
Other Business
Ken Sargent presented a survey of the different ambulance services throughout Iowa.
The survey includes city, population, level of service, number of vehicles, number and
type of personnel, rate structure and base of service. Copies of the survey were dis-
tributed to the Task Force for their information.
The next meeting will be held December 20, 1979, 9:00 a.m. , Mercy Health Center
Auditorium. NOTE: This meeting was subsequently cancelled due to several schedule
conflicts.
NOTE: In reflecting discussion on the appointment of Medical Director at the last meeting,
the minutes state inaccurately, "For clarification purposes, the minutes should reflect that,
according to law, the Medical Director will be appointed by the Dubuque County Medical
Society." This statement should be corrected as follows. "For clarification purposes,
the minutes should reflect that the Medical Director will be appointed by the Dubuque
County Medical Society."
{r
4
THE FINLEY HOSPITAL
December 13, 1979
XAVIER HOSPITAL
Mr. Ken Gearhart
Chairman,
Ambulance Service Task Force
City Hall
Dubuque, Iowa 52001
Dear Ken:
MERCY HEALTH CENTER
Please be advised that at the December 12th meeting of the Tri-
Hospital Planning Conference, the following motion was passed:
"That a letter be sent to the Task Force and the
City of Dubuque, asking that: (1) The Task Force
ensure that they have investigated every avenue
for providing the service, (2) that the City
investigate other potential areas of revenue for
the service (such as appropriate contributions
from other governmental bodies in the service
area) and (3) that other concerned bodies such
as the County Medical Society and the Tri-Hos-
pital Conference have an opportunity to give
input to the Council and the Task Force."
This motion passed after considerable discussion by the Tri-
Hospital Planning Conference's members, and represents a
nearly unanimously consensus on their part.
Sincerely,
Ken W. Sargent
Acting Secretary
SERVICE/LOCATION
CONTACT
PERSON
NUMBER OF
VEHICLES
LEVEL OF
SERVICE
BASE
PERSONNEL
RATES
L. Mary Greeley
Mike Young, EMT-
Two currently. Will
EMT-P
Hospital
1 EMT-P
Base Rate: $60.00
(Ames)
P, Service Coor-
dinator
have three in spring.
1 Basic EMT
Plus $1.50/loaded
mile
Pop. 41,700
(5:17 Employees
are female)
ALS: $120 Plus
'
$1.50/loaded mile
Chargeable Supplies
Suction Catheters
Monitor Electrodes
•
i
Oxygen
Dressings
Suction
Monitor
Area Ambulance
Tim Trosky
Three
EMT -II
Hospital
1 EMT -II and
Base Rate:
Service
EMT -II
1 EMT -I or
City - $57
(Cedar Rapids)
op. 109,900
Ambulance Super-
visor
Basic EMT per
Team
County- $64 non -
emergency plus
$ .74/mile
13 EMT-II's
Port -Port
9 EMT-I's
Standby - $57/hour
9 Basic EMT's
'
Supplies:
(8:13 Employees
are female)
Monitor - $50
Telemetry - $130
•
40% of salaries
Major Trauma - $13
Dffset by traumz.Minor
center
Trauma - $6.50
SERVICE/LOCATION
CONTACT
PERSON '
NUMBER OF
VEHICLES'
LEVEL OF
SERVICE
BASE
PERSONNEL
RATES
Johnson County
Mike Deeds, RN
Three (Two Primary
EMT -II
Private
1 EMT -II and
Base Rate:
Ambulance
(Iowa City)
EMT -II, Coordin-Response
ator
Johnson County
Vehicles,
One Standby)
(Between 080
1200 and
1900-2200
1 Basic EMT
Per Unit
$60 plus $1.50/
loaded mile
'op. 46,850
Ambulance Ser-
Respond from
Currently emplo}
vice
Mercy and U
9 EMT-II's
Advanced Care:
of I Emergency
11 Basic EMT'.
Department
(2:20 Employees
are female)
$150 plus $1.50/
loaded mile
Standby:
•
i
$7.50/hr/attend.
-
Plus $30/hour for
the vehicle
Supplies:
Cervical Collar - $8.
•
Oxygen - $8.00
Suction - $5.00
Dressings - $6.00
Splints - $6.00 '
. Capital -City
Marty Hutt,
Eight Units
Current EMT-
Private
Basic EMT's
Base Rate:
Ambulance
Service.Coor-
_
Basic Planning
dinator
80% of calls are non-
on Paramedic
(1:45 employees
$45 plus $1.60/loaded
(Des Moines)
op. 144,000
emergency .
Service
Majority of per-
are female)
mile
Supplies:
•
sonnel have been
trained in coro-
nary care
,
Oxygen - $10.00
Splints - $5.00
Medical Supplies -$5.1
Rates will rise when
advanced care is pro-
vided
SERVICE/LOCATION
CONTACT
PERSON.'
NUMBER OF
VEHICLES
LEVEL OF
SERVICE
BASE
PERSONNEL.
RATES
5. Des Moines Firc
Chief Murray
Four Primary Response
Basic EMT
Fire Dept.
1 Senior Medic
Not available at
Department
vehicles, two standby
vehicles
(Basic EMT)
1 Fire Medic
this time
Pop. 194,000
(Basic EMT)
Approximately 8,000
calls/year
All employees
are male
6. Midwest Inter-
Doug Cummings,
Three Emergency, One
Basic EMT
Private
All Basic EMT's
Base Rate:
City Ambulance
Coordinator
Non -Emergency
(Obtained
with the ability
(Sioux City)
City contractto
provide i
$50.00
•
Approx. 6,500 calls/
6/1/79)
cardiac monitor -
Pop. 82,000
year
ing
Emergency Response =
$12.00
Night Response - $8.00
Supplies:
•
.
CPR - $25.00
Monitor - $20.00
Oxygen - $12.00
*-Maximum charge of
$75 for patients
within city limits -
specified in city
contract
SERVICE/LOCATION
CONTACT
PERSON
NUMBER OF
VEHICLES
LEVEL OF
SERVICE
BASE
PERSONNEL
RATES
7. M & M Ambulance
Service
(Davenport)
Pop. 100,300
Darryl Chris-
tensen, Coor-
dinator
Three Primary Response
vehicles
Two Standby vehicles
Basic EMT
No Advanced
Care provided
Private with
city contract
Basic EMT's
(4:21 employees
are female)
Base Rate:
$55.00 in city
County calls:
$55.00 plus $1.50/
loaded mile
All supplies used ar
charged to the
patient
8. Superior Ambu-
lance Service
(Burlington)
Pop. 29,900
Don Morgan,
Coordinator
Two Primary Response
vehicles
One Standby vehicle
Approximately 800
calls annually
Basic Care
Service will '
accept only
non -emergency
calls
Private
.
1 Basic EMT
Remainder of
personnel
trained in ad-
vanced first -
aid
Base Rate:
$65.00 in city
County Calls:
$65.00 plus $1.50/
loaded mile
Supplies:
Oxygen - $7.50 city
- $15.00 out
of city
9. Burlington Fire
Department
Pop. 29,900
Fire Chief Don
Mosey .
Four vehicles -
three of these are
fully equipped
modular. -type ambu-
lances
Basic EMT
Fire Depart-
ment
Currently employ
two Certified
EMT-II's with
the remainder
being Basic
EMT's
Base Rate:
$75.00
Out -of -Town Trans-
fers (i.e. Iowa City;
$205
SERVICE/LOCATION
Pop.
DUBUQUE
CONTACT
PERSON
NUMBER OF
VEHICLES
LEVEL OF
SERVICE
BASE
PERSONNEL
RATES
1
). Waterloo Fire
Chief Harold
Three Primary Re-
Basic EMT
Fire Depart-
Basic EMT's
Base Rate:
Department
Smith
sponse vehicles
ment
(2 of the Pri-
mary Response
$37.50 (to be raised
'op. 71,500
Two Standby vehicles
Approximately 3300
calls/year. No trans-
vehicles are
staffed with
on -duty fire
fighters)
to $50.00) plus
$1.50/loaded mile.
This service is sub-
sidized by tax dollar
fers
Council Bluffs
Wayne McCunn
Two Primary Response
Currently Basic
City owned
Basic EMT's
Base Rate:
Ambulance Ser-
vehicles
EMT with cardiacand
operated
'
vice
monitoring ca-
(Seven employee3$65.00
plus $1.00/mil
60,500
3500 calls annually
pabilities
Both vehicleshave
based at
fire station
completed
Creighton Uni-
versity's Para-
Port -to -Port
County:
medic Training
Program in 1976
$91.00 plus $ .50/
loaded mile
Round trip rate .
(within corporate
limits and return
trip within 5 hours)
$85.00 plus mileage
Supplies:
Oxygen - $10.00
OPULATION OF
- 63,000
l
A
Meeting No. 21
AMBULANCE STUDY TASK FORCE
January 11, 1980
9:00 a.m. , Mercy Health Center
Members Present: Kenneth Sargent
Robert Dunphy
Craig Rose
Others Present:
Phyllis Anger
Art Roth
Pat Gabrielson
Ken Gearhart, City Manager
Don Bradley, MHC
C. Reimer, MHC
N. Ertl, MHC
Pat Fley, MHC
Mary Kay Ernst, MHC
LeAnn Krapfl, MHC
Comments from Dubuque County Medical. Society
Gary Rieniets
Rick Kreiman
Don Allendorf
Tania McClain
Chuck Uskavitch
Scott Neyens
Jere Murray, Finley
Joe Hiebel, Xavier
William A. Williams, citizen
Art Hackett, WMT-TV
Bob Freund, TH
Dr. Chapman was present representing the Dubuque County Medical Society. He expressed
the Society's desire for the best possible ambulance service for the City of Dubuque. The
Society further feels that the recommended ambulance commission as outlined by the Task
Force should be established and perhaps should address some of the issues that the Task
Force has investigated Dr. Chapman indicated that the Medical. Society feels the present
system is a good service which could perhaps be improved upon, but feels that the proposal
submitted by Mercy Health Center is an excellent one also. When questioned as to
whether or not he felt the present level of care was satisfactory for the City of Dubuque,
Dr. Chapman indicated that the level of care is adequate, but the number of ambulances
should be increased to two fully equipped and staffed ALS ambulances. It was pointed out
that as costs for provision of two ambulances are investigated, alternatives other than city
based service must be involved. The Medical Society expressed anxiety about losing the
services of the present experienced personnel now on the ambulance crew. The Medical
Society feels that if service is moved out of the City, a very difficult transition period
will be encountered Rick Kreiman expressed a feeling that the question of whether or not
to keep the service within the City should go to a referendum vote rather than being placed
solely with the City Council. It was also indicated, however, that these Council members
are elected by the people to make these decisions.
Review of Draft Report
Ken Gearhart indicated that this is a draft of the body of the report. In addition to this
report, other documents will be attached including Task Force minutes, hospital proposals
and any individual comments which the members wish to make. The Task Force reviewed
the draft and made the following changes:
Page 6. Correction of medical term, 3c) Esophageal Gastric Tube Airway (EGTA).
Page 8, third paragraph. It was felt that a nootnote should indicate that currently three
ambulance driver/attendants have successfully challenged the EMT -II test and therefore
that level of care is protected under law.
2
Page 8, fourth paragraph. The following language change was suggested. "This
translates into a recommendation that the level of service be at least the EMT -II level
with a goal to upgrade the level of care to EMT -Paramedic after one year."
Page 9, fourth paragraph. It was felt by the Task Force that the statement indicating no
interest on the part of private agencies did not accurately reflect the situation. The fol-
lowing language change was suggested. "The Task Force looked at having the service
provided by a private agency and, for many different reasons, one of them being that those
contacted were not interested in providing the service at the level of care that the Task
Force determined it wanted, decided not to give further consideration to that option."
Page 9. Eliminate footnote.
Page 11, first paragraph. The following language was suggested. "Initially, the hospitals
did not feel that they could submit a proposal. However, after a presentation on the
Cedar Rapids Mercy Hospital hospital based service, it was decided by the Task Force to
have each of the three local hospitals prepare a proposal for providing ambulance service.
(See minutes of meeting no. 6 for further details.)
Table I. Columns 8 and 9 will be eliminated. They will be shown on Table II.
Page 14, fourth line. Correction --the word "no" should be eliminated.
Page 14, fourth paragraph. It was felt that additional reasons for selection of Mercy's
proposal should be cited here, including the increase in level of communication between
ambulance and hospital personnel, as well as the fact that having ambulance attendants
working in the hospital setting would provide the benefit of maintaining and upgrading
their skills.
Page 15. Correction to indicate that Mercy Hospital would hire nine registered nurses and
nine basic EMT' s .
Page 16. The training for the R.N.'s will include all those items mentioned in the draft
plus the ability to provide "five minutes of one person uninterupted CPR."
Individual Comments
Don Allendorf provided Ken Gearhart with comments of the three citizen members of the
Task Force. Pat Gabrielson also provided a copy of her individual comments. Although it
had previously been requested that individual comments be handedin at this time, several
members identified difficulties with this deadline. Ken Gearhart requested that all
comments be handed in to him by noon, Monday, January 14. .Several members questioned
the procedure from here. Ken Gearhart reported that he anticipated a work session
scheduled for the Council to discuss the report and also anticipated that Task Force members
would be requested to be present.
Comments from Tri Hospital Planning Conference
Ken Sargent indicated that neither the representative, Mr. Wayne Norman, nor his
alternate would be able to attend the meeting. The Task Force did acknowledge again
receipt of their December 13, 1979 letter which was discussed at the last meeting.
3
Public Education
Ken Gearhart reported that he had not contacted City Council regarding their views on
providing a public education presentation as suggested at the last meeting. It was
suggested that the Task Force raise this question at the anticipated work session.
Closing Comments
Ken Gearhart expressed his appreciation to the members of the Task Force for their
efforts during the past months. It was noted that copies of the final report should be
forwarded to the following organizations for their information: Dubuque County Medical
Society, Tri-Hospital Planning Conference, Area Council of Governments.
JOINT RULES OF STATE DEPARTMENT OF HEALTH AND BOARD OF MEDICAL
EXAMINERS PERTAINING TO THE TRAINING, CERTIFICATION AND SERVICES
PERFORMED BY ADVANCED EMERGENCY MEDICAL TECHNICIANS AND PARAMEDICS
1424 FILED IAB 5/30/79
ARC 0277
HEALTH DEPARTMENT[470]
JOINT RULES OF
STATE DEPARTMENT OF HEALTH
AND
BOARD OF MEDICAL EXAMINERS
The state department of health and the board of
medical examiners jointly, pursuant to the authority of
section 147A.4 of the Code, adopts the following rules
relating to the training and certification of and the
services performed by advanced_ emergency medical
technicians and paramedics.
TITLE XXV
ADVANCED EMERGENCY MEDICAL CARE
CHAPTER 132
TRAINING AND CERTIFICATION OF AND
SERVICES PERFORMED BY ADVANCED '
EMERGENCY MEDICAL TECHNICIANS AND
PARAMEDICS
470-132.1(147A) Definitions. For the purpose of
these rules, the following definitions shall apply:
132.1(1) "Paramedic" means an individual trained in
all areas of advanced emergency medical care, and who
has been issued a paramedic certificate by the board.
132.1(2) "Advanced EMT -I or advanced EMT -II"
means an individual trained to provide advanced
emergency medical care, and who has been issued an
advanced EMT -I or advanced EMT -II certificate by the
board.
132.1(3) "Basic EMT" means an individual who has
satisfactorily completed the United States Department of
Transportation's prescribed course for basic EMTs, as
modified for this state in the current "Basic EMT Policy
and Procedure Manual" dated August 1977, approved by
the governor's emergency medical services advisory
council and administered by the department which is
hereby adopted by the board. The individual shall be
certified as a basic EMT by the department, but shall not
be certified to perform any of the procedures listed in
subrule 132.1(4).
132.1(4) "Advanced emergency medical care" means
such medical procedures as:
a. Administration of intravenous solutions.
b. Gastric or tracheal suction or intubation.
c. Performance of cardiac defibrillation.
d. Administration of parenteral injections of any of
the following classes of drugs:
(1) Antiarrhythmic agents;
(2) Vagolytic agents;
(3) Chronotropic agents;.
(4) Analgesic agents;
(5) Alkalinizing agents;
(6) Vasopressor agents;
(7) Anticonvulsive agents; or
(8) Other drugs which may be deemed necessary by
the supervising physician.
e. Any other medical procedure designated by the
,Bard, by rule, as appropriate to be performed by
advanced EMTs and paramedics who have been trained
in the procedure.
132.1(5) "Advanced emergency medical care
personnel" means any advanced EMT -I, advanced EMT -
II, or paramedic currently certified by the board.
132.1(6) "Board" means the board of medical
examiners appointed pursuant to section 147.14,
subsection 2, of the Code.
132.1(7) "Council" means the advanced emergency
medical care council established by chapter 147A of the
Code.
132.1(8) "Department" means the department of
health.
132.1(9) "Patient" means any individual who is sick,
injured, or otherwise incapacitated.
132.1(10) "Hospital" means any hospital licensed
under the provisions of chapter 135B of the Code.
132.1(11) "Physician" means any individual licensed
under chapter 148, 150, or 150A of the Code.
132.1(12) "Physician designee" means any
registered nurse licensed under chapter 152 of the Code,
or any physician's assistant approved by the board and
certified under chapter 148B of the Code who is
designated by the medical director, by name in writing,
to act as an intermediary for a supervising physician in
directing the actions of advanced emergency medical
care personnel. All such physician designees shall be
trained and certified in advanced cardiac Life support as
outlined in American Heart Association standards as of
August 1977, or its equivalent, and demonstrate
competency equivalent or superior to the level of the
advanced emergency medical care personnel being
supervised as determined by the council. This
designation shall be valid for two years from the date of
such designation unless sooner rescinded. The physician
designee may be redesignated if qualified.
132.1(13) "Training program" means any training
program providing advanced emergency medical care
instruction as approved by the board.
132.1(14) "Training program medical director"
means any duly licensed physician responsible for
directing an advanced emergency medical care training
program.
132.1(15) "Training institution" means any
accredited hospital or institution which meets the -
minimum requirements necessary, as determined and
approved by the board, to conduct the training of
advanced emergency medical care personnel.
132.1(16) "Trainee" means any individual enrolled in
a training program participating in the didactic, clinical,
and field experience portions under supervision.
132.1(17) "Service program" means any twenty-four
hour advanced emergency medical care ambulance
service or rescue squad service that has received
authorization by the department.
132.1(18) "Service program medical director"
means any duly licensed physician who shall be
responsible for overall medical control of the service
program.
132.1(19) "Service program area" means the
geographic area of responsibility served by any given
ambulance or rescue squad service program.
132.1(20) "Medical control" means direction, advice,
or orders provided by physicians, or physician designees.
supplying professional expertise through tele-
communications for the provision of rendering on -site
and in -transit advanced emergency medical care.
132.1(21) "Supervising physician" means any duly
licensed physician who has been trained and certified in
advanced cardiac life support as outlined in American
Heart Association standards as of August 1977, or its
equivalent as determined by the council. who is
designated, by name in writing, by the medical director
IAB 5/30/79- FILED 1425
HEALTH DEPARTMENT[470] (cont'd)
to be responsible for medical control of advanced
emergency medical care personnel via any
telecommunications system when such personnel are
providing advanced emergency medical care. This
designation shall be valid for two years from the date of
such designation unless sooner rescinded. The
supervising physician may be redesignated if qualified.
132.1(22) "Direct supervision" means supervision
provided by a physician, or physician designee, who is
physically present with the advanced EMT -I, advanced
EMT -II, paramedic, or trainee..
132.1(23) "Remote supervision" means supervision
provided by a physician, or physician designee, who is not
physically present with the advanced EMT -I, advanced
EMT -II, or paramedic via any telecommunications
system supplemented with standing orders.
470-132.2(147A) Requirements and standards for
enrollment in advanced emergency medical care
training programs.
132.2(1) No person shall be enrolled in a training
program for advanced EMT -I, advanced EMT -II, or
paramedic training unless the following minimum re-
quirements are met:
a. Applicant shall have a high school diploma or its
equivalent.
b. Applicant shall be currently certified by the
department as an EMT -A (basic EMT), or have a current
national registry EMT -A certificate.
c. Applicant shall be physically able to perform the
functions of an advanced EMT -I, advanced EMT -II, or
paramedic as appropriate.
d. Applicant shall complete a satisfactory personal
interview with either the training program medical
director or designee regarding qualifications including
mental and educational attainments, as well as aptitude
to become an advanced EMT -I, advanced EMT -II, or
paramedic.
132.1(2) Reserved.
470-132.3(147A) Advanced emergency medical
care personnel —certification and renewal standards
and procedures.
132.3(1) An advanced EMT -I, advanced EMT -II, or
paramedic certificate is valid for two years from date of
issuance unless sooner suspended or revoked for cause by
the board.
132.3(2) Application and examination.
a. The application form and instructions for
submittal are provided by the board.
b. The completed application, accompanied by the
required credentials, and examination fee shall be
submitted at least thirty days in advance of the
examination date.
c. Only those individuals who have submitted the
required application and have been notified of acceptance
by the board shall be permitted to write the examination.
d. Prior to the examination date each accepted
applicant shall be sent an admission card which shall be
presented by the applicant for admission to the
examination center.
e. The passing score for each examination shall be
determined by the board.
f. The examination shall be administered at least
twice a year at such times and places as may be
determined by the board.
132.3(3) Re-examination.
a. Any applicant who fails the examination shall be
required to rewrite the entire examination.
b. An applicant who fails to pass the initial
examination may rewrite the examination twice to attain
a passing score. Candidates who fail the examination for
the third time shall repeat the training program before
being eligible to take the examination again.
c. Application for re-examination shall be
accompanied by the examination fee. Application shall be
submitted at least thirty days in advance of the
examination date.
132.3(4) Applicants for certification shall have:
a. Completed and submitted all necessary forms
required by the board.
b. Successfully completed the training program.
c. Passed the written examination approved by the
board.
d. Passed the practical examination approved by the
board.
132.3(5) Applicants from other states shall request
certification from the board and may be issued the
appropriate Iowa certificate providing:
a. The applicant completes and submits all necessary
forms required by the board.
b. The applicant submits adequate evidence of
current certification in another state or has other
recognized certification with standards comparable to
those in effect in Iowa as determined by the board.
132.3(6) A challenge of the certification examination
is available to provide additional sources of potential
advanced emergency medical care personnel because of
previous emergency care training. Following is the list of
categories from which eligibility for acceptance is
determined:
a. Any registered nurse wha is licensed in the state of
Iowa.
b. Any individual who has had education and training
equivalent to the requirements in these rules prior to
their effective date.
c. Exceptions to any of the above categories may be
referred to the board for determination of eligibility.
d. Persons wishing to participate in the challenge
process may make written request for procedural
instructions and requirements to: Board of Medical
Examiners, State Office Building, 300 Fourth Street,
Des Moines, Iowa 50319.
132.3(7) Renewal of certificates shall be required
every two years by the board in order to continue
providing advanced emergency medical care.
132.3(8) The application form and instructions for
renewal of certification shall be mailed to the certificate
holder at least sixty days prior to the expiration date of
the current certificate. In order to be eligible for renewal,
the certificate holder shall have:
a. Completed and submitted all necessary forms
required by the board.
b. A current certificate.
c. Completed a minimum of thirty hours of
continuing education per year as outlined below:
(1) At least six hours formal classroom experience;
(2) At least six hours ambulance run critique:
(3) At least six hours clinical experience in a hospital
under direct supervision; and
(4) Twelve hours to be determined by the medical
di rector.
470-132.4(147A) Levels of training.
132.4(1) '"Advanced EMT -I" means a certified EMT -
A who has successfully completed modules 1, 2, 3, and 5 of
the United States Department of Transportation's para-
medic guide, excluding endotracheal intubation.
1426 FILED IAB 5/30/79
HEALTH DEPARTMENT[470] (cont'd)
132.4(2) "Advanced EMT -II" means a certified
EMT -A who has successfully completed the first six and
the fifteenth modules of the United States Department of
Transportation's paramedic guide, and who has been
trained and certified in advanced cardiac life support as
outlined in American Heart Association standards as of
August 1977, or the equivalent of such standards as
determined by the council and approved by the board.
132.4(3) "Paramedic" means a certified EMT -A who
has successfully completed all fifteen modules of the
United States Department of Transportation's para-
medic guide, and who has been trained and certified in
advanced cardiac life support as outlined in American
Heart Association standards as of August 1977, or the
equivalent of such standards as determined by the council
and approved by the board.
132.4(4) The advanced EMT -I or EMT -II training
program shall consist of classroom, clinical, and field
experience sufficient to develop skill and competency in
the respective categories as outlined in the United States
Department of Transportation's paramedic guide, and
shall be completed within a one-year period. After
certification at the advanced EMT -I or EMT -II level,
individuals shall be eligible for certification at the next
higher level pending successful completion of the
appropriate material.
132.4(5) The paramedic training program shall
consist of classroom, clinical, and field experience
sufficient to develop skill and competency as outlined in
the United States Department of Transportation's para-
medic guide, and shall be completed within two years.
132.4(6) In addition to the medical procedures
outlined in subrule 132.1(4), advanced emergency
medical care personnel may perform any other medical
procedure appropriate to their level of certification not
specified in the United States Department of
Transportation's paramedic guide that has been adopted
by rule by the board providing they have been trained in
the procedure and have received authorization from the
service program medical director.
470-132.5(147A) Training program standards.
132.5(1) Training institution.
a. The training institution shall be a postsecondary
educational institution, or hospital providing a training
program approved by the board.
b. Training program approval shall not exceed four
years. Applicants shall use application forms developed
by the board.
c. Approval for training programs shall be obtained
at least sixty days before the start of a class.
d. A training program without a current active
trainee enrollment shall be subject to automatic review.
e. If a training program loses its medical director, it
shall report this information to the board and provide a
curriculum vitae for the medical director's replacement.
A new class shall not be started until a qualified medical
director has been appointed.
f. Board approval is required before any major
curriculum changes can be instituted. Such proposed
changes shall be submitted to the executive director one
month prior to a regular board meeting for consideration
,nd action. Major curriculum changes include:
(1) Alteration of the present curriculum which
increases or shortens the program, exclusive of vacation
days;
(2) Changes in use of co-operating agencies;
(3) Major change in course offering.
g. A training program shall lose its approval if it fails
to meet any of the provisions of these rules.
132.5(2) Application.
a. Any applicant wishing to establish or reopen a
training institution shall inform the board by writing to
the executive director during the initial planning. Early
consultation and planning with the board is essential for
the development of all types of sound programs in
advanced emergency medical care.
(1) Written application shall be submitted to the
executive director one month prior to a regular board
meeting for board action. The application shall include:
Request for permission to establish or reopen a training
program signed by appropriate officials of the applicant;
evidence of availability of clinical resources; evidence of
availability of physical facilities; and evidence of
qualified faculty.
(2) Survey visits: A survey of the applicant and
clinical resources to be used for trainee experience may
be made by a representative of the board; representatives
of the applicant may be required by the board to meet
with the board at the time the application and reports of
survey (if applicable) are discussed to facilitate board
action.
(3) Report of board action: Written report of board
action accompanied by the board survey reports (if
applicable) shall be sent to the applicant.
b. Established training institutions.
(1) Survey visits: All training institutions may 4e
visited by a representative of the board at regular
intervals as determined by the board. The purpose of the
visit is to examine educational objectives, review training
programs, administrative practices, services and
facilities, and to prepare a written report for review and
action by the board. All visits shall be conducted under
impartial and objective conditions.
(2) Survey of clinical facilities: All facilities used for
clinical instruction may be visited by a representative of
the board as part of the training institution survey. The
purpose of the visit is to review administrative practices,
patient care practices, the facilities and provision for
patient care and trainee personnel, and to prepare a
written report for review and action by the board.
• c. Change of ownership or control.
(1) The board shall be notified, in writing, of any
changes in ownership or control of a training institution
within thirty days of such change.
132.5(3) Contractual agreements.
a. If clinical or field experience resources are located
outside the framework of the training institution, written
contractual agreements for such resources shall be
initiated by the training institution.
132.5(4) Facilities.
a. There shall be adequate classroom, laboratory, and
practice space to conduct the training program. A library
with reference materials on emergency and critical care
shall also be available.
b. The following hospital units shall be available for
trainee experience for each training program:
(1) Emergency services with an average of at least.
1,000 total visits per month;
(2) Intensive care unit or coronary care unit or both;
(3) Operating room and recovery room;
(4) Intravenous or phlebotomy team, or other method
to obtain IV experience;
(5) Pediatric unit;
(6) Labor and delivery suite, and newborn nursery;
IAB 5/30/79 . - FILED , 1427
HEALTH DEPARTMENT[470] (cont'd)
(7) Psychiatric unit; and
(8) Morgue;
(9) An animal laboratory is a recommended, but
optional adjunct.
c. There shall be an advanced emergency medical
care unit closely affiliated with the training institution to
provide field experience. Cardiac telemetry is a
recommended, but optional adjunct to the training
program.
132.5(5) Staff.
a. The training program medical director shall:
(1) Be a physician in a directly related specialty, such
as emergency medicine, who has been or will be certified
within one year as an instructor in advanced cardiac life
support.
(2) Be assisted by a course co-ordinator who is a
physician's assistant, registered nurse, or other
appropriate health professional, who is also certified as
an instructor in advanced cardiac life support. This
individual shall be a full-time educator or a practitioner
in emergency or critical care.
b. The instructional staff shall be comprised of
physicians, nurses, pharmacists, advanced emergency.
medical care personnel, and other health care
professionals who have appropriate education and
experience in emergency and critical care.
c. Preceptors shall be assigned in each of the clinical
units in which advanced EMT or paramedic trainees are
obtaining clinical experience, to supervise their activities
and ensure the quality and relevance of the experience.
Trainee activity records shall be kept and reviewed by the
immediate supervisor(s) and by the course co-ordinator.
132.5(6) Advisory committee. There shall be an
advisory committee for the training program which has
representatives from the training institution and such
other groups as affiliated medical facilities, local medical
establishments, ambulance and rescue squad service
programs, and consumers of health care.
132.5(7) Trainee records.
a. The training institution shall maintain an
individual record for each trainee. Training institution
policy and board requirements will determine contents
necessary to serve the purpose intended. These may
include:
(1) Application;
(2) Health summary;
(3) Trainee record or transcript of hours and
performance (including examinations) in classroom,
clinical, and field experience settings; and
(4) Verification of change of name if change occurs
while enrolled in the training program.
132.5(8) Reports.
a. The training institution shall submit an annual
report to the board on forms provided by the board. This
report shall provide current data on:
(1) Qualifications and major responsibilities of each
faculty member;
(2) Policies used for selection, promotion, and gradua-
tion of trainees;
(3) Practices followed in safeguarding the health and
well-being of trainees, and patients receiving advanced
emergency medical care within the scope of the training
program;
(4) Current enrollment by class and trainee -teacher
ratios;
(5) Number of admissions to training programs per
year;
(6) Number of graduations from training programs
per year;
(7) Curriculum •lesson plans and brief course
descriptions.
132.5(9) Selection of trainees.
a. There shall be a staff selection committee to select
trainees utilizing as a basis the prerequisites outlined in
subrule 132.2(1)"e".
b. EMT -As, who are currently certified in advanced
cardiac life support, may test out of that component of the
advanced EMT or paramedic training program utilizing
procedures developed by the training institution.
132.5(10) Continuing education.
a. Training institutions may provide continuing edu-
cation for advanced EMTs and paramedics which is
commensurate with the continuing education require-
ments detailed in subrule 132.3(8)"c".
b. Training institutions shall provide a special
course(s) for service program medical directors, super-
vising physicians, and physician designees to familiarize
them with advanced prehospital care and their respective
responsibilities.
132.5(11) Financing and administration.
a. There shall be sufficient funding available to the
training institution to ensure that each class started can
be completed.
b. Tuitioncharged to trainees shall be reasonable and
accurately stated.
c. Advertising for advanced EMT and paramedic
training programs shall be appropriate, and there shall
be an official publication describing the course of study.
132.5(12) Trainees.
a. Advanced EMT or paramedic trainees may do
anything that a certified advanced EMT or paramedic
may do, if they are under the direct supervision of a
physician or physician designee, or under the remote
supervision of a physician or physician designee, with
direct field supervision provided by staff directly
associated with the training program.
b. Trainees shall not be substituted for personnel of
any affiliated medical facility or service program, but
may be employed while enrolled in the training program.
470-132.6(147A) Service progra.ui—authorization
and renewal standards and procedures.
132.6(1) General requirements for authorization:
a. Any ambulance or rescue squad seeking to estab-
lish and provide a service program utilizing advanced
emergency medical care personnel shall be authorized by
the department upon the advice and consent of the coun-
cil. Application for such authorization shall be made on
forms prescribed by the department and approved by the
council. Applicants shall complete and submit the forms
to the department not less than sixty days prior to the
requested effective date for the establishment of the ser-
vice program.
b. The service program shall, as a minimum stand-
ard, use emergency medical transport vehicles that meet
current federal KKK-A-1822 specifications and
amendments as of June 25, 1975. These specifications
shall not apply to vehicles used for routine or convalescent
transfers.
c. The equipment and supplies utilized by the service
program shall be those set forth in rule 132.7(147A).
d. The service program shall have a medical director
who is a duly licensed physician.
1428 FILED
HEALTH DEPARTMENT[470] (cont'd)
e. The service program shall maintain a telecom-
munications system between the advanced EMT -I, ad-
vanced EMT -II, or paramedic, and the medical director,
supervising physician, or physician designee.
132.6(2) The medical director shall be responsible
for providing competent medical direction and overall
supervision of the medical aspects of the service program.
132.6(3) Each service program shall:
a. Maintain an adequate number of currently certi-
fied personnel and emergency response vehicles.
b. Provide two personnel on each run with one being
an advanced EMT or paramedic and the other a basic
EMT. A preferable alternative is to have at least three
personnel with at least two being advanced EMTs or
paramedics and the other a basic EMT.
c. Ensure that one advanced EMT or paramedic is in
constant attendance with the patient when advanced
emergency medical care is being provided.
d. Ensure that personnel duties are consistent with
their level of certification and that certification is
current.
e. Notify the department in writing upon the termi-
nation of the medical director.
f. Notify the department in writing as soon as the
selection of a new medical director is made.
132.6(4) The service program shall notify the depart-
ment in writing within thirty days of any increase or
reduction of services being provided.
132.6(5) Advanced emergency medical care person-
nel who, because of equipment malfunction, are unable to
maintain communication with the medical control source
may provide advanced emergency medical care accord-
ing to the established protocols of the respective service
program. They shall, however, immediately contact the
medical control source as soon as communication is re-
established.
132.6(6) General requirements for renewal of
authorization:
a. Service program authorization is valid for two
years from the date of such authorization unless sooner
suspended or revoked.
b. To renew authorization, a service program shall
meet the following requirements:
(1) Continue to meet the requirements outlined in
rules 132.6(147A), 132.7(147A), and 132.8(147A) of these
rules;
(2) Complete and submit to the department the re-
newal application at least sixty days prior to expiration of
the current authorization. Such application may be
obtained upon request to: Iowa State Department of
Health, Emergency Medical Services Section, Lucas
State Office Building, Des Moines, Iowa 50319.
470-132.7(147A) Service program—recordkeep-
ing, equipment, and supply standards.
132.7(1) Each service program shall maintain accu-
rate records concerning the emergency care provided to
each patient. The following data shall be maintained and
provided, upon request of the department, to the
department for evaluation purposes:
a. Number of runs.
b. Type of runs (behavioral, burn, cardiac, neonatal,
poison, spinal cord, trauma, etc.).
c. Number of telemetered runs.
d. Number of cases requiring resuscitation measures:
(1) Number defibrillated;
(2) Number requiring CPR only;
(3) Number successfully resuscitated;
IAB 5/30/79
(4) Number of IV's attempted/started;
(5) Number of intubations attempted/started; and
(6) Number of times antishock trousers were used.
e. Other data of emergency medical care provided, as
may be required by the department.
f. Time factors:
(1) Time of occurrence;
(2) Time dispatcher notified;
(3) Time service program notified;
(4) Time vehicle dispatched;
(5) Time of arrival at scene;
(6) Time departed scene;
(7) Time of arrival at hospital; and
(8) Time when back in service.
132.7(2) Each service program shall establish daily
equipment checklist procedures to ensure that:
a. Electronic and mechanical equipment are in
proper operating condition at all times.
b. Emergency response vehicles are maintained in a
safe operating condition at all times.
132.7(3) All vehicles used in service programs shall
be equipped, as a minimum, with the "Essential Equip-
ment for Ambulances" published by the Committee on
Trauma, American College of Surgeons, as of September
1977.
132.7(4) In addition to subrule 132.7(3) above; vehi-
cles used in advanced EMT -I service programs shall have
as a minimum, the additional equipment and supplies
listed and filed with the department, as approved by the
council. Such list is available upon request to: Iowa State
Department of Health, Emergency Medical Services Sec-
tion, Lucas State Office Building, Des Moines, Iowa
50319.
132.7(5) In addition to subrules 132.7(3) and 132.7(4)
above, vehicles used in advanced EMT -II, or paramedic
service programs shall have, as a minimum, the addi-
tional equipment and supplies listed and filed with the
department, as approved by the council. Such list is avail-
able upon request to: Iowa State Department of Health,
Emergency Medical Services Section, Lucas State Office
Building, Des Moines, Iowa 50319.
132.7(6) In addition to subrules 132.7(3), 132.7(4),
and 132.7(5) above, additional equipment and supplies
shall be carried on service program vehicles as may be
determined by the medical director.
132.7(7) All drugs are to be provided by a hospital
pharmacy or community pharmacy, as per written agree-
ment. Accountability for the exchange, distribution, stor-
age, ownership, and security of drugs shall be subject to
applicable state and federal requirements, and shall be
the responsibility of the hospital pharmacy or community
pharmacy.
132.7(8) Each service program shall ensure that
strict sanitation procedures are in effect at all times. The
following sanitation standards shall apply to all service
program vehicles:
a. The interior and the equipment within the vehicle
shall be clean and maintained in good working order at
all times.
b. Freshly laundered blankets and linen, or disposa-
ble linens shall be used on cots and pillows, and shall be
changed after each patient is transported.
c. Clean linen storage shall be provided.
d. Closed containers shall be provided for soiled
supplies.
e. Closed compartments shall be provided within the
vehicle for medical supplies.
IAB 5/30/79- -
HEALTH DEPARTNIENT[470] (coned)
FILED 1429
f. Implements inserted into the patient's nose, mouth,
or other body orifice shall be wrapped, and properly
stored and handled. Multiuse items shall be kept sterile
and properly stored.
g. When a vehicle has been utilized to transport a
patient known to have a communicable disease, the vehi-
cle shall be appropriately decontaminated.
h. All drugs shall be maintained in accordance with
the rules of the state board of pharmacy examiners. Such
rules may be obtained upon request to: Iowa State Board
of Pharmacy Examiners, State Office Building, Des
Moines, Iowa 50319.
i. The department. without prior notification, shall
have the authority to inspect all such vehicles and supply
inventories to ensure compliance with all applicable
rules.
470-132.8(147A) Service program —medical control.
132.8(1) The medical director may appoint, by name
in writing, a supervising physician(s), or a physician
designee(s) to provide medical control.
132.8(2) Medical control shall be the direct responsi-
bility of the medical director, supervising physician(s), or
physician designee(s).
132.8(3) Medical control shall be provided fromtime
of first notification until the patient reaches the receiving
hospital.
132.8(4) Communications equipment shall be able to
reach any part of the service program area to ensure the
provision of medical control.
132.8(5) The medical director's duties shall include,
but need not be limited to:
a. Maintaining liaison with other physicians, includ-
ing the medical director of the training program and the
supervising physician(s) at the appropriate hospital(s).
b. Monitoring and evaluating, through the
supervising physician(s), the daily activities of the service
program.
c. Co-ordinating continuing education programs for
the service program members as set forth in subrule
132.3(8)"c".
d. Providing individual evaluation and consultation
to service program members.
e. Developing and providing protocols for advanced
emergency medical care.
f. Developing written parameters and protocols to be
followed by the physician designee(s) in supervising
advanced emergency medical care personnel.
g. Ensuring that any physician designee has demon-
strated competency equivalent or superior to the level of
the advanced emergency medical care personnel being
supervised.
h. Informing the medical community of the advanced
emergency medical care being provided according to
approved protocols in the service program area.
132.8(6) Supervising physicians and physician desig-
nees shall assist the medical director periodically by:
a. Providing medical control.
b. Reviewing the advanced emergency medical care
provided.
c. Reviewing and updating protocols.
d. Providing continuing education for service pro-
gram members.
e. Resolving operational problems.
470-132.9(147A) Denial, suspension, or revocation
of service program authorization or renewal —
appeal.
132.9(1) The department may deny an application
for authorization or renewal of a service program utiliz-
ing advanced EMTs or paramedics, or suspend or revoke
such authorization or renewal if the council finds reason
to believe the service program will not or has not been
operated in compliance with chapter 147A of the Code, or
the rules implementing such chapter, or that there is
insufficient assurance of adequate protection for the
public.
132.9(2) The proposed denial, suspension, or revoca-
tion shall be considered by a committee of the councih
consisting of at least two members appointed by the chair
of the council. The committee shall advise the department
of its decision. The department shall then notify the appli-
cant of the granting or denial of authorization or renewal,
or of action to suspend or revoke such authorization or
renewal. Notices of denial, suspension, or revocation shall
be by certified mail, return receipt requested, or by per-
sonal service.
132.9(3) Any request for a hearing before the council
concerning the denial, suspension, or revocation of ser-
vice program authorization or renewal shall be submit-
ted by the aggrieved party in writing to the department
by certified mail, return receipt requested, within thirty
days of the mailing of a notice of intended action by the
department. The address is: Iowa State Department of
Health, Emergency Medical Services Section, Lucas
State Office Building, Des Moines, Iowa 50319.
132.9(4) The department shall prepare the notice of
hearing and transmit same to the aggrieved party by
certified mail, return receipt requested, at least ten days
before the date of the hearing.
132.9(5) The council adopts the rules of the depart-
ment found in 470—chapter 173, Iowa Administrative
Code, as the procedure for hearings before the council.
The council may authorize an administrative hearing
officer to conduct hearings, administer oaths., issue
subpoenas, and prepare written findings of fact,
conclusions of law, and decisions at the direction of_the
council. The members of the committee which make the
initial decision to deny, suspend, or revoke authorization
or renewal.shall not take part in the hearing panel but
may appear as witnesses.
132.9(6) The decision of the council shall be mailed to
the aggrieved party by certified mail, return receipt
requested, or by personal service.
132.9(7) Any appeal to the district court from denial,
suspension, or revocation of such service program autho-
rization or renewal shall be taken within thirty days from
the issuance of the decision of the council. Notice of appeal
shall be sent to the council by certified mail, return
receipt requested, or by personal service. It is not neces-
sary to request a rehearing before the council to appeal to
the district court.
132.9(8) The party who appeals a decision of the coun-
cil to the district court shall pay the cost of the prepara-
tion of a transcript of the administrative hearing for the
district court.
470-132.10(147A) Denial, suspension, or revoca-
tion of advanced emergency medical care personnel
certificates or renewal —appeal.
132.10(1) All complaints regarding advanced
emergency medical care personnel, or those purporting
to be the same, shall be reported to the board.
1130
HEALTH DEPARTMENT[470] (coned)
FILED IAB 5/30/79
132.10(2) .In investigating such complaints the
certificate holder, supervising physician, and other
individuals as appropriate may be requested, and if so
requested, shall appear at a board meeting for the
purpose of responding to such complaints.
132.10(3) The board may deny an application for
issuance or renewal of an advanced EMT, or paramedic
certificate, or suspend or revoke such a certificate when it
finds that the applicant or certificate holder has:
a. Acted negligently in performing the authorized
services.
b. Failed to follow the directions of the supervising
physician.
c. Rendered treatment not authorized under chapter
147A of the Code.
d. Violated any of the provisions of or failed to comply
with pertinent requirements of chapter 147A of the Code,
or the rules implementing such chapter.
e. Furnished false, misleading or incomplete infor-
mation to the board.
f. Pled guilty to or have been convicted of a serious
misdemeanor or felony relating to advanced EMT or
paramedic services.
132.10(4) The proposed denial, suspension, or revoca-
tion shall be considered by a committee of the board
consisting of at least two members appointed by the chair
of the board. The committee shall advise the executive
director of its decision. The executive director shall then
notify the applicant of the granting or denial of
certification or renewal, or of action to suspend or revoke
such certification or renewal. Notices of denial,
suspension, or revocation shall be by certified mail,
return receipt requested, or by personal service.
132.10(5) Any request for a hearing before the board
concerning the denial, suspension, or revocation of such
certification or renewal shall be submitted by the
aggrieved party in writing to the board by certified mail,
return receipt requested, within thirty days of the
mailing of a notice of intended action by the board. The
address is: Board of Medical Examiners, State Office
Building, 300 Fourth Street, Des Moines, Iowa 50319.
132.10(6) The board shall prepare the notice of hear-
ing and transmit same to the aggrieved party by certified
mail, return receipt requested, at least ten days before the
date of the hearing.
132.10(7) The board adopts the rules of the depart-
ment found in 470—chapter 173, Iowa Administrative
Code, as the procedure for hearings before the board. The
board may authorize an administrative hearing officer to
conduct hearings, administer oaths, issue subpoenas, and
prepare written findings of fact, conclusions of law, and
decisions at the direction of the board. The members of
the committee which make the initial decision to deny,
suspend, or revoke certification or renewal shall not take
part in the hearing panel but may appear as witnesses.
132.10(8) The decision of the board shall be mailed to
the aggrieved party by certified mail, return receipt
requested, or by personal service.
132.10(9) Any appeal to the district court from
denial, suspension, or revocation of such certification or
renewal shall be taken within thirty days from the issu-
ice of the decision of the board. Notice of appeal shall be
--sent to the board by certified mail, return receipt
requested, or by personal service. It is not necessary to
request a rehearing before the board to appeal to the
district court.
132.10(10) The party who appeals a decision of the
board to the district court shall pay the cost of the prepa-
ration of a transcript of the administrative hearing for
the district court.
470-132.11(147A) Denial, suspension, or revoca-
tion of training program authorization or renewal —
appeal.
132.11(1) The board may deny an application for
authorization or renewal of a training program, or sus-
pend or revoke such authorization or renewal if the board
finds reason to believe the training program will not or
has not been operated in compliance with chapter 147A of
the Code, or the rules implementing such chapter, or that
there is insufficient assurance of adequate protection for
the public.
132.11(2) The proposed denial, suspension, or revo-
cation shall be considered by a committee of the board
consisting of at least two members appointed by the chair
of the board. The committee shall advise the executive
director of its decision. The executive director shall then
notify the applicant of the granting or denial of authoriza-
tion or renewal, or of action to suspend or revoke such
authorization or renewal. Notices of denial, suspension,
or revocation shall be by certified mail, return receipt
requested, or by personal service.
132.11(3) Any request for a hearing before the board
concerning the denial, suspension, or revocation of train-
ing program authorization or renewal shall be submitted
by the aggrieved party in writing to the board by certified
mail, return receipt requested, within thirty days of the
mailing of a notice of 'intended action by the board. The
address is: Board of Medical Examiners, State Office
Building, 300 Fourth Street, Des Moines, Iowa 50319.
132.11(4) The executive director shall prepare the
notice of hearing and transmit same to the aggrieved
party by certified mail, return receipt requested, at least
ten days before the date of the hearing.
132.11(5) The board adopts the rules of the depart-
ment found in 470—chapter 173, Iowa Administrative
Code, as the procedure for hearings before the board. The
board may authorize an administrative hearing officer to
conduct hearings, administer oaths, issue subpoenas, and
prepare written findings of fact, conclusions of law, and
decisions at the direction of the board. The members of
the committee which make the initial decision to deny,
suspend, or revoke authorization or renewal shall not take
part in the hearing panel but may appear as witnesses.
132.11(6) The decision of the board shall be mailed to
the aggrieved party by certified mail, return receipt
requested, or by personal service.
132.11(7) Any appeal to the district court from
denial, suspension, or revocation of such training pro-
gram authorization or renewal shall be taken within
thirty days from the issuance of the decision of the board.
Notice of appeal shall be sent to the board by certified
mail, return receipt requested, or by personal service. It
is not necessary to request a rehearing before the board to
appeal to the district court.
132.11(8) The party who appeals a decision of the
board to the district court shall pay the cost of the prepa-
ration of a transcript of the administrative hearing for
the district court.
These rules are intended to implement section 147A.4
of the Code.
[Filed 5/11/79, effective 7/5/79]
These rules were published under notice of intended
IAB 5/30/79 FILED,.
HEALTH DEPARTMENT[470] (cont'd)
action in the Iowa Administrative Bulletin dated April 4,
1979 (ARC#0160), have been reviewed by the
Administrative Rules Review Committee April 24, 1979,
and a public hearing concerning the proposed rules was
held April 26, 1979. All oral and written comments were
considered and as a result the following changes were
made:
Subrule 132.1(3) has been substantially rewritten at
the request of the Administrative Rules Review
Committee.
Subrule 132.1(22) has been amended for purposes of
clarification.
Paragraph 132.2(1)"b" has been deleted and the
following paragraphs relettered.
Paragraph 132.3(4)"c" has been deleted and the
following paragraphs relettered.
Paragraph 132.3(5)"b" has been amended to reflect
minor word changes.
Paragraph 132.3(6)"d" has been amended to reflect an
address change.
Paragraph 132.3(8)"d" has been deleted.
Rule 132.4 has been amended for purposes of
clarification by adding a new subrule: 132.4(6).
Subparagraph 132.5(4)"b"(2) has been amended to
reflect minor word changes.
Subparagraph 132.5(4)"b"(3) has been amended to
reflect minor word changes.
Subrule 132.5(11) has been amended to delete
paragraph 132.5(11)"d" which will appear in paragraph
132.5(12)"b".
Subrule 132.5(12) has been amended by moving the
body of the subrule to paragraph 132.5(12)"a", and by
rewriting and adding the material formerly found in
paragraph 132.5(11)"d" as paragraph 132.5(12)"b".
Paragraph 132.6(1)"b" has been amended for purposes
of clarification.
Subrule 132.10(5) has been amended to reflect an
address change. _
Subrule 132.11(3) has been amended to reflect an
address change.
These rules shall become effective July 5, 1979.
[Published 5/30/79]
EDITOR'S NOTE: For replacement pages for IAC, see IAC
Supplement, 5/30/79.
1431
ARC 0278
PHARMACY EXAMINERS[620]
Pursuant to the authority of sections 147.76 and
258A.10 of the Code of Iowa, the Board of Pharmacy
Examiners adopts the following rules:
ITEM 1. Add the following new chapter:
CHAPTER 10
DISCIPLINE
620-10.1(258A) General.
10.1(1) The board has the authority to impose
discipline for any violations of chapters 147, 155, 203,__
203A, 204, 205, and 258A or the rules promulgated
thereunder.
10.1(2) The board has the authority to impose the
following disciplinary sanctions:
a. Revocation of a license or registration.
b. Suspension of a license or registration until further
order of the board or for a specified period.
c. Nonrenewal of a license or registration.
d. Prohibit permanently, until further order of the
board, or for a specified period, the engaging in specified
procedures, methods or acts.
e. Probation.
f. Require additional education or training.
g. Require a re-examination.
h. Order a physical or mental examination.
i. Impose civil penalties not to exceed $1,000.00.
j. Issue citation and warning.
k. Such other sanctions allowed by law as may be
appropriate.
10.1(3) The following factors may be considered by
the board in determining the nature and severity of the
disciplinary sanction to be imposed:
a. The relative seriousness of the violation as it relates
to assuring the citizens of this state a high standard of
professional care.
b. The facts of the particular violation. . _ -
c. Any extenuating circumstances or other counter-
vailing considerations.
d. Number of prior violations or complaints.
e. Seriousness of prior violations or complaints.
f. Whether remedial action has been taken.
g. Such other factors as may reflect upon the
competency, ethical standards and professional conduct
of the licensee or registrant.
10.1(4) The board may impose any of the disciplinary
sanctions set out in subrule 10.1(2), including civil
penalties in an amount not to exceed $1000.00, when the
board determines that the Licensee or registrant is guilty
of the following acts or offenses:
a. Fraud in procuring a license. Fraud in procuring a
license includes but is not limited to an intentional
perversion of the truth in making application for a license
to practice pharmacy in this state, and includes false
representations of a material fact, whether by word or
conduct, by false or misleading allegations, or by
concealment of that which should have been disclosed
when making application for a license in this state, or
attempting to file or filing with the board any false or
forged diploma. certificate or affidavit or identification
or qualification in making an application for a license in
this state.
b. Professional incompetency. Professional incompe-
tency includes but is not limited to:
HOSPITAL PROPOSALS FOR PROVIDING AMBULANCE SERVICE
"T
APPENDIX VI
The Finley Hospital
Ambulance Service
Proposed Expense Budget
FYE 11/30/80
Direct Expense
Salaries (See Notes 1 & 2)
Medical Specialist Fees
Fuel Oil
Vehicle Repairs & Maintenance
Equipment Repairs & Maintenance
Supplies
Miscellaneous
TOTAL DIRECT
Indirect Expense
Bldg. Depr./Interest/Insurance (See Note 4)
Employee Health & Welfare
Administrative & General
Plant Operation & Maintenance
Laundry
Nursing Administration
TOTAL INDIRECT EXPENSE
TOTAL AMBULANCE SERVICE EXPENSE
NOTES:
Option I Option II
1.A.L.S(24 Hr) 2 A.L.S. (24 Hr)
1 Transfer
(12 hr)
$184,939
5,000
4,620
1,000
1,400
13,690
2,000 -
$212,049
$ 3,640
24,209
31,403
4,585
3,256
19,672
$86,765
$298•, 814
$218,653
5,000
4,620
1,000
1,400
13,690
2,000
$246,363
$ 3,640
28,622
36,472
4,585
3,256
21,592
$98,167
$344,530
1. Staffing Proposals:
A. Option I.
1. A.L.S. vehicle with one (1) EMT II and one (1) EMT I
available 24 hours/day.
2. 1 Transfer vehicle with 1 driver and 1 LPN available
12 hours/day - 7 days/week.
B. Option II.
Two (2) A.L.S. vehicles with one (1) EMT II and one (1) EMT I for
each. One-third of time of second vehicle staffing offset for
hospital service.
C. Both proposals assume location of all vehicles is at Finley Hospital.
2. Data for Proposals:
Total Manhours 32,840
Salary Cost 200,161
Benefit Hours 3,064
Benefit Cost 18,492
Average Hourly Rate 6.095
F.T.E. 15.8
29,920
169,295
2,765
15,644
5.658
14.4
The Finley Hospital
Ambulance Service
Proposed Expense Budget
Page 2
3. Rates Proposed:
Rate I Revenue I Rate II Revenue II
Transfer 1600 calls x $ 20.00 $ 32,000 $ 30.00 $ 48,000
Emergency Sick 700 calls x 160.00 112,000 180.00 126,000
Emergency Acct. 675 calls x 200.00 135,000 220.00 148,500
Code Blue 75 calls x 250.00 18,750 270.00 20,250
Mileage charge out of city @
1.00/mile 2,000 2,000
$299,750 $344,750
These rates do not allow for bad debt.
4. If hospital depreciates ambulance vehicles add $8,000/vehicle/year.
THE FINLEY HOSPITAL
350 N. Grandview Ave. Dubuque, Iowa 52001
PROPOSAL
OF
DUBUQUE COMMUNITY AMBULANCE SERVICE
BASED -AT
THE FINLEY HOSPITAL
November 5, 1979
-1-
I. Introduction
The Finley Hospital has been instructed to provide the Dubuque Ambulance
Study Task Force with a proposal for the management of ambulance services
for the City of Dubuque. The Finley Hospital is best qualified to operate
such a service if the City of Dubuque decides to transfer operation of the
ambulance service to a local hospital.
The Finley Hospital is prepared to operate the ambulance service for the
citizens of Dubuque and the surrounding tri-state area in compliance
with Chapter 132 of the Iowa Code entitled Advanced Emergency Medical
Care (See Appendix V) and wishes to call the Task Force's attention to
several points which we believe makes Finley best qualified to assume
operating responsibility.
1. The Finley Hospital is fully accredited by the Joint Commission on.
Accreditation of Hospitals.
2. The Finley Hospital is the locally owned and operated non-sectarian
community hospital in Dubuque. A list of members of the board of
The Finley Hospital is enclosed. (See appendix I.)
3. The Finley Hospital's current construction offers the newest and
most modern hospital facility in the area, emphasizing an expanded
emergency capability. (See appendix II.)
4. The Finley Hospital has an enclosed heated vehicle storage and
unloading bay included as an integral part of its emergency facilities.
5. Due to its central location, The Finley Hospital is the most readily
accessible facility.
6. Staffing
a. The Finley Hospital has certified Advanced Cardiac Life Support
providers on duty in all critical care areas at all times.
(Instructors (8); Providers (25); See appendix III.)
b. In addition, all physicians covering The Finley Hospital
emergency services are ACLS providers or instructors.
c. The Medical Director of Emergency Services at Finley Hospital
is on the faculty of the Iowa affiliate of the American Heart
Association for Advanced Cardiac Life Support and :is the former
chairman of the Working Committee For Emergency Cardiac Care
for Iowa. (See appendix IV.)
d. Since 1975 all emergency physicians at The Finley Hospital have
practiced emergency medicine exclusively at The Finley Hospital
and do not engage in any other kind of medical practice in any
other hospital or community. These physicians have 7, 14 and
30 plus years of broad based medical experience. All are M.D.'s
and are eligible to take specialty board exams, to be offered
for the first time in 1980 by the American Board of Emergency_
Medicine.
7. The Finley Hospital has a CT scanner available on its campus and full
neurological capabilities.
8. A heliport is presently available to Finley Hospital.
Therefore, The Finley Hospital believes it has superior capabilities to operate
the ambulance service.
II. Scope of Ambulance Services
1. The Finley Hospital will operate at least two fully equipped advanced
life support ambulances, to be provided by the City. Maintenance and
replacement of this equipment is to be determined by contract negotiations.
2. The Finley Hospital is prepared to provide ambulance services to all
residents of Dubuque, Grant and Jo Daviess counties.
3. Staffing for this service will include:
A. Finley Emergency Medical Director •
B. Ambulance Medical Services Manager
C. At least one EMT II per ambulance on duty at all times; balance
of attendants at least EMT I.
D. Each ambulance to have a minimum of two attendants.
E. Services rendered to all citizens regardless of race, creed,
color, national origin, religion, sex and ability to pay.
F. Service operated 24 hours, 7 days per week on a continuous basis.
G. Patient transfers in the service area on prescheduled basis.
H. Transport to the facility of the patient's choice except for
life threatening illness or injury when transport shall be to
the nearest life support facility.
I. Primary response time for ambulance #1, immediate departure.
Secondary response time, three (3) minutes departure. Total
response time comparable to present system.
J. Continued response of the nearest engine company to all life
threatening emergencies and continued ambulance response to all
fire calls.
III. Other considerations:
1.' Starting Date
Starting date will be six (6) months after receipt of final approval
from Iowa Health System Agency and State Health Facilities Council
with Certificate of Need and Section 1122 approval. These approvals
are not automatic and must have the complete support and endorsement
of the City of Dubuque, Mercy Health Center and Xavier Hospital.
2. Policy Commission
We propose that the control of service
be established in a commission that shall
include representation from at groups:
Finley Hospital
Mercy Health Center
Xavier Hospital
City of Dubuque
Service Area Representatives
Finley Emergency Medical
3. Dispatch
We propose the establishment of the 911 universal emergency dispatch
system for Dubuque. This system is now recognized world wide.
4. Recruitment
The Finley Hospital has the only hospital owned and operated School
of Nursing in Dubuque, founded in 1897, signifying Finley's continued
involvement in health education. Emergency department physicians at
Finley have been the medical directors of the EMT courses at area
colleges, local volunteer, fire departments, and were instrumental
in establishing CPR training into the City of Dubuque and the Junior
High and High School curricula. In addition, Finley, through the
efforts of its physicians, nurses and administration has been the
leader in CPR and ACLS training in Dubuque since its inception in
Iowa. Finally through our association with South East Iowa Emergency
Medical Service Council we will have ready access to their programs
for recruitment purposes. These relationships will enable Finley to
policy and practice for this
appointed by City Council
least the following
2 representatives
2 representatives
2 representatives
1 representative
(Non Provider) 3 representatives
Director (ex officio) ChaiLman
recruit EMT personnel already familiar with our program.
5. Training
An application is pending for the designation of Finley Hospital
as an Emergency Medical Services training institution. Iowa law
requires all training facilities for EMT's to be so designated.
(See appendix V, page 8) Finley will provide a minimum of 30
continuing education hours per employee as required by Iowa Law.
(See appendix V, page 7) All training will be provided in'accordance
with the standards established by the United. States Department of
Transportation, National Highway Traffic Safety Administration in
their Training Course for Emergency Medical Technicians and Paramedics.
6. Term of Contract
We propose a contract term of three to five years with automatic
renewal if agreeable to both parties.
7. Fees
Standard fees will'be established for services rendered regardless
of location. These fees will include special charges for Advanced
Life Support Services. For calls outside Dubuque city limits,
appropriate mileage charges will be added. It is our intention to
establish the fee structure for the ambulance service in an appropriate
fashion such that the service should break-even.
8. Budget
Budget for the operation of the ambulance service will be prepared in
accordance with the dictates of the Policy Commission. 'This budget
will be prepared using the American Hospital Association's Chart of
Accounts for Hospitals as modified by the American Institute of
Certified Public Accountants Audit Guide for Hospitals and the
American Hospital Association's Cost Finding and Rate Setting For
HospitalsManual. All costs will be prebudgeted on definitions of
the scope of service to be provided by the Policy Commission and fees
will be set according to these predetermined budgeted costs. 0f
course, both fees and budget should require the approval of the Policy
Commission.
9. Reconciliation
We propose at the end of each fiscal year to provide the Policy
Commission with an audited total statement of operations revenue
and expense. This audit will be prepared by an independent auditing --
firm.
10. Cost of Service
We are not proposing a specific cost of operation for an ambulance
service at this time. We propose to prepare a break-even budget in
conjunction with the Policy Commission prior to Health Systems Agency
and State Health Facilities Council Review. Prior considerations to
include the items listed below must be given before budget preparation
begins. These items include:
1. Definition of the service area. to be covered.
2. Cost figures relative to the type of services rendered.
3. Determination of location for ambulances not based. at Finley.
With the support of the Policy Commission, Finley guarantees no future
tax subsidies would be necessary for ambulance service.
-4
IV. Recommended next step:
Due to the length of time involved to implement a program change of this
magnitude, we recommend that the City implement Recommendation #3 of the
Ambulance Task Force Subcommittee, which states: "we feel that the present
ambulance charges should be raised in accordance with the level of care
provided." If the City requires assistance in the establishment of
appropriate charges, the hospital staff will be willing to be of service.
Thank you.
•
Emergency Medical DirecgO
/ap
Chief of Staff
AzL4.
Executive Director
APPENDIX I
Richard Bonaldi, M.D.
William Dall, M.D.
Barbara Ellsworth
Charles Gilliam
David Hammer, Esq.
Marge Hendry
Herbert Hughes
William Jansen
William Knapp
Richard Loetscher
Ross Madden, M.D.
Betty Mueller
Bert Muir
Wayne Norman
Walter. Peterson, Ph.D.
Helen Province
Robert Scott
Chester Solomon
Richard Van Bell
Betty Vanderloo
N. J. Yiannias
APPENDIX II
.10
TRAUMA CENTER - OUT PATIENT AREA
Main Trauma Multiple Injury
Main Medical Emergency
Orthopedic Emergency
Exam and Treatment Rooms Four (4)
Endoscopic Room (1)
3 beds
2 beds
2 beds
Medical Director's Office
E. R. Physician's sleeping quarters and dressing room
Emergency Nurse Manager Office
Emergency Nurse Clinician Office
Cart and Wheelchair Storage
Shower Head - Chemical & Nuclear Accidents
Separate out -patient entry and waiting area
Consultation Room - Privacy Assured
Nurses Station and Medication Room
Finley Emergency Area is adjacent to:.
Laboratory, operating rooms, x-ray, nuclear medicine, EKG, EEG,
physiotherapy, stress testing; respiratory testing and
respiratory therapy - Adjoin emergency department and all
are on the same level for rapid access in emergency situation.
Fully enclosed ambulance and emergency entrance with automatic doors and
vehicle storage capability.
The following persons have
course taught according
PROVIDER LEVEL
EMERGENCY DEPARTMENT
Mary Leary, R.N.
Margie Grevas, R.N.
Sue Hermsen, R.N.
Marianne Lytle, LPN
Terri Whittemore, R.N.
Becky Leytem, R.N.
Marge Pike, R.N.
LuAnn Ambrosy, R.N.
Mary Jean Simon, R.N.
RECOVERY ROOM
Betty Takes, R.N.
Judy Kenniker, R.N.
Sandy Laustsen, R.N.
Rebecca Reisch, R.N.
Linda Luensman, R.N.
INTENSIVE CARE UNIT
Sharon Baker, R.N.
Mary Busch, R.N.
Kim Bau, R.N.
Jan Haney, R.N.
Mary Kalb;. R.N.
Lorrie Lat'tner, R.N.
Judy Mennig, R.N.
Di Sprengelrneyer, R.N.
OTHER PERSONNEL
Robin Hanten, R.N.
Lori Kamentz, CRTT
Ric Bankson CRTT,EMT
APPRENDIX III
successfully completed the Advanced Cardiac Life Support
to the Standards of the American Heart Association.
INSTRUCTOR LEVEL
Kimberly Steiner, R.N., CCRN
Jan Schwab, R.N., CCRN
Diane Boleyn, R.N.
Phyllis Anger, R.N., EMT
Jan Hixon,'R.N.
Ruth Scheitzach, R.N.
Daniel Bohle, M.D.
Charles C. Griffin, M.D.
APPENDIX IV
Charles C. Griffin, M.D.
1323 University Avenue
Dubuque, Iowa 52001
B. S. Degree Loras College Dubuque, Iowa, 1943
M.D. Degree College of Medicine University of Iowa 1946
Rotating Internship U.S. Marine Hosp ,tat, Chicago, Illinois 1946-47 .
Surgical Residency U.S. Marine Hospital, Chicago, Illinois 1947-49
General Practice of Medicine, Dyersville, Iowa 1949 - 1973 less 1965-66
Past President Medical Staff Xavier Hospital
Past President Medical Staff Dyersville Community Hospital - 1969-71
Past Vice President Dubuque County Medical Society
Director Student Health - UNC-G Greensboro, North Carolina 1965-66
Director Emergency Services, Mercy, Cedar Rapids, Iowa 1973-75
Director Emergency Services, Finley, Dubuque, Iowa 1975-Present
Listed in Who's Who in Midwest 1970
Member American College EmergencyPhysicians
Past Chairman Working Committee Emergency Cardiac Care Iowa Affiliate American.
Heart Association
Iowa Affiliate Faculty Advanced Cardiac Life Support American Heart Association
Deputy Coroner Dubuque County 1949-1973
City Health Officer, Farley, Iowa 1955-73
Member Dubuque County Board of Health 1977-78
APPENDIX IV
American Heart Association ACLS
National Affiliate Faculty (members of ANA - Emergency Cardiac Care Committee)
IHA - State Affiliate Faculty
./
Instructors
Responsibilities of Affiliate Faculty:
1. Train instructors in ACLS
2. Monitor ACLS instructors for the purpose of certification and recertification
3. Assist instructors•to train providers in ACLS
4. Assist the affiliate or chapter committee_whose responsibility if is plan,
implement and evaluate their Emergency Cardiac -Care program.
5. Become involved in the development and implementation of local and state
emergency medical services systems.
6. Guide and assist medical training institutions to integrate ACLS courses
into the curricula.
Responsibilities of Instructor
1. Train and certify providers in ACLS
2. Assist the affiliate committee to plan, implement and evaluate their
Emergency Cardiac Care systems
3. Become involved in the development and implementation of local and state
emergency_,m€dtical services systems.
4. Serve their medical training institutions as directors or faculty.
Responsibilites of Provider
1. Deliver ACLS
The course director for an ACLS course will be a physician certified in ACLS.
3
SLIDE 6
APPENDIX IV
AMERICAN HEART ASSOCIATION
ADVANCED TRAINING NETWORK
The advanced training network seen in this .slide proceeds from the national
faculty to affiliate faculty, to instructor, to a provider in ACLS. -
National Faculty are physician members of the American Heart Association
Emergency Cardiac Care Committee and, those affiliate faculty who have
served as faculty for the American Heart Association Affiliate Faculty
Training Programs. -, 1n affiliate faculty member can be recognized as
national faculty on
1. Recommendation of a National Faculty member
2. Recommendation of the committee responsible for Emergency
Cardiac Care in his or her affiliate
3. The approval of the American Heart Association Emergency
Cardiac Care Committee
4. Current Curriculum Vitae
5. The number of basic and advanced cardiac life support courses in
which he or she served as a faculty member or a course director
in the past two years
The responsibilities of the National Faculty are to:
1. Organize and implement national training programs for affiliate
faculty when the need is present.
2. Monitor affiliate faculty candidates who are conducting
instructor training courses for the first time.
3. Assist affiliate faculty to train instructors in advanced cardiac
life support.
4. Assist instructors to train providers in advanced cardiac life
support.
5. Consult with other national and local organizations as a.
designated representative of the American Heart Association.
6. To fulfill national and affiliate training needs until affiliate
capability is sufficient to fulfill both national and local teaching
and testing requirements.
7. Provide consultation to the American Heart Association
Committee on Emergency Cardiac Care, special projects and
programs as requested.
8. Become involved in the development and implementation of
local, state or national emergency medical service systems.
9. Assist the affiliate or chapter committee responsible for
planning, implementing, and evaluating their emergency cardiac
care programs.
10. Guide and assist medical training institutions to integrate ACLS
courses into the curricula.
11. Appoint Affiliate Faculty surrogates from time to time to
monitor and assist other instructor ACLS courses when the
National Faculty in that area cannot accomplish this task.
n
1401.
1
a
.Affiliate Faculty are physicians, registered nurses, or other appropriate
paramedic personnel who have attended and successfully completed an
American Heart Association Affiliate . Faculty Training Program.. An
instructor can be recognized as an affiliate faculty member by completing
all of the following:
1. Successful participation as an instructor in, or direction of, two
provider or instructor ACLS courses a year. -
2. The recommendation of either one affiliate or national faculty
person.
3. Recommendation of the affiliate committee responsible for
emergency cardiac care.
In these instances certification and recognition as an affiliate faculty person
are contingent on:
1. His or her acting as a director or faculty member for an
instructor course in ACLS within the year.
2. Recommendation of • the national faculty instructor who
monitored the first course in which the affiliate faculty served
as an instructor or course director. This must be completed
within• one year of the recommendation or. within a year of
attendance at affiliate faculty instructor's course. •
The responsibilities of Affiliate Faculty are to:
1. Train instructors in ACLS.
2.,,, Monitor ACLS instructors for the purpose of .certification and
recertification as they conduct provider courses in ACLS.
3. Assist instructors to train providers in ACLS.
4. Assist the affiliate or chapter committee whose responsibility it
is to plan, implement and • evaluate their Emergency Cardiac
Care Program.
5. Becorne involved in the development and implementation of local
and state emergency medical service systems.
S. Guide and assist medical training institutions to integrate ACE.
courses into the curricula.
An Instructor is any provider of ACLS who has attended and successfully
completed an instructor course in ACLS.
The responsibilities of an instructor are to: .
1. Train and certify providers in ACLS.
2. Assist the affiliate committee responsible to plan, implement
and evaluate their Emergency Cardiac Care systems.
3. Become involved in the development and implementation of local
and state emergency medical services systems.
4. Serve their medical training institutions as directors or faculty.
A Provider is anyone who has responsibility to deliver ACLS. This can be a
physician, registered nurse, or appropriate paramedic personnel who has
attended and successfully completed a provider course in ACLS.
1
APPENDIX IV
5
CERTIFICATION - RECERTIFICATION
Certification and recertification of National Faculty are the responsibility of the
American Heart Association Emergency Cardiac Care Committee, and will be done every
two years.
Certification for others is the prerogative of the course director of either provider or
instructor courses in ACLS. All course directors for ACLS must be physicians and
certification is contingent on his following American Heart Association guidelines for the
development and implementation of provider and instructor courses. It is primarily
because of current state laws pertaining to the practice of medicine that the American
Heart Association recommends that only physicians be course directors in ACLS. In
addition, all EMS systems partially or totally funded by HEW recommend physician control
and supervision. F
Recertification for the provider, instructor and affiliate faculty is the responsibility of
the• affiliate committee responsible for emergency cardiac care training. Issuance of
American Heart Association cards is contingent upon the utilization of recommended
course outlines as suggested in the instructors' manual of basic and advanced cardiac life
support, The minimum yearly recertification is to obtain 85°6 or higher on the written
exam and to be proficient in all 8 stations.
MONITOR SYSTEM
Responsibilities of National Faculty Monitor and Affiliate Faculty Candidate
Final certification of an .affiliate faculty candidate is contingent upon his functioning as a
faculty member or course director of an ACLS instructor course within a year of the time
he or she has taken an affiliate faculty instructor course in advanced cardiac life support
or recommendation by his or her affiliate. The candidate must send an outline of his
proposed instructors' course to the national faculty person at least two weeks prior to the
date of the course. It is recommended that he or she contact the national faculty person
or his designated affiliate faculty surrogate and make appropriate arrangements at least
one month prior to the date of the course. The funds derived from the instructor's course
must be sufficient to pay for the national faculty person's transportation, room and board. —
The honorarium is a matter to be determined between the national faculty and the course
director.
The national faculty person should meet with the course director and hisor her faculty the
day before the course to review the ability of the faculty to function as instructors in any
of the eight stations. The national faculty person will have.the prerogative to request the
affiliate faculty candidate to function as an instructor in any of the eight stations a?:d
monitor his skill -and ability to adequately instruct according to the American Heart
Association guidelines. The national faculty will also monitor the candidate in the method
by which he or she carries out his or her course responsibilities. The national faculty
person will, upon completion of the course, submit,a course outline and recommendation
or denial of certification of the appropriate affiliate faculty to the AI -IA Division of
Education and Community Programs.
It is recommended that the affiliate committee responsible for implementation of
emergency cardiac care programs develop a similar monitoring system. In other words, it
will be the responsibility of a member of the affiliate faculty to monitor an instructor
during his or her first provider's course. These guidelines are the prerogative of the
�-' affiliate committee responsible for ECC. The national guidelines, as set forth here, are
minimal standards and each affiliate may make these requirements more stringent if they
believe it will improve and further implement ACLS training on a state or regional basis.
PROVIDER COURSE
SLIDE 7
1. The course director must be a physician who is certified by the
American Heart Association as an instructor in ACLS if the course is
offered for certification of the provider. It is recommended that the
course director who is an instructor for the first time use at least one
affiliate faculty member as part of the faculty for the first provider's
course that he or she conducts. Please see "Monitor" section above for
further information.
2. The other members of the course faculty should be certified
instructors in ACLS, or specialists in specific content areas.
3. The maximum niir aber of registrants should be no rnore than 48 in the
ACLS Course for Providers because of the time constraints during the
practical performance and testing sessions. One needs about 14-18
faculty members for the 48 participants, wh n the lecture and
practical sessions run simultaneously.
4. As a prerequisite to the ACLS program, registrants must be curre.ntly
certified in Basic Life Support according to AHA Standards unless the
BCLS course is an integrated part of the ACLS course.
5 Registrants must be either medical, nursing, paramedic, or allied
health personnel whose daily occupation demands proficiency and
certification in the knowledge and skills of ACLS. In addition, all non -
physicians should have a letter of recommendation from the physician
medical director of their EMS program.
6. If the course is designed for certification according to American heart
Association Standards, the course outline must adhere to the American
Heart Association guidelines.
7. Station 111 must be managed by a person certified in Basic Life
Support.
INSTRUCTOR COURSE
1. The course diEs.sza must be a physician who is certified by the
American Heart Association and registered with the national office as
national faculty or registered with an affiliate office as affiiitte
facult in ACLS. It is recommended that other members of the ccrse"'
a:.swsoewa�
faculty snow D e certified instructors in Basic and Advanced Cardiac
Life Support.
2. When the course director is an affiliate faculty candidate, he or she
must utilize at ieast one national faculty person as part of the faculty
for the first instructor's course in ACLS that he or she conducts. He
or she may wish to be a director or on the faculty for a provider curse
first because of local circumstances. Please refer to section on
National Faculty Monitoring of affiliate faculty for further informa-
tion.
APPENDIX V
"TI'd DaAR.1' E Tr[470]
STATE DEPARMENT OF HEALTH
BQARD OF 1. ICAL E A`,• ' S
'The state department of health and the board of rrdical e.v.aminers
jointly, pursuant to the authority of section 147A.4 of the Code,
adopts the following rules -relating to the training and certification
of and the services performed by advanced ererg`ncy redical technicians
and pare.„1-2dics.
TITLE XXV
A.DVAll= Ei' .0 CY N ICr',L CART.
GRAPIER 132
TRAINING Aiu-? CETIF'ICATION OF AID SERVICES Fx ttt U ti D
BY ADvAist. Ei �T c ;cY t ICAL TECI- ZCIAfS A"J PARAJJ1CS
e
132`.:.(1) 'Parodic" rreans an individuu_i, trained in all areas of
advanced u urg ncy medical care, and who has been issued a pard.,::_dic
certificate by the board.
132.1(2) "Advanced E T-1 or advanced EMT -II" means an individual
trained to provide advanced e «rgency medical care, and who has been
issued an advanced EX -I or advanced 1?T-II certificate by the board.
132.1(3) "Basic ET" n ass an individual who has satisfactorily
completed the United States depar. mart of transportation's prescribed
.course for basic F T's, as modified fo= this state in the. current
"Rasic IItr Paley:and Procedure Manual" dated August, 1977, approved
by the governor's emergency medical services advisory council and
administered by the departuent Which is hereby adopted by the board.
The individual shall be. certified as a basic EXL' by the depart_.:::t, but
shall not be certified to perform any of the procedures listed in
subrule 132.1(4).
132.1(4) . "Advanced emergency medical care" mans such medical p_oced,r-es
Admdnistration of intravenous solutions.
b. Gastric or tracheal suction or intubation.
c. Performance of cardiac defibrillation.
d. Administration of parenteral injections of any of the following
classes of drugs:
(1) AntiarrhythnLc agents;
(2) Vagolytic agents;
(3) Chrcnotropic agents;.
(4) Analgesic agents;
(5) Alkalinizing agents;
(6) Vasopressor agents;_
(7)- Anticonvulsive agents; or
(8) Other drugs which ray be dear d necessary by the supervising
physician.
e. Any other medical procedure designated by the board, by rule, as
appropriate to be performed by advanced E•Ts and paramedics who have
been f`"-ained in the procedure
132.1(5) "Advanced erergency medical care perscr .e1" r =71s any
advanced EO'-I, advanced r: T-II, or paramedic. currently cerified by
the board.
132.1(6) "Board" r a.."a"ns the board of medical e:L_"-"iners Tinted
pt.=su.ant to section 147.14, subsection 2, of the Code.
132.1(7) "Council" means the advanced emergency rr dica _care council
esrablished by c:napter 147A of the Code.
132.1(8) "Depart<rc:tt" rreans the department of health.
132.1(9) 'Patient" rreaans any individual \�llo is sick, injured, or
otherwise incapacitated.:"_
132.1(10) "Hospital" means any hospital licensed trader the provisions
of chapter 1353, of the Code.
132.1(11) "Frays i cia_•n' ` means any individual al licensed'= chapter 148,
150, or 150A, of the Code.
15'2.1(12) "Physician designee" pans a y registered nurme licensed
trader chapter 152, of the Code, or any physician's assist tt approved by
the ---board. and certified trader chapter 1483, of the Code ti. is designated
by the medical director, by r e in writing, to act as an interm da y
for a supervising physician in directing the actions of -alsranced e:ergency
medical care personnel.. All. such physician. designees shall be trafr. d
and certified in advanced cardiac' life support as cr tlined in Arr ric r
. heart association standards as of August, 1977, or its equivalent, and'
dnstrate coupetency equivalent or' superior to the level of the
advanced arerge:ncy medical care perscrnel being supervised as determined
•by the council. This designation shall ba valid for tt years frcnt the
date' of .such designation unless sooner rescinded. The physician designee
may be redesignated if qualified.
132.1(13) "Training Drop art' means any training progran. providing
advanced arergarcy medical care instruction as approved by the board.
132.1(14) "Training prograa medical director" r -ns any duly
,licensed_ physician r spcnsible for directing an advanced awrgency
medical care trainirg prop an.
-3-
z
by-Lne board, to conduct the training o advanced erre.rga;cy medical care ...
personnel.
•
132.1(16) 'Trainee" 'Trans any individ'!a1 enrolled in a training program
participating in the didactic, clinical, and field experience Portions
under supervision.
132.1(17) "Service program" means any 24 hour advanced emergency ::edicai
rare ambulance service or rescue squad service that has received authori-
-zaticn by the department. ! _
132.1(18)... "Se,vice program medical director" means any duly licensed
physician who shall be responsible for overall uedical control of the
"service program.
132.1(19) "Service program area" means the geographic area of respensi-
.,
bility served by any given d;:=.)ulanceor rescue squad service program.
132.1(20) "Medical control" roans direction, advice, or orders provides
• by physicians, or physician designees, supplying professional expertise
through teleculmunLcations for the provision'of rendering on -site anal -
in-traisit advanced emergency 'radical care.
132.1(21) "Sipe_vising physician" rr..,ans any duly licensed physician
who has bean trained and certified in advanced cardiac life support as
outlined in American heart association standards as of August, 1977, or
its equivalent as deterrrdned by the council, who is designated, by
rare in writing, by the r; dica1 director to be responsible for medical
control of advanced emergency medical care personnel via any telecodr,
trmications system when such personnel are providing advanced erergency
medical care. This designation shall be valid for two years from the
; date of such designation unless sooner rescinded. The supervising
physician 'ray be redesignated if qualified.
132.1(22) 'Direct supervision" means supervision provided by a physician,,
or physician designee, •who is physically present with the advanced ENJ-I, -
advanced F2T-II, paramedic, or trainee. •
-4-
•132.1(23) :'RQrrnte supervision" .means supervision provided by a .
physician, or physician designee, who is not physically present with the
,advanced ENT -I, advanced %•f-II, or paramedic via any tele nicatio,s
.System supplemented with standing orders.
470--132.2 (147A) Requirements and stand rds for enro1L«t in advanced
etmrgency medical care training p,00 aa4.
132.2(1) No persc shall be enrolled ir. a trait ' tr r
� P � oo--am for -
advanced ENT -I, adv- .ced ENT -II, -.'or paramedic training unless the
following rdnim.:an require nts are met:
a. Applicant shall have a high school diploma or its equivalent.
b. Applicant shall be currently certified by the department as an
ENT -A. (basic ENT) , or have a current national. registry ENT -A. certificate.
c. Applicant shall be physically able to perform the functions of an
advanced ENT -I, advanced E: -II, or paramedic as appropriate.'.
d.. '-Applicant shall cc::;ple_e a satisfactory personal interview uitn
either the training program medical director or designee regarding
qualifications including r en'eal and educational attainments, as well as
aptitude to become.an advanced.E -I, advanced ENT -II, or paratedic.
470--132.3 (147A) Advanced emergency medical care personnel -
certification and renewal standards and procedures.
132.3(1) An advanced Ez-I, arced --II, or paramedic certificate
is valid for two years from date of issuance unless sooner suspended or
. revoked for cause by the board.
.132.3(2) -Application and e <srunaticn.
a. The application form and instructions for submittal are provided
by the beard.
b.. The completed application, accompanied by the required credentials,
'and examination fee shall be sum itt-ed at least 30 days in advance of
the examination date.
•
-5-
c.,p' `liy those individuals ..::o have sub '.. =ed the required apaliwtica
and have been notified o; acceptance by the board shall be peti.'tted to
Write the examination.
. d. Prior to the examination date each applicant shall be
sent an admission card [:'tic? shall be presented by the applir Pnt for
admission to the examination center.
e. The passing score for each ei:a":_i.natiOn shall be determined by the
board.
f. The examination shy ,._ be ad ai i s tered a'. least twice a year at
_ su:h tires and places as .-ay be determined by the board.
132.3(3) Pe-exa:=..nari .
a. Any applicant who fails the examination shall be required to rewrite
the entire examination.:
b. An applicant. Who '_"ails to pass the initial examination i j rewrite
the examination twice to attain a passin score. Candidates uho fail the
examination for the third time shall repeat the training p roo au before
being eligible to take the examination again.
Application for re-e_a_.::inaticn shall be acco.eJanied by the exam atTo`'
fee. Application shall be submitted at least -30 days in advance of the
examination date.
132.3(4) Applicants for certification shall have:
a. Completed and submitted all necessary torus required by the board.
b. Successfully co:pleted the training program.
c. Passed the written examination approved by the board.
d. Passed the practical examination approved by the board.
132.3(5) Applicants from other states shall request certification from
the board and Pray be issued the appropriate Iowa certificate providing:
a The applicant completes and submits all necessary forr:s required
'by the beard:
b. The applicant submits adequate evidence of current certification in
another state or has other recognized certification -Firth stanards cr-
parable to those in 9ffect in Iowa as deterrrined by the board.
132.3(6) • % challenge of the certification e'.' r1natict is available to
provide additional sources of potential advanced emergency redical care
per °•ne1 because of previous s e-ergc ? training..
-o -Y F'oliotinfl is the.
list of categories fro.,. w•hich.eligibility for acceptance is determined:
a. Any registered nurse who is licensed in the state of Iowa.
b. Any individual c :o his had education and training equivalent to -
• the requirements in these rules prior to their effective date.
c. Exceptions to'any of the above categories may be referred to the
. board for determination of eligibility.
d. Persons wishing to participate in. the challenge process may rake
written request for procedural instructions and requirements to:
Board of Medical Ex4mu_ners, State Office Building, 300 Fourth Street,
l;es Voines,:.Iowa, 50319..
- :132.3 (7) -. Ra lewa1 of certiicates • shalll be required every two years
:by the board •in order to continue providing advanced enter gency medical'
132.3(8) The application form and instructions for renewal of
certification shall be railed to the certificate holder at least 60 days
prior -to the
expiration date of the current certificate *- tod o
,,
be:elagible_45.renecyal4a the. certificate holder shall have.
a.-- Completed and submitted all necessary forms required red by the board. -
b. A current certificate.
c. :,Cu leteedta o30 his of '`
... 1e ...of- ng e&ca'ion'pe�,. y avl
as outlined below: i�ontanu..,.G,
(1) ,`At least 6,,hours��.oxrq1 crasssroo� ""i
,,- -. Pxpezzence�
(2) 5A e.st 6 t,ouys aribri7Tee 61 i .qari
(3) t .least o hoursc-T1-k ec "e.. erse:ice_zri a hospztal-,:under.-direct
'W- .�`3- ..c .-.. ...i%..-i.n.-.c=a�i`-w.v+... ..v_. vs ."K r .
s v�J�oi,�yd----.-7,-;ti T.' i_ .
(4) I2 hour tc be determ nect7gy- d calr di<ecto
.' 470--132,4 (147A) `'Levels• of training.
132.4(1) "Advanced F a' -I" reams a certified E-A who his successfully
completed rrodules-1, 2, 3, and 5 of the United States depart nx:.Lt of
transportation's parodic guide, excluding endotracheal intubaticn.
4
132.4(2) �'Advs,icee Eu Trans is certified all -A c.'o has successfully.
ccmpleted the first srd , _ .-_..,P. - •---.,.K.-e.-.i
•�.. tnef'fte�nrnc.lQs oltne Liiited�States#
•
c?epartrr3'rt of traisportdtzc s pig iodic
: bar [+i1'J
standk....s as determined by the council ark?proved by the board.
r....
132.4(3) "Paramedic''means a certified ?^Awho has successfully
completed all fifteen modules of the United Staces department of
transportation's paramedic guide, and vho has been trained and certified
in advanced cardiac life seaport as outlined in American -heart association
st n-lards as of August, 1977, or the equivalent of such standards as
determined by the co:ricil and approved by the board.
132.4(4) The advanced -I or training program shall consist
- of classroom, clinical, and field experience sufficient to -develop skill
and competency in the respective categories_ as outlined in. the L;r'ted
• States department of.. transportation's paramedic guide, and shall be
completed within a one-year period. After certification at the advanced
ENT -I or EMT -II level, individuals shall be - eligible for certification
at the next higher Level pending successful:coupletion of the appropriate
material.:
• 132.4(5) The paramedic training program shall consist of classroom,
___clinical, and field:experience sufficient to develop skill and competency
as outlined in the United States deparu t of transportation's parodic
gs.de, and shall be completed within two years.
132.4(6) In addition to the medical procedures outlined in sub.*le 132.1(4),
advanced emergency redica1 care persoL..el ray perform any other red_cal
proce *re appropriate to their level of certification not specified in.tne
.United,States deoartn nt of transportatic n's pare edic guide that has been .
adopted by rule by the board providing they have bean trained in the
procedure and have received authorization from the service programirredia.al
director.
474--132.5 (147A) Training program standards.
132.5(1) Training institution.
a. The training institution shall be a post secondary educational
-8-
insu lion, or hospital providing a tram,_ •.g program approved .by the
board.
b. Training program approval shall not exceed four years. Applicants
shall use application fortis developed by the board.
c. Approval for training prograirs shall be obtained at least 60 days
.before the start of a class.
d. A training program without a ci.rent active trainee enrol L t
shall be subject to automatic review.
e. If a training program loses its medical director, it shall report
this infor ation o the board and provide a curriculum vitae for the
nedical director's replacement. A new class shall not.be started until
•a qualified medical director has been appointed..
f. Board approval is required before any major cur-ri ilu?a changes can
be instituted. Such proposed changes shall be submitted to the executive
director one iunith prior to a regular board meeting for consideration
and action. Major curriculum. changes include:
(1) Alteration of the present curriculun which increases or shortens
the program, exclusive of vacation days;
(2) Changes in use of co-operating agencies;
(3) Major change in course offering.
g. A training program shall lose its approval if it fails to met any
of the provisions of these rules.
132.5(2) Application. ,
a. Any applicant wishing to establish or reopen a training institution
shall inform the board by writing to the executive director during the .
initial planning. Early consultation and planning with the board`is
essential for the development of all types of sound programs in advanced
emergency redical care..
(1) Written application shall be submitted to the executive director
one month prior to a regular board meeting for board action. The appli-
cation shall include: ,request for permission to establish or reopen a
training program signed by approprihte officials of the .applicant;
-9-
of ( 3ical facilities; and evidence of-lified faculty.
(2) Survey visits:
A survey'of the applicant and clinical resources
to be used for -trainee experience „ay be made by a representative of the
board; representatives of the applicant may be required by the board to
reet with the board at the tin the application and reports of surrey
(if applirrhle) are discussed to facilitate. board action.
(3) Report of board action: V.ritten report of board action acccr a ied
by the board survey reports (if applicable) shall be sent to the applicant.
b. Established training institutions.
(1) Survey visits: All training institutions ,:ay be v sited by a
representative of the board at regular intervals as determined by the
board. The purpose of the visit -is to examine educational objectives,
review training proga,s, administrative practices, services and facilities,
and to prepare a wr-itten. report "for. revies: and action by the board. All
visits shall be conducted u'der'i^partial and objective conditions.
(2) Survey of clinical facilities: All facilities used for clinical
instruction maybe visited by a representative of the bond as part of
the training institution survey. The purpose of the•visit is to review
administrative practices, patient care practices, the farlities and
provision for patient care and trainee personnel, and to prepare a
written report for review and action by the board.
• c. Change. of ownership or control.
(1) The board shall be notified, in writing, of any dranges in owner-
ship or control of a training institution within 30 days of such change.
132.5(3) . Contractual agreements.
a. - If clinical or field experience resources are located outse the
.framedork of the training institution, written contractual agreements
for such resources- shall be initiated by the training institution.
132.5(4) Facilities.
a. there shall be. adequate classroom, laboratory, arrt practice space
to conduct the training, program. A library with refer_.e r.ateri is cn
J t
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crc ley and critical care shall also b ailable.
tt
b. The following hospital units shall be available for trainee experience
for each training program:
(1). .Emergency services with an average of at least 1,000 total visits
pe 'rrcnth;
(2) - Intensive care unit or coronary care mit or both;
(3) Operating room anti recovery room;
(4) Intravenous or phlebotomy team, or other method to obtain IV
experience;
(5) - Pediatric tirr;t;
.(6)-'-babor.and delivery suite,
(7)
Psychiatric unit; and
(8) thrgue;-
(9) An animal laboratory is a recommended, but optional adjunct.
c. There shall be an advanced erergency medical care unit closely
affiliated with the training institution to provide field experience.
C'arc1iac telemetry is a reco t ended, but optional adjunct to the training
Frro an-
132.5(5) Staff.
a. The training program medical director shall:
(1) Be a physician in a directly related specialty, such as
n dicine, who has been or will be certified within one year
in advanced cardiac, life support.
(2) Be assisted by a course coordinator who is a physician's assistant,
-registered nurse, or other appropriate health professional, who is also
certified as an instructor in advanced Cardiac life support. This..
.individual shall be a full -tine educator or a practitioner n emergency
or critical care..= -
b.=The,instructianaI.staff shall be comprised of physician;,:n•.irses,
phari;acists, - advanced emergency medical care personnel, and other health
e rgency
as an instor
care professionals who have appropriate education and experience in
J 4
emergency and critical. care.
-11-
ad1.%. ed fE T or paramedic trainees are c.k, :ining clinical experience.'to
supervise their activities and ensure the quality and reIw ce 'of the
experience. Trainee activity records shall be kept and Brie.;ed by the
inin diate supervisor(s) and by the course coordinator.
132.5(6) Advisory cormittea. There shall be an advisory committee
for the training program which has representatives from the training
institution and such other groups as affiliated medical acilities, local
n dical establishments, ti_>u1ance and rescue sad- seivi ca prog=s, and -
consumers of health care.
132.5(7) Trainee records.
-a. The training institution shall rain_tain an indivict'1 record for
each trainee. Training institution policy and board reqireneats will
determine contents necessary to serve
- include:
(1) Application;
(2) Health summary;
the purpose intend
(3) Trainee record or transcript of hours and perfor.:.=nre (including
exa :anations) .in classroc_, clinical, and field ecperieaca setti gs; and -
(4) Verification of changa of name if change occurs vIlle enrolled in
the training program.
132.5(8) Reports.
a. The training institution shall submit an annual rert to the board -
--s
on forms provided by the board. This report shall proviaa currant data ca:
(1) Qualifications and major responsibilities of each faculty marber;
(2) Policies used for selection, promotion, and graduation of trainees;
(3)
Practices followed in safeg :--mding the health andwell being of
trainees, and patients receiving advanced emergency uedir21 care within
the scope of the training program;. •
.
• (4) ' Current enrolls: nt by class and trainee -teacher ratios;
(5) N tuber of admissions to training programs per year;
-12-
0.:4 u r or gracu<itions . tror, traink programs per year;
(7) Curriculum lesson plans and brief course descriptions.
. 132.5(9) Selection of trainees.
i. There shall be a staff selection cor:rrittee to select trainees
utilizing as a basis the prerequisites outlined in subruie 132.2(1)"e".
b. ET -As, who are currently certified in advanced cardiac life
support, may test outof component f that c of
o"''�-- the advanced alr or paramedic
training program utilizing procedures developed by the training institution.
132.5(10) Continuing education.
Training institutions rya provide continuing , __ n
Y P ccn_�.rnzina education for advanced
.EMTs and paramedia which is ecuuensurate with the continuing education
requirements detailed in subrule 132. 3 (3) "c'
b.. Training institutions shall provide a special course(s) for service
program uedical directors, supervising physicians, and physician designees
to familiarize them with advanced prehospital care and their respective
responsibilities.
132.5(11) Financing and administration.
a. There shall. be sufficient funding available to the training
institution to ensure that each class started can be completed.
b. Tuition charged to trainees shall be reasonable and accurately stated.
c; Advertising for advanced E?- r and paramedic training programs shall
be appropriate, and there shall be an official publication describing the
course of study.
132.5(12) Trainees.
• a. Advanced EMT or paramedic trainees may do anything that a certified
advanced EMT or paramedic ua do, if they
. _ Y_axe under the direct super_visica
of -a physician or physician
designee, nor.under
r the remote supervision of -
a physician or -physician designee, with direct field supervision provided
by staff directly associated with the training g Proms. -
b. Trainees shall not'be substituted for personnel of any affiliated
_ redical facilityor service program, but .*nay be erployed while enrolled
in the training program.
-13-
132.0(1) General requirements for au!q.-_.zatic-n.
•
a. Any arrbulc nce or rescue squad seeking to establish and provide a
service program utilizing advanced crerg`ncy medical care personnel shall
• be authorized by the department upon the advice and consent of the cau nc '_
Application for such authorization shall be rade on forms prescribed by
the department and approved by the council.- Applicants shall complete
and submit the forms to. the departs nt not less than 60 days prior to the
requested effective date for the establisLa.-1.nt of the service program.
b. The service program shall; as a mi.nirrnzn standard, use emergency
.
redical transport vehicles that n et. current. federal nal-A-1822 specifi-
cations and amendments. as of June 25, 1975. These specifications shall
not apply to vehicles used for routine or convalescent transfers.
c. The
equipment and supplies utilized by the service program shall be
those set forth in rule 132:7.
d. The service prop a i shall- have a redical director who is a duly
licensed physician.
e. The service program shall ueintain a telecommunications system
between the advanced EMT -I, advanced E i-II or paramedic, and the
medical director, supervising physician, or physician designee.
132.6(2) The medical director shall be responsible for providing.
competent direction and overall supervision of the uedical
aspects of the service program.
132.6(3) Each service program shall:
a. Maintain an adequate nu tber of currently certified personnel, . and
erergency response vehicles.
b. Provide two personnel on each ruawith one being an advanced aE or
par�,ik:dic and the other a basic E-O. A preferable alternative is to have
at least three personnel with at least two being advanced EM s or paramedics
•
and the other a basic E-r.
C. Ensure that one advanced Er or Para odic is in constant attendance
with the patient when advanced emergency radical care is being provided.
-14-
d. .- sure that personnel duties are. co;! L_ .tent with their level of
certification and, that certification is' current.
e. Notify the department in writing Lyon the termination of the .
medical director.
f. Notify the department in writing as soon as the selection of a
n=w rredical director is made.
132.6(4) The service program shall notify the depart .ent in writing.
within30 days of any increase or redt.Iction of services being provided.
F
132. 6(5) Advanced emergency rredical rare personnel who, because of
equip nent ralfuncti ri, are unable to maintain coarzmication. with the
redical:control source tray provide advanced emergency rradical care
- according to the established protocols of the respective service program.
They shall, however, immediately contact the medical control source as
soon as cony: ication is re-established.
132.6(6) General requirements for renewal of author'7.ation:
a. Service programs authorization is valid for two years from the date
of such authorization unless sooner suspended or revoked.
b. To renew authorization, a service program shall see
requirements:.
(I) Continue to meet the requirements outlined in rules 132.6, 132.7,
and 132.8 of these rules;
(2) Complete and submit to the department the renewal application at
least 60 days prior to expiration of the current authorization. Such
the following
-application may be obtained upon request to: Iowa State Deoartrent of
Health,YEmcrgmcy Medical Services Section, Lucas State Office Building,
Des Moines, Iowa, 50319.
470--132.7 (147A)
supply standards..
132.7(1) Each service program shall maintain accurate records concerning
•- the emergency care provided to each patient. The following data shall be -
reintained and provided, -
upon request of the depart,int, to the deparL.It,
-15-
b. .Type of runs (behavioral, b:,r=n, cardiac, r.cec fatal, pDiso:t, spLii
. cord, tra��ra, _ etc.) .
c. Ntrrbar of teiettered runs.
d. IS fiber. of cases requiring resuscitation measures:
(1) `:';r ba.r defibrillated;
(2) N.rrber requiring C ?, only;•
(3) N rb r successfully resuscitated;
(4) Number of IV's att i..pted/started;
(5) I rber of incubations atteited/started; and
(6)
Nurber of tirres anti -shock trousers were used. .
Other data of emerge<icy medical care provided, as ray be recuired
•
by the depazt;,it.
f. Tire factors:
(1) Tire of occurrence;
(2) Time dispatcher notified;
(3) Time service program notified;
(4) Tire vehicle dispatched;
(5) Tirm of arrival at scene;
(6) Tires departed scene;
(7) Ti-re of. aLLival at hospital; and
(8) Time when back in service.
132.7(2) -- Ea Z_ s ',ri cb progr ball, establish dui gyp eqt wit: ch st
p`-oredure. t..-:ajsiTMe: -fiat a .
a. Ele-8-- --c: a� d n cha iicalseauip-: t e,-in-proper,:cp✓r in
at;all•xt s
b. E-=::z=g`^c retpc 1sa a 8-e_-ate
ccneattazi"a-tTaz11t-, s�
132.7(3) All vehicles used in service proo gas shall be equipped, as a
mini -;r, with the "Essential Equiprent for hula ces" published by the
w�,�,ittee on Trauma., r::erican College of Surgeons, as of Septe.ber, 1977.
J
-16-
•
T-(- arvice programs shall have as a �: i : , the additio:�.al equi Arent
and supplies listed and filed with the department, as approved by tha
comeil. Such list is available_ rpcn request to: Iona State Dcpa_rtr nt
of Health, Emergency radical Services Section, Lucas State Office Building,
Des Ibises, Iowa, 50319.
132.7(5) in addition to subrules 132.7(3) and 132.7(4) above, vehicles
used in advanced ENT -IT,- or paramedic service programs shell have, as a
minimum, the additional equipment and supplies listed and filed with the
departTant, as approved by the cou c 1. Such list is available upon
request to: - IowaY State Departs nt of Health, Emergency 1:e&cal Services
Section, TITcas State Office Building, Des K2 roes, Iowa, 50319.
132.7(6) In addition -to subrules 132.7(3),.132.7(4), and-132.7(5) above,
additional equipment a=id supplies shall be carried on service program
vehicles as Tray be determined by the medical dire' tor.
132.7(7) All drugs are to be provided by a hospital pharmacy or
•
cam -unity pharmacy, as per written agreement. Accountability for the
exchange, distribution, storage, -ownership, and security of drugs shall
•
be subject to applicable state and federal requirerents, small be the
responsibility of the hospital pharmacy or co,aluTnity phrar,:acy.
132.7(8) Each service program shall ensure that strict sanitation
procedures are in effect at all times. The following sanitation standards
• shall apply to all service program vehicles:
a. The interior and the equipment :within the vehicle shall be clean '
and raintained in good working order at all tires.
b. Freshly laundered blankets and linen, or disposable linens shall be
used on cots and pillows, and shall be changed after each patient is.
Clean linen storage shall be provided.
d. Closed containers shall be provided for soiled supplies.
e. Closed compartments shall be provided within -the vehicle for
medical supplies. 3
•
s
-17-
ork 'e snail he :.rapDca, a_na properJ.y x tL c:u
•
items shall be apt. sterile and properly.stored.
g. Ulan a vehicle has been utilized to transport a patient known n to
have a cci-A mi cabledisease, the vehicle shall be appropriately decontm i
nated. -
h. All drugs shall be maintained in accordance with the rules of the
state board of pharmacy exa irers. Such rules ray be obtained a on request
to: Iowa State Board of Pharmacy Examiners, State Office Building, Des
Mines , Iowa 50319.
The department, without prior notification, shall have the authority
to inspect all such vehicles and supply inventories to ensure compliance
with all applicable rules.
470--132.8 (147A) Service pros am --.medical control.
132.8(1) The nedical director gray appoint,._by name inwriting, a super--
vising physician(s), or a physician designee(s) to provide radical control
132.8(2) iradical control shall be the direct responsibility of the
rrsdical director, supervising physician(s) or physicia-n: designees) .
132.8(3) redi cal control shall. be provided from tirre of first notific
tion until the patient reaches the receiving hospital.
132.8(4) Communications equiprent shall be able to reach any part of
the service program area to ensure the provision of redical control.
132.8(5) 'The medical director's duties shall include, but need not be
limited to:
a. _Maintaining liaison with other physicians, including the medical
director of the training program and the supervising physician(s) at
the appropriate hospital(s).
b. - Ebnitoring- and evaluating, through_ the supervising physician
daily.. activities of the service program.
c: • Coordinating continuing education programs for the service program
rerbers as set forth in subrule-132.3(0)"c'.
-18-
•
lla.-li_IA, W:l Cl:::al_'LCO Service program
e. Developing and providing. protocols for advanced e:^a-,ency -r dical
care.
f. Developing written parameters and protocols to be followed by the
physician designee(s) in supervising advanced emergency reedical care
personnel.
.
g. .Ensuring that any physician designee has demonstrated competency
equivalent or superior to the level of the advanced en'rgercy medical
care personnel being supervised.
h. . In ort t rg the medical community of the advanced emergency medical
care being provided according to approved protocols in the service
program area.
e.
132.8(6) Supervising physicians and physician designees shall assist
the radical director periodically by:
a. Providing medical control.
Reviewing the advanced emergency medical care provided.
Reviewing and updating protocols.
Providing continuing education for service program mar -hers.
Resolving operational problems.
470--132.9 (147A)
Dial, suspension, or revocation of service pro -
gran authorization or renewal --appeal.
132.9(1) The departn it ray deny an application for authorization or ,
renewal of a service pro, --am utilizing advanced EMI's or paramedics, or.
suspend or revoke such authorization or renewal if the council finds
reason to believe the service program will not or has rot been operated in
compliance with chapter 147A of the Code, or the
rules implementing such chapter, or that there is insufficient assurance
of adequate protection for the piblic.
132.9(2) The proposed denial, suspension, or revocation shall be
considered by a committee of the council consisting of at least two members
appointed by the chair of the council. The committee shall advise the
-19-
of action to.suspeYnd or revoke such authorization or renewal.. Notices
of denial, suspension, or revocation shall be by certified rail, return -
receipt requested, or by personal service.
132.9(3) Any request for a hearing before he council concerning the
denial, suspension, or revocation of service program authorization or
renewal shall be submitted by the a g ieved party in writing to the
deparieent by certified rail, return receipt requested, within 30 days of
the railing of a notice of intended action by the department_ The address.
is: Iowa State Depar ant of Health, E ar-gency Medical Services Section,.
Lucas State Office Building, Des i-iines, Ica, 50319.
132.9(4) The deparui nt shall prepare the notice of hearirg and transmit
same to the aggrieved party by certified rail, return receipt requested,
at least 10 days before the date of the hearing.
132.9(5) The council adopts the rules of the department found in
470--chapter 173, Iowa Administrative Code, as
before the council. The council ,ay authorize
officer to conduct hearings,.adrinister oaths,
the procedure for hearings
en administrative hearing
issue subpoenas, and pre-
- pare written findings of fact, conclusions of law, and decisions at the
direction of the council. The members of the committee thich rake the-- -
initial decision to deny, suspend, or revoke authorization or renewal
shall not take part in the hearing panel but may appear as witnesses.
132,9(6) -The decision of the council shall be mailed to the aggrrihved
party by certified nail, return receipt requested, or by personal service.
132.9(7) Any appeal to the district cost from denial, suspension, or
revocation of such service progra^n authorization or renewal shall be -
taken within 30 days from the issuance of the decision of the council.
Notice of appeal shall be sent to the council by certified rail, return
receipt requested, or by personal service. It is not necessary to
request a rehearing before the council to appeal to the district court.
132.9(8)- The party who appeals a decision of the council to the
district court shall pay the cost of the preparation of a transcript of
-20-
470
,2.10 (147A) Tani s.Isu,n or revocation of advanced
urgency mcdic<zl care personnel certificates or rent :al --appeal.
• 132.10(1) •All cc :ulaints regarding advanced emergency medical care
pe su.alel, or those purporting to be the same, shall be reported to the
•o
board.
132.10(2) In investigating such complaints the certificate holder,
supervising physician, and other individuals as appropriate may be rec•aested,
and if so requested, shall app.ar at a board meeting for the purpose of
responding to such co:pl aints .
132.10(3).The board may deny an application for issuance or rene;a1 of
an advanced EMT, or paramedic certificate, or suspend or revoke such a
certificate when it finds that the applicant or certificate holder has:
a. Acted negligently in performing the authorized services.
b. Failed to folio--e the directions of the supervising physician.
c. Rendered treatu nt not authorized under chapter 147A of the Cow.
d. Violated any of the provisions of or failed to curly rith pertinent
- re u r nts of Chapter 147A of the Code, or the
rules implementing such chapter. `
e. Furnished false, misleading or incomplete information to the board.
f. Pled guilty to or have been convicted of a serious i sda-ea or or
felony relating to advanced EMT or paramedic services. --
132.10(4) The proposed denial,•stspension, or revocation shall be
considered by a cc;i,L,ittee of the board consisting of at least two members
appointed by the chair of the board. The committee shall advise the
executive director of its decision. The executive director shall the
notify the applicant of the granting or denial of certification or renewal,
or of action to suspend or revoke such certification or renewal. Notices
of denial,- 'suspension, or revocation shall be by certified mail, return
receipt requested, or by personal service.
132.10(5) Any request for a hearing before the board concerning the
dental, . suspension, or revocation of such certification or rencsal shall
-21-
''.et'u_n receipt requested, within
of intended action by the board.'
of railing of a notice
she ad,iress is: P. oard of I'ouical
Examiners, State Office Building, 300 Fourth Street, Des mines, Iowa, 50319.
132.10(6) The board shall prepare the notice of hr-ing....d transmit
selik.. t0 the aar eveu party by certified mail,. return receiptrequested,
at least ten days before tha date of the .hearing.
132.10(7) The board adopts the rules of 'the department found in
4707-chapter 173, Iowa Ad-Pi-listrative Code, as the procedure for hearings
the'1' authorize 7 administrative � e a Y tr r c "� r
before board. The board may aati:_griz� �..-� r.�..��n� officer
to conduct hearing , administer oaths, issue subpoenas, and prepare written
findi gs- of fact, conclusions of lava, . and decisions at the direction of -
the board. The reubers of the coruittee which make the initf 1 decision to
deny, suspend, or revoke certification or renewal shall not take part in
the hearing.panel but may appear as witnesses.
132.10(8) The decision of the board shall be mailed led to the aggrieved
p rty by certified rail, return receipt requested, or by personal service.
132.10(9) Any appeal to the district court from denies;., suspension, or
-revocation of such certification or renewal shall be ta'_:5,t within 30 days
from the issuance of the decision of the board. Notice of appeal shall be
• sent to the board by certified _ail, - return receipt requested, or by
personal service.. It is not necessary to request a rehearing be_`ore the
board to appeal to the district court.
132.10(10) The party who appeals a decision of the board to the district
court shall pay the cost of the preparation of a transcript of the admini-
strative hearing for the district court. _
•
470--132.11 (147A) Denial, suspension, or re -vocation of training program
•author-i 7ation or renewal --appeal.
132.11(1) The board ray deny an application for authorization or renewal
of a training program, or suspend or revoke such authorization or renewal
if the board finds reason to believe the 'training programwill not or has
-22-
no
operated in compliance 'c1e 3_r.147A of the Cede, or the
rules implementing such. chapter, or that here is insufficient
assurance of adequate protection for the public. .
132.11(2) the proposed denial, suspension, or revocation shall be con-
sidered by a committee of the boardtansisting of az least t.o t:.erbers
appointed by the chair of to board. The committee shall .advise the
executive director of its decision. The executive director shall then
notify the applicant of the =..anting or denial of authorization or renewal, -
j
or of action to suspend or revoke such authorization or renewal. Notices
of denial, sususpension,o:�, or revocation shall be by certified wail, return
receipt requested, or by personal service.
132.11(3) Any request fora hearing before the board concerning the
denial, suspension, or revocation of training program authorization or
renewal shall be submitted -by 'oe a ieved park- in •4rit:an ; to the board: -
by certified wail, return receia_ requested, within 30 days of the mailing
of- a notice of intended action by t:.a boar-d. The address is: Board of
...Medical Examiners, State Office Building, 300 Fourth Street,Des ? ne
Iaaa,j 50319.
132.11(4) The executive director shall prepare the notice of hearing
and transmit sa,AL to the aggrieved party by Certified rail, return receipt
requested, at lest 10 days before the date of the hearing.
132:11(5) :The board adopts to rules of the department fo'.md in
470--chapter 173, Iowa Administrative Code, as the proced=e for hearings
before the board. The board ray authorize an adri ris+_-rative hearing
officer to conduct hearings, administer oaths, issue subpoenas, and pre- •
pare written findings of fact, ccrcl;:s cis of law, and decisicns at the
direction of the board. The members of the com ittee rake the
initial decision to deny, suspend, or revoke authori7,1ion or renewal
shall.i of -_take part in the -hearing panel but ray appear as witnesses.
132.11(6) The decision of the board shall be wailed to the aggrieved
-party by certified mail, return receipt requested, or by personal service.
y
-23-
on- >.Gocatiori of such training program • -horizaticr or renewal shall be
takes t`ithln 3Q days from the issuance of the decision cf` the board.
Notice of appeal shall be sent to the board by certified rr. il, return
receipt requested,.:or by personal service. It is not rumessary to revue
a rehearing. before t` ,- board to appeal to the district t..
132.11(8) The party who appeals -a decision of t:� bo rd
to the district
court shell pay the cost of the preparation of a transcript of the admini-
strative hearing for the district court.
These rules are intended to i.mplerrnt chapter 147A of the Code.
These rules Were published under -notice of intended action in the Iowa
A Lu..rastrative Bulletin: dated April 4,. 1979 (ARC -0160) , have been reviewed
by the AdMinistrative Ruffles Review Ccznittee April 24, 1979,. and a public
hearing concerning the proposed rules was held April 26, 1979. All oral
and written col:m.e:its were considered and as a result the following changes
were wade:
- ,SSubrile..132.1(3) has been .sUbstantially rewritten at 1-77, request of the
Administrative Rules Review Committee.
• S.Sruie 132.1(22) has been amended for purposes of clarification.
Paragraph 132.2(1)b has been deleted and the fo11owing paragrai,hs re-lette_e:
Paragraph 132.3(4)c has been deleted. and the following paragraphs -letterer
Paraaph 132.3(5)b has been amended to reflect minor. word changes,
•Paragr. aph 132.3(6)d has been amended to reflect an address change..
Paragraph 132.3(8)d has been deleted.
Rule 132.4 has been a ended for purposes of clarification by adding a new
subrule: 132.4(6).
Subparagraph 132.5(4)b(2) has been amended to reflect minor word changes.
Subparagraph 132.5(4)b(3) has been amendcd to reflect minor k-ard changes.
S.iorule 132.5(11) has bean ar..=ided to delete paragraph 132.5(11)d which
will appear in paragraph 132.5(12)b.
Subrlle -132.5 (12)'h.s been amended by moving the body of the s.brtle to
p. ragaph 132.5(12)a, and by rewriting and adding the material formerly
found in paragraph 132.5(11)d as paragraph 132.5(12)b.
Para ph 132.6(1)b hat beaa 2r-eaded for ( poses of clarification.
Stbrule 132.10(5) hns been = eked to reflect an address crszt' gc.
S'brule 132.11(3) has: been u-:ended to reflect an address change. .
These. rules shall beccre effectiv a July 5, 1979.
. /%AY 9, 19”
Tr;
IeORYA.N L. ptv.q.E.4sKI, CC'2OESSIO iER
MZA S LA EE ..DLPART;•EJT OF ' m
6.rC,-� M. RHODES, J, CIiAIRPaS i
&^1RD OF 1 EDICAL c CA2 M=
-25-
Additional equipment and supply list on file with the Io :a State Department
of Health, Emergency I•p diCai Services Section, as approved by the Psvanc
ed
Emergency Z.T.edical C'.,.1 e Council.
Intravenous fluids and supplies, in medicine box:
6 Alcohol wipes
6 Eetadine ,wi pes
1 Tactated ringers, 1000 ml
2 Micro -drip a iinistration. sets
1 Roll tape (1 in.) _
2 Solution administratic n sets
2 .: Tourniquets
2 Vacuum tubes (CBC-Clot)
2 5% D/r;T, 250 or 500 ml
3 ,2 x 2" sponges
3 4" x 4" sponges
3 16 gauge plastic catheter needle 2 2 in.
3 18 gauge plastic catheter needle 22 in.
3 20 gauge plastic catheter needle 2 in.
3 23 gauge butterflys
2 16, 18, 20, 23, and 25 gauge needles
Intravenous fluids and supplies in service program. ve cle:
2 Lactated ringers, 1000 ml
2 Micro -drip administration sets
4 Normal saline for irrigation, 1000 rtl
2 Solution administration sets
5 5% D/-NaC.1, 500 ml
.Respiratory equipnt and supplies:
4 Aromatic a_awnia, 0.4 m1 aspirol
2 Cricothyroid needles .
2 Esophogeal obturator airways
Adjunctive respiratory support equipm nt necessary to provide
adequate ventilation as may be deeri d n ecessPry by the medical
director. -
i
ACC/2/2/ i9
ADVANCED- i i-II OR PA_ AI,EDIC SERVICE CE PROGRAN
DL'.'.g and additional equipment and: -supply list on file with the Iona" State
Department of Health, Emergency : `medical Services Section, 23 approved by
the Advanced Errrgency Medical Care Council.
.;ANi, i. Y NAME
3
J
2
2
2
2
4
ilinophylline Inj ection
Atropine Sulfate Inj ection
Calcium Chloride or Gluconate Inj.
D22xa ethasone Sodium Phosphate Inj.
Dextrose Injection, 50'%
Di azoxide Injection (Hyperstat)
Diphenydra;nine HCI Injection
Dopamine HCl Inj. (Intropin)
Epinephrine HC1 Injection
4 Epinephrine HC1 Injection
2 Furosemide Injection (T asix)
2 Isoproterenol HCI Injection
2 Lidocaine HCI. Injection
2 iv tararainol Bitartrate Injection
2 O. y tocin. -Injection __ _
2 Phenytoin Sodium Inj ection
NOT FOR DUCT INJECTION -
CONCENTRATION
25 , a/m1
0.1 mg/ml
100 mg/E1
4 rg/ml
25 Gii/50 ni
15ua/nl
50 mg/ml
40 mg/ml
1:1,000
(1 g/ml)
1:10,000
(0.1 mg/mi)
10 n-g/ml
0.2 a/ml,.
(1:5,000)
200 mg/ml (207) 10 m1
10mg/,r' 10 ml
10 units/m1 1 m].
50 mg/ml 2 m1
MUST BE DIT Ul ru PRIOR TO INJECTION
2 Diazepam Injection (Valium)
2 Lidocaine HCI Injection
2 2 thylprednisolone Sodium Succinate
Injection. (Solu-M.edrol)
2 Nbrphne Sulfate Injection
4 Naloxone Injection (Narcan)
2 .Physostigmine Salicylate Inj.
2 Procainamide HCI Inj (Pronestyl)
4 Sodium Bicarbonate Inj. (Adult)
2 Sodiu-r? Bicarbonate Inj. (Pediatric)
5 rg/m1
20 mg/ml (2%)
40 mg/Vial
10 mg/ml
0.4 mg/m1
1 mg/ml
100 mg/ml
1 mEq/ml
1 mEq/ml
ORAL MEDICATIONS
2 Carbonated Glucose
2 Glucose Paste
.2 Ipecac Sythp
1 -Nitroglycerin Sublingual Tablets : 0.45 <<a
(1/150 Gtn)
EQUIPT-E Ti
V0T l nE C.ARPJEa
10 rrl Ampule
10 m1 Syringe
10 m1 Ampule •
1 m1. Syringe
50 ml Syringe
20 w1 ul.e -
1 m1 Syringe
5 m1 Ampule
1 m1 Ampule_
10 ml - :Syringe
10 m.1 u1e•
5 nil Syringe
Syringe
Vial
Ampule
Ampule--
2 nil Syringe
5 ml Syringe
• 1 Vial Vial
1 ml
1 m1
2_ 71
10 mi
50m1.
10 nil.
7 oz
80 Gm
30 m1
25's
Endotracheal. tubes
es
Taryngoscope
'Portable battery operated monitor/recorder/defibrillator •
1 mi Tu ee•-
Apule
Ampule
Vial '
Syringe
Syringe
Bottle
Squeeze Bottle =
Bottle
Bottle
ram.• /2/2/79
XAVIER HOSPITAL - REVISED
Ambulance Attendant's Salary
Coordinator's Salary
Benefits for first year
Cost of Operation
Insurance (Workinan's Comp. 3/100)
Insurance (Vehicle)
Training (100,000 over 3 years)
Vehicle (Maintenance)
Gas
Sub Total
Total
Indi rect
Bldg. Deprec.
Equip. Deprec.
*Adm. & General
Operation Plant
Laundry
*Nursing Adm.
1980 Cost Projection
211,953
18,000
229,953
32,193
262,146
6,899
12,000
33,333
4,000
5,000
61,232
323,378
1,000
11,540
31,030
-0 -
2,700
15,000
61,270
*Accumulated cost method of departmental allocation.
*Although we allocate based on patient days and therefore no overhead would have been
made, medic :re regulations would mandate an,ra.11ocation-Estimate
Total 384,648
10% Uncollectable
Grand Total 423,113
City Calls 92/Call
Outside City Calls 110/Ca11
Outside City Mileage 75/mile
Emergency Charge 100/call
2700 City Calls
A. 1300 transfers
B. 1400 emergencies
300 out of city
Rate Projection
248,400
33,000
3,375
140,000
Total 424,775
E.R. Charge includes all supplies
XAVIER HOSPITAL - REVISED
Ambulance Attendant's Salary
Coordinator's Salary
Benefits for first year
Cost of operation
Insurance (W'orkman's Comp. 3/100)
Insurance (Vehicle)
Training (100,000 over 3 years)
Vehicle (Maintenance)
Gas
Sub Total
Total
Indirect
Bldg. Deprec.
Equip. Deprec.
*Adm. & General
Operation Plant
Laundry
*Nursing Adm.
1980 Cost Projection
211,953
18,000
229,953
32,193
262,146
6,899
12,000
33,333
4,000
5,000
61,232
323,378
1,000
11,5 0
31,030
-0-
2,700
15, 000
61,270
*Accumulated cost method of departmental allocation.
*Although we allocate based on patient days and therefore no overhead would have been
made, mediclire regulations would mandate an, allocation -Estimate
Total 384,648
10% Uncollectable 46
Grand Total 24 3,113
Rate
City Calls 92/Call
Outside City Calls 110/Ca11
Outside City Mileage .75/mile
Emergency Charge 100/call
Total
2700 City Calls
A. 1300 transfers
B. 1400 emergencies
300 out of city
E.R. Charge includes all supplies
Projection
248,400
33,000
3,375
140,000
424,775
XAVIER IHOSPITAL
AlBULANCE SERVICE
PROPOS AL
The following proposal is being submitted by Xavier Hospital for an
ambulance system is based on the suggested minimal guidelines.
Should Xavier Hospital receive the ultimate task of supplying ambulance
service to the City of Dubuque and East Dubuque, and Dubuque County, this
proposal is in no way intended to be final because there are many variables
that have not been studied. This is due to lack of time to properly prepare
a proposal with adequate statistical information.
There were many assumations that were made in order to conclude this initial
proposal:
1. One ACLS.ambulance would be stationed at Xavier Hospital and one ACLS
ambulance would be stationed at one of the other hospitals in Dubuque.
,Because there was no time to obtain a proper estimate from either hospital
on the cost of physically housing an ambulance at their respective hospitals,
no figure was appropriated when determining the total cost.
If additional revenue were needed to pay for building new garages or re-
modeling existing structures at either Finley or Mercy, the rate structure
would be adjusted upward accordingly.
2. As there is no way to accurately predict availability of trained personnel,
it was assumed that all personnel would need to be trained from the beginning
which will be very time consuming and costly. Since the attendants would
need to be in training at least six months, at the hospital's expense, a
subsidy would be needed to pay salaries while the attendants are in training.
If there would be no subsidy, the rates would again be adjusted higher.
3. Since the city owns the ambulance, the hospital would be allowed to continue
using the city garage for maintenance and the city will continue to insure
present coverage on the vehicles.
4. The Fire
transfer
5. The total
ambulance
Department will continue to respond to all calls as they do now, except
calls, and continue to do dispatching.
salaries including operating costs, will be'allocated to the
service and not to other departments within the hospital
6. Training could be done locally utilizing all resources in the Dubuque area,
and there would be an adequate number of qualified candidates.
7. An ambulance service in one hospital or two, would not adversely effect
service to the third.
8. Considering all the unknown factors, including
a.
b.
c.
d.
Approval from Certificate of Need
Approval from Health Systems Agency
Support of the Tri-Hospital Planning Council
Availability of personnel
effective date of operation would be a minimum of six to nine months.
- 1 -
STAFFING PROPOSAL
Two people each shift at each location 24 hours per day, 7 days per week,
52 weeks per year.
2 people X 2 locations X 24 hours X 7 = 672 hours per. week
672 40 = 16B Full-time equivalent
For 10 days vacation per year + 7 holidays + 3 days sick time per year per
each full time equivalent we would need:
16,8 X 10 = 168 days + 7 = 117.6 days - 6.8 X 7 = 117.6 days + 16.8 X 3 = 50.4 days
168 + 117.6 + 50.4 = 336 days = 26884: 2080 = 1.3 fulltime equivalent
16.8 + 1.3 = 18.1 F.T.E.
It is estimated that this will break down to 12 full-time and 10 to 12 part-time
people.
An additional full-time equivalent will be needed as. a Coordinator -Instructor
Supervisor.
1980 Cost Projection
Ambulance Attendant's Salary
Coordinator's Salary
Benefits cost for first year
211,953
18,000
229,953
32,193
262,146
Cost for Operations
Garage remodeling (Xavier Hospital) 15,000
Insurance (Workmen's Comp $3/100) 6,899
Training Cost 2,000
Data Processing 2,000
Vehicle Maintenance 4,000
Gas 5,poo
Depreciation
Indirect (10%)
10% Uncollectables
34,899
15,000
49,899
Total 312,045
31,205
343,250
34,325
Total Cost 377,576
1981 Cost Projection
Ambulance attendants Salary 251,940
Coordinators Salary 20,000
271,940
Benefits (X20%) 54,388
SubTotal 326,328
Cost for Operations
Insurance (W/C) 8,158
Training 500
Data Process 2,000
Vehicle Maintenance 4,000
Gas 5,500
Depreciation 15,000
10% Indirect
SubTotal 35,158
Total 361,486
36,149
1g% uncollectable
1982 Cost Projection
Ambulance Attendants Salary
Coordinators Salary
Benefits (20%)
Cost of operations
397,635
39,764
437,399
274,549
21,600
296,149
59,230
355,379
Insurance (W/C) 8,884
Training 500
Data Process 2,0b0
Vehicle Maintenance 4,000
Gas 6,000
Depreciation 15,000
102 Indirect
10% uncollectable
36,384
391,763
39,176
430,939
43,093
474,032
RATE PROPOSAL
1980
In city calls
Outside city
Outside city mileage
Emergency charge
Supply Revenue
1981
In city calls
Outside city
Outside city Mileage
Emergency charge
Supply Revenue
1982
In city calls,
Outside city calls
Outside city mileage
Emergency charge
Supply Revenue
65 /call 195,000
110.00/call 36,850
.75 /mile 3,375.
100.00/call 140,000'
4,200
Total 379,425.00
78.00/call 234,000
130.00/call 39,000
1.00/mile _4,500
112.00/call 156,800
4,500
Total 438,800.00
85.00/call
140.00/call
1.00/mile
120.00/call
Total
255,000
42,000
4,500
168,000
4,500
474,000.00
There are infinite variations of rate structures that can be proposed to
achieve the amount of revenue necessary to run the ambulance service. The
above are examples of the amount that will have to be charged to achieve
the proposed bottom line.
These rates are based on the following:
3,000 City Calls
A 1600 - Transfers
B 1400 - Emergencies
300 - out of city
4
Some concluding thoughts after the attempt at a reasonable proposal:
1. Due to lack of time we were unable to study the Medicare/Medicaid
reimbursement effects on the hospital for the service, this definitely
would effect the rate.
2. We must consider the pressures by outside groups relating to the high
cost of health care. An ambulance will add to this cost.
3. Perhaps from the three proposals, develop one set of specifications
for a formal bid.
4. Compare the proposal against the present system to determine the actual
need for a change if the city rates are adjusted to meet the expense.
5. In light of the seemingly high cost, restudy the need for a
comprehensive ambulance service of the proposed scope for the population
base.
6. In conjunction with #5 perhaps again study the possibility of the city'
handling emergency calls and hospitals handling routine transfer calls.
7. If the city were to retain the ambulance service, remove the rate structure
from a city ordinance to enable the fire department to adjust rates more
easily. _
8. Two ambulances, one located in the north part of Dubuque and one in the
south part, should be a definite consideration, no matter who retains
the service.
__.4i1=MMEI
REVISED EXPENSE BUDGET & RATE PROJECTIONS
FOR
AMBULANCE SERVICE PROPOSAL
BY
MERCY HEALTH CENTER
11-13-79
AMBULANCE SERVICE - PROPOSED EXPENSE BUDGET
OPTION 1 OPTION 2 OPTION 3 OPTION 4
DIRECT EXPENSE:
Salaries $ 248,500 $ 148,700 $ 184,200 $ 270,900
Fuel & Oil 4,900 4,900 4,800 4,800
Vehicle Maintenance/
Repairl 1,800 1,800 1,200 1,200
Equipment Maintenance/
Repair 1,800 1,800 1,200 1,200
Miscellaneous 900 900 900 900
TOTAL DIRECT 257,900 158,100 192,300 279,000
INDIRECT EXPENSE:
Depreciation, Interest,
Insurance - Bldg. 5,600 7,300 5,600 4,300
Deprec. - Equipment2 19,700 19,700 9,500 9,500
Fringe Benefits 30,800 18,400 22,800 33,600
Admin. & General 43,500 28,200 31,900 45,200
Maint. & Repairs -
Plant 5,900 7,700 5,900 4,600
Operation of Plant 7,400 9,600 7,400 5,700
Laundry 2,300 2,300 2,300 2,300
TOTAL INDIRECT EXP. 115,200 93,200 85,400 105,200
TOTAL EXPENSE
$373,100 $ 251,300 $ 277,700 $ 384,200
1MHC will maintain & repair all vehicles and equipment
2Options 1 & 2 include $10,000 depreciation on new ambulance; options 3 & 4 do not.
All options include depreciation on existing ambulances and equipment.
SAMPLE RATE PROJECTIONS
FOR
VARIOUS ALTERNATIVES
The rates shown below are for discussion purposes only. They are
based on the following assumptions:
1. 2,556 Basic Care Calls (including transfers)
375 Intermediate Care Calls
I 69 Advanced Care Calls
i3,000 Total Annual Calls
2. 10o Non -collectible Rate
3. "Self -Supporting" Options assu-le no subsidy
4. "Subsidized" Options assume a $50,000 per year front-end
subsidy by the City of Dubuque
OPTION 1:
Self -Supporting Subsidized
Total Charges $414,000 $359,000
Less Non -collectible - 41,000 - 36,000
Net Charges '373,000 323,000
Subsidy -0- + 50,000
Total Revenue $373,000 $373,000
CHARGE STRUCTURE
Rates Revenue Rates Revenue
Basic $114.50 $292,662 $ 93.00 $237,708
Intermed. 260.00 97,500 260.00 97,500
Advanced 350.00 24,150 350.00 24,150
$414.312 $359,358
OPTION 2:
Total Charges $279,000 $223,000
Less Non -collectible - 28,000 - 22,000
Net Charges 251,000 201,000
Subsidy -0- + 50,000
Total Revenue $251,000 $251,000
CHARGE STRUCTURE
Rates Revenue Rates Revenue
Basic $ 76.00 $194,256 $ 54.00 $138,024
Intermed. 181.00 67,875 181.00 67,875
Advanced 245.00 16,905 245.00 16,905
$279,036 $222,804
SAMPLE RATE PROJECTIONS FOR VARIOUS ALTERNATIVES
OPTION 3: Self -Supporting Subsidized
Total Charges $309,000 $253,000
Less Non -Collectible - 31,000 - 25,000
Net Charges 278,000 228,000
Subsidy -0- + 50,000
Total Revenue - $278,000 $278,000
CHARGE STRUCTURE
j Rates Revenua Rates Revenue
Basic $ 86.00 $219,816 $ 64.00 $163,584
Intermed. 190.00 71,250 190.00 71,250
Advanced 260.00 17,940 260.00 17,940
$309,0C3 $252,774
OPTION 4:
Total Charges $427,000 $371,000
Less Non -collectible 43,000 - 37,000
Net Charges s84,000 334,000
Subsidy -0- + 50,000
Total Revenue $384;000 $384,000
CHARGE STRUCTURE
Rates Revenue Rates Revenue
Basic $122.25 $312,471 $100.25 $256,329
Inteimed. 244.00 91,500 244.00 91,500
Advanced 335.00 23,115 335.00 23,115
$427,086 $370,854
i
AMBULANCE SERVICE PROPOSAL
BY
MERCY HEALTH CENTER
November 5, 1979
INDEX
1. Summary 2
2. Benefits Summary of a MHC operated service 4
3. Analysis of the Law - Title 25 - Advanced Emergency Medical 6
Care (and Delineation of Staffing Educational Options
based on it)
4. Staffing 12
5. Policy Formation for Ambulance Operation 19
6. Pro Forma Budgets 20
a. Operating 21
b. Capital 22
c. Rate Implications 23
7. Appendices 25
a. Proposed Traffic flow Pattern for Ambulance Garage 26
b. Proposed Ambulance Garage Blueprint 27
c. Job Description - Manager of Dubuque Ambulance Service 28
This proposal is based on the following assumptions:
1) Level of care provided, ownership, etc. is as defined in the
"assumptions used for submitting proposals" agreed upon by the Ambulance
Task Force at its October llth meeting.
2) The provisions of Title 25 of the Advanced Emergency Medical Care
Act are met, so that the City may continue to have an advanced level
of ambulance service.
3) Questions regarding professional liability insurance coverage, orderly
transfer of operating responsibility for the service, an agreeal•le "start
date," etc. can be mutually, successfully resolved in the future.
4) The service receives CON approval from the state.
.5) The City of Dubuque continues to provide initial Dispatcher service.
PROPOSAL SUMMARY
Date of Initiation of Service - March 1, 1980 (assuming CON approval by
that date).
Geographical Coverage - Same as presently covered by city -operated service.
Number of Vehicles Used - Three are recommended (two vehicles transferred
by city. Number Eleven used in ACLS services, Number Twelve used
as transfer vehicle. New ACLS vehicle purchased). Proposals
are also given for a two vehicle operation.
Staffing - Eight R.N.'s, ten basic EMT's, one Instructor and one Depart-
ment Manager will be hired. (R.N.'s will qualify as EMT -Pis
prior to initiation of service so that service will continue to
qualify as Advanced Level under state law). EMT's will advance
to EMT II level within one year.
Education - Mercy will operate an EMT -II training program to provide neces-
sary levels of skilled staff. The educational program will also
be responsible for continuing education for staff and preparing
R.N.'s for EMT-P certification.
Service Locations - Several alternate proposals are given. We recommend
consideration be given to a two -location (North - South) opera-
tion where one ACLS vehicle and the transfer vehicle would be
based at Mercy, one ACLS vehicle would be based at Xavier.
Cost and Charges - Costs and the charges necessary to cover them vary,
depending upon which option is selected on number of vehicles
in service and service location. Please refer to page 20 for sum-
mary.
Capital Expenses - This proposal contemplates that all capital costs neces-
sary for the service will be borne by Mercy as its investment
in the service. This includes the cost of constructing an
ambulance garage (for all vehicles based at Mercy) on its premises
at its expense, the cost of a new ACLS ambulance, and all neces-
sary supportive equipment. This option has been chosen because
of its advantage in lowering total community cost by maximizing
third party reimbursement. (Should this option not be chosen,
operating costs for depreciation of approximately $20,000 yearly
can be deducted.) All capital costs are delineated in the pro
forma budget section. A blueprint for the proposed ambulance
garage is also included.
Operational Policies - This proposal deliberately excludes detail with re-
gard to operating policies. It does, however, provide for the
establishment of a policy -making Board to formulate initial oper-
ating guidelines and serve as a forum for the resolution of prob-
lems on a continuing basis.
-3-
PROPOSAL SUMMARY /
Level of Service - This proposal assumes that it is the desire of those con-
cerned that the service at all times be certified and operated at
the Advanced Level as specified in Title 25 of the Advanced Emer-
gency Medical Care Act.
SUMMARY OF BENEFITS OF A MHC OPERATED SERVICE
In addition to advantages the reader may note in reading through
the proposal, we feel these additional facts are noteworthy:
*Perinatal Center - Mercy is the recognized center for
high risk maternity and neonatology care for the area.
*Trauma Center - Mercy has been officially designated
as the Trauma Center for Northwest Illinois.
*Heliport - Mercy has the only heliport which meets FAA
standards (for transfer of trauma cases to other specia-
lized centers).
*Neurosurgery - Mercy is the neurosurgical center for the
area.
*Cardiology - Mercy has the capability to do both "open
heart" and "cardiac cath" procedures.
*Emergency Psychiatric Service - all requests for psychiatric
support are provided here.
*Substance Abuse Unit - patients suffering from alcoholic or
other substance abuse are cared for at Mercy.
*C.T. Scan - patients requiring either head or full body
computerized tomographic scans may be cared for at Mercy.
*Poison Information Center - Mercy operates the poison infor-
mation center for this area.
*Same Day Surgery Program - patients qualifying for same day
surgery may have that need met here.
*Multihospital System - Mercy has experience in working closely
with other area hospitals.
*24-Hour Phaiuiacy - Mercy operates a pharmacy round-the-clock
for patient and family convenience in emergencies.
*24-Hour Respiratory Therapy Service - Mercy has trained
respiratory therapists on duty at all times.
*Full Emergency Power - Mercy has full electrical reserve
power in a disaster situation.
*Ability to Establish an EMT II Training Program - In Dubuque
only Mercy can qualify to operate such a program.
We feel that our central location (close to major streets and high-
ways), our large pastoral care staff, and our significant resources and
experience in patient and employee education are also distinct advantages
for the ambulance program.
In comparison with a city based system, the reader may wish to give
consideration to these suggested advantages:
*The opportunity for staff to keep skill levels current
to continue and broaden competency levels - increases
from their involvement in hospital activities.
*Utilizing R.N.'s as care givers results in a very broad,
high quality of care given.
*Mercy will be able to fill needed E.M.T. II positions through
operating its own E.M.T. II Training Program much more econom-
ically than the City could send staff to Iowa City.
*Comparable costs for the same quality of service delivered
through a city based service have not been analyzed, but
staffing cost offsets available to a hospital based service
have not been practical for a city based system in th past.
ANALYSIS OF THE LAW
DELINEATION OF STAFF AND EDUCATIONAL OPTIONS
FOR EITHER A CITY OR HOSPITAL -BASED SERVICE
According to the Joint Rules of the State Department of Health
and the Board of Medical Examiners, Title XXV, Chapter 132, effective
July 5, 1979:
"Ambulance and rescue squad service programs that wish to provide
Advanced Emergency Care, utilizing advanced E.M.T.-I's, advanced
E.M.T.-II's or paramedics" must comply by January 5, 1980.
A. CITY -BASED AMBULANCE SERVICE
Legislative and Educational Requirements:
Our City -Based Ambulance Service must come in compliance with the
law by January 5, 1980 since they are currently providing advanced
emergency medical care. In order to comply:
1. Personnel must submit application to the State Board of Medical
Examiners, accompanied by the required credentials, at least 30
days in advance of the next scheduled certification exam. This
examination includes completion of modules #1 through ##6 and
module #15 of the D.O.T.'s Paramedic Guide and certification
in Advanced Cardiac Life Support (A.C.L.S.).
Content of these Modules:
##1 Role and the Responsibility of the E.M.T.
#2 Patient Assessment
##3 Shock and Fluid Therapy
#4 General Pharmacology
##5 The Respiratory System
#66 The Cardiovascular System
#15 Telemetry and Communication
The certification test involves a practical and written exam; a 75%
total accumulative score must be obtained. In the past, fragmented com-
ponents have been presented to the city ambulance personnel. In order to
challenge the E.M.T.-II test, approximately 16 hours of review sessions
would be appropriate.
2. The service itself shall complete and submit the required applica-
tion forms to the State Department of Health 60 days prior to the
requested effective date for the establishment of the program.
Staffing patterns that reflect that at least one E.M.T.-II is in
constant attendance when Advanced Emergency Medical Care is being
provided must also be documented. The source of Medical Control
must also be outlined. Medical Control is defined as:
a. Medical Director (licensed physician).
b. Supervising Physicians (one @ each hospital. Certification in
A.C.L.S. is a mandatory requirement).
c. Physician Designee at each hospital where patients are
delivered (a Physician Designee may be an R.N. certified
in A.C.L.S. and responsible for communication with ambu-
lance personnel when Advanced Emergency Medical Care is
being delivered in the field).
Currently, the Dubuque Ambulance Service is capable of providing
Advanced Emergency Medical Care using Ambulance ##11. Ambulance ##12,
being staffed with Basic E.M.T.'s not currently trained in A.C.L.S.,
is not capable of providing a service where starting I.V.'s, defibril-
lating, administering medications, inserting esophageal airways, etc.
is required.
In order for the existing city -based ambulance to become compliant
with the law by January 5, 1980, personnel attending patients on both
Ambulance ##11 and #12 must be certified to the E.M.T.-II level prior �o
this date. There are several ways this can be accomplished.
(Please refer to the chart entitled, "City -Based Ambulance Service"
on the following page.)
co
CITY -BASED AMBULANCE SERVICE
>TAFF ING
�IIONS
TRAINING
TIME FACTOR
DATE OF I
COMPLIANCE
LEGAL IMPLICATIONS/REMARKS
Prepare
le 6 EMT's
;o currently
:aff #11 to
lallenge the
!T-II exam.
:suming
.ese 6 EMT's
ss both the
itten and
actical
ams, they
y then be
spersed
ong 6 Basic
T's to pro-
de 24 hour
T-II cover-
e on both
its.
General review of
modules #1-#6 and
##15. Review A.C.L.S.
materials.
/
30 days
January 5, 1980
After this date
the challenge
With a staffing pattern such as this, we must
first assume; 1) All 6 personnel can success-
fully challenge the EMT -II exam (25% failure-
rate statewide) 2) Circumstances involving
illness, vacation, LOA's, etc., can be
immediately replaced by another certified EMT-:
process ends for
EMT's.
If there is not constant, 24 hour EMT -II
coverage on both ambulances, the State
Department of Health may revoke the service's
license to provide Advanced Emergency Medical
Care. Since the certified delivery of advancec
care is dependant upon both a current service
program certificate as well as the staffing of
certified personnel, the level of medical care
would revert to a Basic service. In order to
again provide an Advanced Level of Emergency
Care, the service program must re -submit an
application for certification to the State
Department of Health. Consequently, the
community would be without Advanced Life
Support Services for a minimum of 60 days.
Recruit
eviously
rtified
T-II's from
her service
Iowa.
Familiarize personnel
with the geographical
surroundings of the
Dubuque -area.
Immediate
January 5, 1980
Additional sources of EMT -II personnel may be
obtained in this manner in order to assure
adequate EMT -II coverage.
Recruit
T-II's from
her states
d make
rangements
r these
ople to
allenge•
:oa' s EMT-I1,--
am -
Geographical review,
assess knowledge of
personnel's medical
background.
30 days
January 5, 1980
The challenge
As above
process ends for
EMT's.
CITY -BASED AMBULANCE SERVICE
rAFFING
'IONS
TRAINING
TIME FACTOR
DATE OF
COMPLIANCE
LEGAL IMPLICATIONS/REMARKS
Provide
-II trainir
Basic EMTs
This type of Advanced
training may only be
done at an approved
training facility.
"The following units
shall be available
for trainee experienc
for each training
program"
-Emergency services
with an average of
at least 1,000 total
visits per month.
- ICU or CCU or both
-Operating room and
Recovery Room
- IV or phlebotomy
team, or other
method to obtain
IV experience'
- Pediatric unit
- Labor and delivery
suite and newborn
nursery
- Psychiatric unit
-Morgue
5 months
Following grad-
uation
This is an alternate way to provide additional
EMT -II personnel, however, the training time
and costs involved may limit the feasibility
of this option. Currently, the nearest
approved training facility is located in Iowa
City at the University of Iowa.
B. HOSPITAL -BASED AMBULANCE SERVICE
As we commented previously, any ambulance service that provides an
Advanced Level of Emergency Care prior to July 5, 1979, and intends to
do so into 1980, must be certified by the Iowa State Department of Health
before January 5, 1980. As we have seen, this would be a difficult task
for a City -Based Ambulance Service to accomplish. What would be the
legal implications for a Hospital -Based Ambulance Service? According
to a representative from the Iowa State Department of Health, the development
of a hospital -based service, utilizing new personnel, would be viewed as
a new service. Therefore, the date of compliance mandated by Advanced
Emergency Medical Care legislation, would be the date the new service
begins providing advanced levels of care in the field by EMT's. If,
however, RN's would be utilized as the personnel rendering advanced levels
of emergency care, the service would be viewed as an extension of existing
hospital service. The RN's providing direct patient care would be governed
by the Nurse Practice Act, not Advanced Emergency Medical Care legislation.
In order for a Hospital -Based Ambulance Service to provide advanced
emergency medical care, various staffing and educational options are
available.
(Please refer to the chart entitled, "Hospital -Based Ambulance Service"
on the following page.)
HOSPITAL -BASED AMBULANCE SERVICE
`;1AFFING
)I'TIONS
TRAINING
TIME FACTOR
DATE OF
COMPLIANCE
LEGAL IMPLICATIONS/REMARKS
1 Service
:affed
cclusively
7 RN's
-16 hour ACLS Course
-48 hour coronary
care course
-36 hour general
review session incl
basic extrication
techniques, comm-
unication, driving
ambulance protocals
etc.
30 days for training
Not governed by the
Advanced Emergency
Medical Care
legislation
An entirely RN staff would not be governed by
Advanced Emergency Medical Care legislation
since all direct patient care would be
delivered by the RN. All such acts would be
governed by the Nurse Practice Act. The
service would be an extension of existing
hospital emergency services.
Split
:affing,
;ing one RN
id one Basic
As above for RN's
For the EMT:
-Orientation
-Mechanics of settint.
up an IV
-Attaching the
monitor
-Preparing the
esophageal airway
•
30 days training for
all
•
Not governed by the
Advanced Emergency
Medical Care
legislation
Again, RN's would not be governed by Advanced
Emergency Medical Care legislation. Since
_Basic EMT's will not provide advanced care,
they are also exempt from Advanced Emergency
Medical Care legislation.
RN Responsibilities: IV insertion, arrhythmia
IT per unit
recognition, defibrillation, the administratioi
of medications and any further advanced life
support care.
EMT Responsibilities: Assisting the RN with
advanced care (attaching IV's, attaching
monitoring pads, preparing intubation
equipment, CPR, etc.) This EMT will be
responsible for the basic needs of the patient
while the RN will be ultimately responsible
for any advanced life support measures.
Split
affing,
ing one RN
d one
[T-II per
it
T-II's may
recruited)
way prev-
As above for RN's
However, when
advanced EMT's are
providing an advance.
level, of care, the
RN's must also be
certified and
prepared to challeng-
AI -II or EMT-P exa
RN's: Minimum of 30
days
EMT's: If previously
certified in Iowa they
could begin immediatel
If recruited from .-.
another state-30 days
If advanced training
is required-5 months
A minimum of one
certified RN or one
-
certified EMT -II
• must staff each unit
when the hospital -
.based service begin -
operation
STAFFING
To initiate the hospital based ambulance service we will hire eight
R.N.'s and ten Basic E.M.T.'s. The first month of employment will be
classroom and clinical instruction. Following this we will staff each
A.C.L.S. ambulance with one R.N. capable of rendering advanced care and
one E.M.T. as support. Their duties will be:
R.N. - Advanced Care:
I.V. insertion
Administer medications
Arrhythmia recognition
Defibrillation
Intubation
E.M.T. - Support or Basic Care:
Attach monitor electrodes
Set up I.V.'s
Basic Life Support - C P.R.
Prepare equipmtnt
Bandaging
Splinting
Extrication
The transfer vehicle will be staffed with two Basic E.M.T.'s initially.
We believe that this will be a satisfactory staffing pattern because:
1. More accurate assessment of patient requirements for transfer
can be made by R.N. taking the request call.
2. The A.C.L.S. ambulance can be dispatched if, when arriving at
the scene, it is deteLmined by E.M.T. that the patient requires
advanced care.
3. The E.M.T. will be receiving education towards E.M.T. II level.
If this is not satisfactory the transfer vehicle can be staffed with
an R.N. and E.M.T. for the first year. After the first year it will be
staffed with one E.M.T. and one E.M.T. II.
During the first year of operation the R.N.'s will be educated to the
Paramedic level and nine of the Basic E.M.T.'s will be educated to the
level of E.M.T. II. This will be done by the unit instructor following
application and certification of the educational program.
It will be necessary to establish an E.M.T. II training program for
the following reasons:
1. The difficulty in recruiting presently Certified E.M.T. II's.
2. The closest training program presently is in Iowa City.
The program is five months in length. The cost of sending
E.M.T.'s to the program is $500.00 per E.M.T. registrant plus
travel, lodging, etc. It would also be difficult to recruit
persons who would be willing to be away from Dubuque for five
months.
Several staffing patterns were reviewed and assessed. Staffing with
all registered nurses was eliminated because of cost and possible recruit-
ment problems. An all E.M.T. II staff was also eliminated due to recruit-
ment problem and reduced capability for their use in the hospital, causing
higher cost to the service.
The attached detailed personnel budget reflects a combination staff
of R.N.'s and E.M.T.'s. It is the most cost effective staffing pattern
and provides advanced care on three vehicles by year end. This triples
the advanced emergency care available to the city.
Staffing is provided for two A.C.L.S. ambulances at all times and one
transfer vehicle between 7:00 A.M. and 4:00 P.M. Personnel work twelve
hour shifts and have every other weekend off. (See attached schedule).
We have also included a breakdown of costs, education, etc. for an
option where all three vehicles would be Mercy based, and two cost break-
downs for a two vehicle system.
MERCY HEALTH CENTER NURSING SERVICE TIME SCHEDULE Unit
Name
Mon
Tue
Wed
Thur
Fri
Sat
Sun
Mon
Tue
Wed
Thur
Fri
Sat
Sun
_
R.N.
A.C.L.S!!l
8a
8
E.M.T.
8a
8
8
8
__
8
8
8
-_
_
R.N.
A.C.L.S!12
8a
88
__
8
E.M.T.
8a
8
-
8
8
8
8
8
R.N.
A.C.L.S.#1
8.
8
___
8
8
__
8
8
8
E.M.T.
8.
8
8
8
8
8
8
R.N.
A. C. L. S. # 2
8.
8
___
8
8
__
8
8
8
E.M.T.
8.
8
__
8
8
__
8
8
8
R.N.
A.C.L.S.#1
__
8a
8
8
__
8
8
__
8
8
E.M.T.
__
8a
8
8
__
8
8
8
8
R.N.
A.C.L.S./2
__
8a
8
8
8
1 8
___
8
8
E.M.T.
__
8a
8
i 8
__
8
8
___
8
8
R.N.
A.C.L.S.%1
8
8
8
__
8
8
-__
8
8
E.M.T.
8.
8
8
8
8
___
8
8
R.N.
A.C.L.S.#2
__
8.
8
8
8
8
__
8
8
E.M.T.
8
8
1 8
8
8
8
8
Transfer
_
E.M.T.
7-4
7-4
7-4
7-4
7-4
__
7-4
7-4
7-4
7-4
7-4
E.M.T.
7-4
7-4
7-4
7-4
7-4
7-4
7-4
7-4
7-4
7-4
•
0A104
-14-
PERSONNEL BUDGET
Option #1
3 VEHICLES - 1 Transfer at Mercy
1 A.C.L.S. at Mercy
1 A.C.L.S. at Xavier
VEHICLES
STAFFING AT YEAR END
COST
EDUCATION
OF SET
1 Transfer
1 E.M.T. )80
$ 9,120
None
Transfer Lab/Pharm/Surger
hours
1 E.M.T. II )
11,440
Done by Education Inst.
Equip. 2 hours per day
$2,912.
R.N. Admitting
1 A.C.L.S.
4 R.N.'s )84 hours
$ 63,772
Done by Education Inst.
70 hours = $13,286.
4 E.M.T.'s )
50,232
Done by Education INst.
Nite Desk Clerk
N.S. _ $16,744
1 A.C.L.S.
4 R.N.'s. )84
$ 63,772
Done by Education Inst.
None identified
hours
4 E.M.T. II)
50,232
Done by Education INst.
None identified
1.5 FTE Replacement
23,914
1 Manager
19,600
1 Education Inst.
$ 17,294
Subtotal
$309,376
Offset
32,942 •
Total
$276,434
$32,942
Option #2
PERSONNEL BUDGET
3 VEHICLES LOCATED AT MERCY!
VEHICLES
STAFFING AT YEAR END
COST
EDUCATION
OFFSET
Transfer for Pharmacy/
1 E.M.T. ) 80 hours
$ 9,120
None
Lab/Surgery 2 hrs./day
Transfer 1
1 E.M.T. II)
11,440
Done by Education Inst.
$2,912
A.C.L.S. #1
4 R.N. E.M.T.-P) 84
$ 63,772
Done by Education Inst.
R.N. admitting
4 E.M.T. II )hours
50,232
Done by Education Inst.
70 hours=$13,286
•
/
A.C.L.S. #2
4 R.N. E.M.T.-P)84
$63,772
Done by Education Inst.
E.R. Nurse 16 hrs/day
4 E.M.T. II )hours
50,232
Done by Education Inst.
$42,515. R.N. Float
Pool-8 hours=$21,257
Orderly Surgery
.
80 hours=.$11,960
Night DC, NS 112 hours=
1.5 F.T.E. Replacement
$23,914
$16,744
1 Manager
19,600
E.M.T. II 168 hours
in Allied Health=$24,000
1 Education Instructor
17,294
Subtotal
$309,376
Offset
132,674
Total
$176,702
$ 132,674
Option ##3
PERSONNEL BUDGET
2 Vehicles Located at Mercy!
VEHICLES
STAFFING AT YEAR END
COST
EDUCATION
OFFSET
1 A.C.L.S.
4 R.N.'s )84
$ 63,772
Done by Education Inst.
R.N. Admitting 70 Hours
hours
4 E.M.T.'s)
50,232
$13,286
Nite Desk Clerk N.S.
$16,744
1 A.C.L.S.
4 R.N.'s )84 Hours
$ 63,772
Done by Education Inst,
R.N. Float Pool 8 hours=
4 E.M.T.'s)
50,232.
$21,257
R.N. - E.R. 8 hours=
$21,257
1.5 F.T.E.
23,914
E.M.T. to Allied Health
Replacement
84 Hours=$12,012
1 Manager
19,600
1 Education Instructor
17,294
Subtotal
$ 288,816
Offset
84,556
Total
$ 204,260
Total $84,556
Option #14
co
PERSONNEL BUDGET
2 VEHICLES - 1 A.C.L.S. at Mercy
1 A.C.L.S. at Xayidr
VEHICLES
STAFFING AT YEAR END
COST
EDUCATION
OFFSET
1 A.C.L.S.
4 R.N. )84
$ 63,772
Done by Education Inst.
R.N.,Admitting 35 hours=
hours
4 E.M.T,t s)
$ 50,232
$6,643
Nite Desk Clerk N.S.-P.T.=
$8,372
1 A.C.L.S.
4 R.N.'s 84 hours
$ 63,772
Done by Education Inst.
None identified
4 E.M.T. II
50,232
Noue identified
1.5 F.T.E.
$ 23,914
Replacement
1 Manager
$ 19,600
1 Education Instructor
17,294
Subtotal
288,816
Offset
15,015
Total
$ 273,801
$ 15,015
l
POLICY FORMATION
Most of the operating decisions necessary for a smoothly function-
ing service can be made by the manager responsible for the department
and reviewed for budget implications with a city fiscal representative.
However, we believe that overall policy guidance for ambulance operation
should be more broadly based. We would suggest the formation of an
Ambulance Service Council with the following membership:
Two representatives from the City of Dubuque appointed
by the City Manager.
One representative from each of the three hospitals.
One representative from the area nursing homes.
We would suggest the group met on an "as needed" basis, be chaired
by one of the two City representatives, and have as staff the Manager
of the Department. As owner, the City should designate scope of authority,
etc. for the Council.
PRO FORMA BUDGETS
AMBULANCE SERVICE - PROPOSED EXPENSE BUDGET
DIRECT EXPENSE:
Salaries
Fuel & Oil
Vehicle Maintenance/
Repair1
Equipment Maintenance/
Repair
Miscellaneous
TOTAL DIRECT
INDIRECT EXPENSE:
Depreciation, Interest,
Insurance - Bldg.
Deprec.- Equip.
Fringe Benefits
Admin. & Genl.
Maint. & Repairs
Plant
Operation of Plant
Laundry
Nursing Admin.
TOTAL INDIRECT EXP.
TOTAL EXPENSE
OPTION 1
$ 276,400
4,900
OPTION 2 OPTION 3 OPTION 4
$ 176,700 $ 204,300 $ 273,800
4,900 4,800 4,800
1,800 1,800 1,200 1,200
1,800
900
285,800
5,600
19,700
34,200
53,200
5,900
7,400
2,300
22,700
151,000
$ 436,800
1,800 1,200 1,200
900 900 900
186,100 212,400 281,900
7,300
19,700
21,900
36,200
7,700
9,600
2,300
14,700
119,400
$ 305,500
1MHC will maintain & repair all vehicles and equipment
5,600
9,500
25,300
38,900
5,900
7,400
2,300
16,500
111,400
$ 323,800
4,300
9,500
33,900
50,800
4,600
5,700
2,300
21,900
133,000
$ 414,900
2Options 1 & 2 include $10,000 depreciation on new ambulance; Options 3 & 4 do not.
All options include depreciation on existing ambulances and equipment.
AMBULANCE SERVICE - PROPOSED CAPITAL BUDGET
DEPRECI- ESTI-
ATION MATED
STATUS' LIFE
I. HOUSING FACILITY & EQUIPMENT
Building (Garage, Office,
Classroom, Lounge) D-P (30) $254,000
Remote TV Camera & Monitor ( 8) 500
Office Furniture & Equipment (10) 1,300
Classroom Furniture & Equipment (12) 1,900
Lounge Furniture (12) 500
Lockers D-F (18) 1,400
I. TOTAL
II. EDUCATIONAL EQUIPMENT
2 Recording "Annies" @ $1,200 (10) 2,400
1 Non -fade Oscilloscope
Arrythmia Trainer (10) 1,200.
Other Equipment (10) 1,400
II. TOTAL
III. DEPARTMENTAL EQUIPMENT
Coveralls, Coats, Raingear D-F ( 2) 1,700
4 Motorola Pagers @ $450 D-F ( 5) 1,800
2 Recorders & Tapes D-F ( 5) 900
III. TOTAL
1
2
IV. EQUIPMENT FOR EXISTING AMBULANCES
Automotive Tools & Equipment (10) 3,000
1 Hand Held Radio D-F ( 5) 1,500
2 "Mast" Trousers @ $350 D-F ( 3) 700
IV. TOTAL
V. NEW AMBULANCE & EQUIPMENT2
3rd A.C.L.S. Ambulance D-F ( 4) 31,000
Life Pak V D-F ( 5) 8,650
1 Hand Held Radio D-F ( 5) 1,500
Cot & Splints D-F ( 7) 1,200
Suction & Ventilator D-F ( 5) 500
"Mast" Trousers D-F ( 3) 350
Stair Chair & Stretcher D-F (10) 300
V. TOTAL
$ 259,600
5,000
4,400
5,200
43,500
GRAND TOTAL $ 317,700
D-P indicates PARTIAL depreciation charged to Ambulance Service
D-F indicates FULL depreciation charged to Ambulance Service
MHC recommends purchase of a 3rd ACLS ambulance & supporting equipment. The
existing 1975 ambulance would then be used as a transfer vehicle and as
a backup for the other two ACLS ambulances. In the future, MHC will purchase
new vehicles & equipment as needed; the oldest vehicle would always serve as
the transfer vehicle.
-22-
SAMPLE RATE PROJECTIONS
FOR
VARIOUS ALTERNATIVES
The rates shown below are for discussion purposes only. They are based
on the following assumptions:
1. 2,556 Basic Care Calls (including transfers)
375 Intermediate Care Calls
69 Advanced Care Calls
3,000 Total Annual Calls
2. 10% Non -collectible Rate
3. "Self -Supporting" Options assume no subsidy
4. "Subsidized" Options assume a $50,000 per year front-end
subsidy by the City of Dubuque
OPTION l: Self -Supporting Subsidized
Total Charges $486,000 $430,000
Less Non -collectible - 49,000 - 43,000
Net Charges 437,000 387,000
Subsidy -0- + 50,000
Total Revenue $437,000 $437,000
CHARGE STRUCTURE
Rates Revenue Rates Revenue
Basic $142.50 $364,230 $120.50 $307,998
Intermed. 260.00 97,500 260.00 97,500
Advanced 350.00 24,150 350.00 24,150
$485,880 $429,648
OPTION 2:
Total Charges $340,000 $284,000
Less Non -collectible - 34,000 - 28,000
Net Charges 306,000 256,000
Subsidy -0- + 50,000
Total Revenue $306,000 $306,000
CHARGE STRUCTURE
Rates Revenue Rates Revenue
Basic $100.00 $255,600 $ 78.00 $199,368
Intermed. 180.00 67,500 180.00 67,500
Advanced 245.00 16,905 245.00 16,905
$340,005 $283,773
SAMPLE RATE PROJECTIONS FOR VARIOUS ALTERNATIVES
OPTION 3:
Total Charges
Less Non -collectible
Net Charges
Subsidy
Total Revenue
CHARGE STRUCTURE
Self -Supporting Subsidized
$360,000
- 36,000
324,000
-0-
$324,000
$304,000
- 30,000
274,000
+ 50,000
$324,000
.Rites Revenue Rates Revenue
Basic $1Cf.O0 $270,936 $ 84.00 $214,704
Intermed. 1:' J0 71,250 190.00 71,250
Advanced 2f>.` JO 17,940 260.00 17,5+0
$360,126 $303,894
OPTION 4:
Total Charges $461,000 $406,000
Less Non -Collectible - 46,000 - 41,000
Net Charges 415,000 365,000
Subsidy -0- + 50,000
Total Revenue $415,000 $415,000
CHARGE STRUCTURE
Rates Revenue Rates Revenue
Basic $135.50 $346,338 $114.00 $291,384
Intermed. 244.00 91,500 244.00 91,500
Advanced 335.00 23,115 335.00 23,115
$460,953 $405,999
APPENDICES
EXIST I N C EM ER.
ENTRANCE
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-4 (18K
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=
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1 STORAGE CA
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).. o"
PROFUSE) 1,ME31:3!. /2, riCE
SCALE: " i! 0
DATE,
APPROVED BY:
RAWN �V.,
jsED
JOB DESCRIPTION
MANAGER OF DUBUQUE AMBULANCE SERVICE
GENERAL STATEMENT:
The Manager of the Dubuque Ambulance Service involves the continued
'development, implementation, maintenance, and ongoing evaluation of the
service and personnel on a twenty-fout hour basis. Of prime importance
is the development of each staff member to reach optimal professional
practice and autonomy.
This role encompasses both managerial and educational responsi-
bilities.
JOB FUNCTIONS:
A. Qtiality of Patient Care
1. Assigns primary patient responsibility.
2. Evaluates quality of patient care by:
a. Review of ambulance records
b. Ambulance calls critique with staff
c. Ambulance Advisory Committee
d. Joint meetings with Emergency Room staff members
e. Personnel observation and evaluation in the field
3. Collaborates with staff to develop relevant protocols
4. Works a rotation of shifts to evaluate care delivery.
5. Promotes patient -centered conferences by either conducting or
facilitating same.
6. Collaborates with physicians to enhance a collegial approach to
patient care.
7. Researches, implements and evaluates with staff, new approaches
to patient care.
8. Collaborates with Head Nurse of Emergency Room regarding methods
to improve quality of patient care.
B. Coaching and Development
1. Accompanies individual staff members on ambulance calls to assess
knowledge and skills, plan and initiate developmental process.
2. Acts as resource to staff:
a. Validates decision making
b. Consults in patient care plan formulation
c. Instructs in skirls.
d,. Teaches theory -nursing process; disease processes
e. Teaches/validates problem -solving techniques
3. Identifies developmental needs of staff.
4. Assists staff in developing plan for individual professional growth -
goal setting.
5. Coordinates educational and experimental opportunities for individual
staff through unit instructor.
6. Assists with orientation of new personnel.
7. Evaluates unit personnel on a scheduled basis.
8. Collaborates with other managers in the evaluation of staff
assigned to other units.
9. Makes rounds with individual staff members to assess knowledge
and skills, plan and initiate developmental process.
-29-
C. Self -Development
1. Identifies own developmental needs.
2. Attends management classes.
3. Participates in unit group meetings.
4. Prepares presentations, informal and formal classes regarding
emergency care..
5. Seeks out resources to validate own decision -making and problem
solving techniques.
6. Seeks feedback and criticism from colleagues.
7. Utilizes clinical opportunities to advance and/or to apply knowledge
and skill.
8. Attends skill training and staff development programs within hospital,
Maintains current knowledge ofemergency trends through journals.
10. Attends physician lectures regarding disease processes, Med. and
Nursing management.
11. Attends university extension classes.
12. Attends community educational programs.
D. Direct Patient Care
1. Assumes on a continuum primary patient care responsibility which
includes:
a. care giver
b. care planner
c. patient teacher
d. communicator across disciplines
_e. coordinator of care.and other patient activities
2. Assists other staff in their patient care
3. Performs specific procedures where individual expertise demonstrated
(e.g., IV's, ABG's).
E. Budget/Finance Management
1. Prepares with resource input, unit budget for fiscal year.
2. Determines adequate number and distribution of F.T.E.'s to meet
unit staffing needs.
3. Determines standard amount of equipment and supplies needed for
unit operation.
4. Reviews budgetary analysis reports to assess unit effectiveness
and/or identify problem areas.
5. Communicates budgetary goals and goal status to staff.
6. Sets staffing limits to reach productivity goal.
7. Validates overtime.
8. Checks time cards of unit personnel.
9. Approves overtime.
F. Administrative
3. Negotiates management objectives yearly with Director of
Service.
2. Reviews and asseses management objectives on a monthly basis with
the Director of Service.
3. Communicates hospital plans, policies, goals, and objectives to
staff.
-30-
F. Administrative (continued)
4. Communicates staff's (unit's) goals and objeqives, plans
with Director of Service.
5. Assumes weekend ''House Supervision" on rotating basis.
QUALIFICATIONS:
R.N. with Coronary Care experience
Advanced Cardiac Life Support instructor
Demonstrates leadership ability
Teaching experience preferred
E.M.T. certification preferred
G. Community Responsibilities
1. Member Tri-Hospital Emergency Room Committee
2. Meets with Finley and Xavier personnel twice yearly
3. Civil defense involvement
4. Establishes regular communication with Fire Department and
.law enforcement agencies.
5. Attends E.M.S. Council and cooperates with Task Forces.
6. Member Tri-Hospital
7. Promotes and maintains good interpersonal relationships with
patients, families, and public.
8. Participates in community health programs
• H. Staffing/Staff Selection
1. Selects personnel. .for hire in accordance with hospital policy.
2. Plans staffing on a 24 hour basis.
.3. Monitors patient acuity to plan realistic staffing.
4. Disciplines and terminates personnel in accorance with
hospital policy.
5. Prepares and/or approves time schedules.
6. Makes out daily assignment df duties.`
I. Research
1. Promotes nursing research (e.g. patient care, staff evaluation,
budget management, etc.)
2. Implements research findings when appropriate.
J. Safety/Security
1. Promotes safety principles in patient care delivery.
2. Reports safety hazard to appropriate department for correction
(Environmental Services, Maintenance).
3. Assures compliance with regulatory agencies, and hospital policie._,
(e.g. narcotics, crash carts, keys, fire drills, and disaster plan, etc.)
4. Assures compliance with infection control policies on unit.
5. Assures compliance with Iowa Law regarding ambulance service.
0
3
9
Z
rt.
w
COMMENTS BY AMBULANCE STUDY TASK FORCE MEMBERS
AMBULANCE STUDY TASK FORCE ANALYSIS
It seems appropriate to review the 23. April, 1979 Outline of Study
of Ambulance Service as prepared by Ken Gearhart. A few basic points
are established from which the ambulance study discussions and decisions
evolved.
The purpose of the study was "to review and evaluate ambulance services
provided the citizens and visitorsOf the city of Dubuque and make
appropriate recommendations:
The objective(s) identified was "to provide the community with the
highest possible level of ambulance service consistent with a
'reasonable level of risk and the ability of the community to pay
for it".
The proposed areas to be studied and evaluated included, but were not
limited to,
(1) Level of service
(2) Scope of service
(3) Provision (Provider) of service
(4) Financing of service
(5) Ambulance personnel issues
(6) Impact of state regulations on ambulance service
It appears important to use the present service and its development
as a frame of reference. Currently, the ambulance service is provided
by the city of Dubuque Fire Department to Dubuque and surrounding
areas. Two fully equipped first --line ambulances and one reserve
vehicle are maintained by the fire department. The primary ambulance
(Ambulance #1) is operated by 6 Ambulance Driver/Attendants. The
second ambulance (Ambulance #2) and the reserve vehicle are manned
by on -duty firefighters, Ambulance #2 and the reserve vehicle are
used for emergencies when Ambulance #1 is out.
The ambulance service is regulated and licensed under City Code Chapter 18,
Sections 18-16 through 18-56. Service area and rates are established by
the code in sections 18-52 through 18-55. The current rate is $35 for a
city call and $40 plus a $.50/mile charge for an out -of -city call. A city
subsidy is added to the revenue from rate charges to meet the total
expense of the ambulance service.
With this background information the task force proceeded with some initial
considerations. The implications of the 5. July, 1979 state regulations
regarding ambulance service operation were studied. The new regulations
establish the standards for training and certification of ambulance
personnel. These regulations affect service programs which choose to
provide advanced emergency medical care, such as that presently provided
by the city of Dubuque.
The consensus of the task force was to operate an EMT II minimum service
level, with the scope and area of service to remain the same. Because of
revenue considerations, all facets of the present ambulance service
(i.e., emergency and transfer calls) are needed to support the program.
To provide such service in the future, the use and maintenance of at
least 2 fully equipped ACLS ambulances was deemed necessary.
The analysis of the provision of service (i.e., Ano could or should
provide the service) included an investigation of city, private and
hospital -based operations. No apparent private agency was available
to provide an EMT II level of service. The city of Dubuque and each
of the three city hospitals presented a number of options for the
provision of ambulance service.
After much consideration and discussion, the majority of the task force
membership voted in favor of a Mercy Health Center proposal over other
hospital and city proposals. This proposal would provide a service
maintaining two fully equipped ACLS ambulances operating 24 houL-5 per
day, plus an additional ACLS operating Monday through Friday between
7:00 a.m. and 4:00 p.m. for the purpose of transfer calls only.
I am supportive of, and firmlyicommitted to, the task force decision.
serve
While the present ambulancellis good, the time may have come to try to
expand upon that service an'd provide an even higher level of coverage
to the Dubuque area citizenry. This appears to be most easily available
through a hospital -based operation. The Mercy proposal endorsed offer
the highest level of care for the least amount of monetary expense.
A good case can be made for the value of operating an ambulance service
through a medical institution. Within a medical setting, there can be
a more natural development of individual specialization and progression
of total ambulance service. Ambulance personnel (EMTs) working out of
a hospital environment undergo constant health -related. education. EMTs
in a hospital are part of a total medical working staff, performing
daily duties related to the health field. The resource pool of
available personnel is increased because of the larger employee base
in a hospital as opposed to the city fire department. Scheduling
of personnel becomes easier because of varying staffing patterns and
working shifts within a hospital environment.
The utilization of ambulance personnel in other working areas of a
hospital serves as an offset, thereby reducing the total ambulance
service expense. Hence, the ambulance operation through a hospital
becomes a more cost efficient one than that through a municipal
government agency.
A city of Dubuque -owned, hospital -operated ambulance service would
still allow the city to have a handle on the operation. The control
of the level and quality of service could be obtained through an
exclusive hospital -city contract. In addition, state legal reguire-
ments for emergency medical service certification would mandate a
certain minimum operational service level. A medical environment
might be more conducive tothe observance of present and possible
additonal future state regulations.
The creation of a city ambulance commission to oversee policies and
procedures for a hospital -based ambulance service should alleviate
any problems or questions that might arise. There should be little
difficulty in insuring the interests of other hospitals or groups.
Specific procedures should be established to observe patient hospital
preference or to follow geographical zones.
Dispatching functions could continue through the city, with the hospital
scheduling routine transfers. The fire department could continue to
respond to resuscitator calls and a good working relationship between
professional firefighters and ambulance personnel should be expected.
The current rate structure must be revamped regardless of what service
is provided, and by whom. It seems favorable and almost imperative to
keep rates at as low a level as possible. While it ideal to suggest a
self-supporting operation of the ambulance service, the question of a
city subsidy must be raised. It can be argued that a city subsidy using
tax dollars is a type of "insurance policy" assumed all possible users.
Others contend that the full cost of service should be borne by the
individual user. If a city subsidy is appropriate for a privately
operated service, it should certainly be considered as a means to reduce
overall ambulance rates. Subsidies on the part of other jurisdictions
should be investigated and encouraged. The possible application for
funds from other government sources for acquisition of additional equip-
ment or improvement of service should be pursued.
This suggested movement of ambulance service base from a city fire
department operation to a hospital operation must be accompanied by
an analysis of the nature and purpose of municipal governments and
private agencies. The necessity of some type of emergency medical
service is a given; the provision and level of service is subject to
continual debate. It is important to look at the level of care preferred
and the cost of that care versus the underlying risk factor.
The task force's decision to place the ambulance service at Mercy Health
Center was based, and should be judged, on long-term rather than
immediate benefits to the community. Initial difficulties accompanying
any change should be expected. Challenges from medical, legal and
public sources will be forthcoming. However, solid support from all
factions of the service area is necessary to provide for the ultimate
good of citizens of Dubuque and surrounding areas.
Ann E . Sweeney
Don Allendorf
jack Shaffer
January 1, 1980
In my opinion, the city could maintain the present ambulance service
and alleviate a number of identifiable problems. However, an increase
in care coverage through the maintenance of two fully equipped ACLS
ambulances is desireable and appears justifiable. Anything less than
the present service would be a tremendous loss.
A number of city options for ambulance service came before the task
force. Several would in no way upgrade the present service. Only
option #5 meets the minimum level of care suggested by the task force,
that of two ACLS vehicles. Such an option is an expensive alternative
and perhaps too great a cost for the city.
Several compromise options that fall somewhere between the present
service and the two vehicle proposal were arrived at. However, none
seems to be an easily workable alternative because of administrative,
personnel and scheduling problems.
Option #7, alternating the role of ambulance driver/attendant and fire-
fighter, was perhaps the most viable. However, I have a great deal of
reservation with the dual role prospect. The jobs of firefighter and
ambulance driver/attendant are two distinctly different ones; each is
a profession in its own right. Hopefully, those performing the
functionsof ambulance driver/attendants would be doing so because of
a genuine interest in the nature of the work and not because of any
wage incentive offered to pursue the assignment. The education and
training necessary for certification as an EMT at any level should
be borne by the individual and should eventually be a pre -condition
of employment as an ambulance driver/attendant.
An ambulance commission would probably not be necessary with any type
of city -operated service since problems could be dealt with directly
through the fire department, city manager and city council.
Ann E. Sweeney
Don Allendorf
Jack Shaffer
January 1, 1980
As a member of the Task Force representing the majority
of transfer calls currently made by the City Fire Department
service, I endorse the recommendation made by our committee
to have a city owned Ambulance Service manned and operated
by Mercy Hospital.
If the council should reject the recommendation of the
Task Force and retain the service in the Fire Department,
I would be in favor of 2 ALC ambulances on duty. One could
be responsible for emergency calls and a second vehicle
would be responsible for transfer duties. This, I know,
would be a costly operation - requiring 12 drivers.
If the council votes to have the Ambulance Service remain
as is, I would endorse a private firm doing Transfer Service.
I realize the city would lose the revenue from such an arrange-
ment because 55% of ambulance service rendered now is from
transfer calls. The present service of using the No. 11
ambulance for all transfers and emergencies with No. 12 as
backup on emergency calls is not adequately meeting the
needs of the transfer customer. There are delays up to as
many as 4 hours before the ambulance can respond. The current
ambulance personnel feel there is a need for 2 ambulances to
be operating.
Because the Task Force, in making their recommendation,
carefully considered various options, I affirm my vote for
the Mercy Option 2.
Patricia Gabrielson
Nursing Home Representative
January 10, 1980
This minority report is prepared by Gary Rieniets, Administrative Assistant at
Xavier Hospital, and a member of the Ambulance Task Force.
The following are some points that I feel are important and should be a part of
the total report to the City Council. I am e:,pressing concerns that may adversely
effect the hospital I represent or the service as I see it now.
1. The Task Force report refers to a thirteen member commission to be set up whose
purpose is, among many things, to protect the interest of the other two hospitals
to assure they receive their share of the emergency type business. I simply do not
believe that the commission can control the impact that a hospital based ambulance
service will have on the other two hospitals in Dubuque. I am deeply concerned
that ultimately Xavier and Finley hospitals will lose emergency type business
which Mercy will gain. This is not a direct criticism of Mercy Health Center in
Dubuque, but rather a fact that will occur no matter which hospital has the ambulance
service in the city.
I was told in a call I made to St.Luke's Hospital that in 1979 St.Luke's received
2,528 ambulance visits as opposed to 2,915 ambulance visits to Mercy, or 46.4% of
the ambulance business. The person felt that there had been a definite decline in
the percentage of ambulance visits to St. Luke's over the past several years.
Cedar Rapids has a committee set up that also discusses where ambulances take the
patients to assure the hospital of their choice.
The following are some reasons why one hospital will gain business, the other lose:
A. An ambulance attendant employed by the base hospital will be more loyal to that
hospital and if there is any doubt where a patient should go, this attendant
will take that patient to the hospital where he/she works.
B. The public soon becomes aware of where the ambulance service is based and
assumes that hospital is the only hospital to take any emergency to, either
by ambulance, by car, or walk-in.
I feel that it is important for all to realize that a change from the present
system to the proposed system will ultimately change the health care delivery
- 2 -
System in Dubuque and will adversely effect two out of three hospitals in
Dubuque.
2.Each Dubuque hospital was to present a proposal that would be their best effort
to operate the ambulance service on a break-even basis. That was done with some
very pronounced differences that effected costs.
Examples:
Whereas one hospital felt there could be no offset costs, one hospital had offset
cost in excess of $160,000. On another point, one hospital felt that $100,000
was needed to train the ambulance attendants over three years, but another hospital
felt that most of the people could be hired and consequently very little would be
needed for training. Each hospital had logical arguments to support their position
and this is not the point. The point of this is, that I feel that one proposal can
not be all right or all wrong on all differing points, and that the decision could
have been made on more valid comparisons.
It is unfortunate that more specific criteria was not developed so that all
proposals could have been presented on a comparable basis.
The cost of each proposal became a major factor in the decision making.
3. I have concern about response time. In several of the meetings discussion was held
on the possibility of two ambulances, one at the south side of Dubuque and one at
the north side. This plan was scrapped due to costs and all vehicles will now be
housed at Mercy on the south side of the city. The response time will be increased
to any points north of where they are presently located as one ambulance is now
housed at Fire Station #4 on University and another at the Central Fire Station.
4. I have also concern that the Task Force did not consider the suggestions from other
groups. I am referring primarily to the County Medical Society which represents
many doctors who use the emergency facilities in Dubuque. They have expressed, in
writing, a desire that the ambulance service remain with the city. In addition to
this group there were many people that expressed the same wish that the ambulance
- 3 --
remain with the city. It appears that since they disagreed with the majority
of the Task Force, they must be wrong. I find that the public who has talked
with me about the service is quite knowledgeable and concerned.
5. The last item of concern I have involves personnel.
The ambulance attendants are well trained and are able to perform their duties
under adverse conditions. The majority of nurses that have discussed the
ambulance study with me have expressed their own concerns about their physical
ability to work in conditions other than the emergency room setting. I am not
questioning the training of the nurses in life support and life saving techniques,
just the physical ability of some to perform the job.
In summary, I have expressed some thoughts on some of the issues that concern
me as a member of the Task Force and a representative of Xavier Hospital.
CARY RI1I Ig-Lc..-ttj 17,
T S ,
Administrative Assistant
THE FINLEY HOSPITAL
350 N. Grandview Ave. Dubuque, Iowa 52001
January 14, 1980
TO: Honorable Mayor and City Council
FROM: Phyllis J. Anger, R.N., Member, Ambulance Study Task Force
SUBJECT: Minority Report to the Ambulance Study Task Force Report
The purpose of this report is to bring to your attention some areas where I,
as a task force member, disagree with the findings of the ambulance task force.
In this regard I wish to refer you to the Summary of Task Force Recommendations
found in the task force report.
Recommendation #1. The level of service to be provided by the ambulance service
should be at least Emergency Medical Technician II (EMT -II)
level with a program over one year to upgrade the level of
care to EMT -Paramedic level.
Comment:
It is my view that there is no need at the present time for
EMT -Paramedic level in Dubuque. This level of care is primarily
utilized in rural areas of a state where the immediate accessiblity
of physician skills is not available. In Dubuque, physicians are
readily accessible and therefore the increased cost for EMT -Paramedics
are not justified in my opinion.
Recommendation #5. Ambulance service should continue to be owned by the City, but
should be operated by Mercy Hospital and the level of service
should be full-time ALS ambulances and one eight hour ALS transfer
vehicle.
Comment:
I am opposed to the recommendation that a hospital run the service
for the following reasons:
a. Cost
1. The proposal as outlined would require a capital
investment of some 300,000 plus dollars for physical
plant expansion at the hospital. The city already has
adequate parking facilities for the ambulances in their
present locations as well as on the north end.
2. Turnover of civil service personnel versus health
personnel is much smaller. With this type of turnover
the cost of continued training if the service is operated
at a hospital would be significantly higher.
3. Training. At the present time the city services are
operational with three EMT -IX plus 9 ACLS providers.
converting the service to a hospital would require the
hiring or training of up to 20 new personnel.
4. Investment of the city or the hospital in ambulances
has already been accomplished but the mechanism for
costing these ambulances has not been clearly spelled
out if the ambulances were to be turned over to a hospital.
Costs for the acquisitions of these vehicles therefore have
not been properly accounted for in my opinion.
Honorable Mayor and City Council
January 14, 1980
Page 2
5. Hospital proposals did not adequately address many
cost factors. This is caused since the task force
was unable to settle on requirements for several
issues and thus these issues were never appropriately
defined. For example,proposals all differed with
regard to how supplies would be costed, how the cost
of the ambulance amortization would be handled, the
way in which indirect expenses were to be allocated to
the service and especially those of nursing administration
within the hospital, and finally no ambulance task force
time was utilized to assess the reality of "hospital
claimed personnel offsets". These and other unanswered
questions made the task of the task force into finding
cost of the competitive service options virtually
impossible.
b. Risk
1. The city ambulance service presently is knowledgeable
of the community's streets which is absolutely essential
in minimizing response time. Lay personnel are at a
great disadvantage when compared to a fire service with
regard to their knowledge of the intricacies of Dubuque
streets. This is known to be a problem in cities such
as Cedar Rapids where fire services are not employed.
2. The city services are already trained and knowledgeable
in out of hospital care. Here, I refer to such techniques
as extrication, rescue, splinting and bandaging, and basic
fire fighting, functions which are not used by hospital
based personnel. Thus even the most highly trained
registered nurse prepared to give life saving service within
the hospital can find that when forced to work in the "field'
the services they can render would not be adequate.
c. Credibilityand stability associated with a city operated servic(
is perpetual in nature rather than temporary when in the private
sector under a specific two or three year contract. This concerns
me with regard to the way in which the citizens would view such
a service.
d. Service. The Finley, Xavier, and city proposals did not address
a three vehicle proposal. The level of service in Dubuque at this
time is adequately covered by two vehicles. The additional third
vehicle by the hospital allegedly further reduces service costs.
This is true only if you accept "hospital offsets" which were
attributable primarily to the use of registered nurses, a
concept which has many detractors and which was not studied by
the task force.
e. Finally the operation of hospital based service has been devisive
in other communities since one hospital's employees can steer
significant numbers of patients to that hospital creating serious
concerns for program and financial viability of other hospitals.
Because of this fact, the hospital subcommittee proposal was to
leave the service with the city. See report of subcommittee
dated August 16, 1979 submitted by me. Copy attached.
Honorable Mayor and City Council
January 14, 1980
Page 3
Recommendation
Recommendation
Recommendation
Recommendation
Recommendation
#6. The recommended rate structure
ambulance service should be
Transfer Rate $63
Basic Service Rate $110
Advance Care Rate $170
Comment:
The transfer rate as proposed will be unacceptable to patients
needing transport for diagnostic and therapeutic services from
one hospital institution to another. This fee structure will
increase the present structure for these transfers by double.
This fee structure will probably force hospitals to transport
patients themselves to protect the patient from basic transportation
costs of upwards of $126.00 for the purpose of receiving a CT -Scan
radiation therapy, etc. The Finley Hospital proposal recognized
this problem with lower transfer fees.
for the Mercy Hospital based
as follows:
#7. The Ambulance Study Task Force strongly recommends that a city
subsidy be considered to lower the proposed rate structure.
Comment:
This recommendation is not consistent with the task force charge
to reduce city subsidy. Further the subsidy should not occur
if public monies are to be shifted to the private sector. Subsidy
is appropriate if the city continues to operate the service.
#9. The patient's right to go to the hospital of his/her choice must
be protected.
Comment:
The "right of the patient" has never been an issue. However,
the position of many patients under stress is to do exactly as
the expert suggests. In addition, many patients do not have
a preference. The impact. on the hospitals is serious and was
discussed under recommendation five. The actual impact of this
type of activity has reduced the amount of activity in one hospital
in the state of Iowa by almost 20% since the advent of an ambulance
service based in a competitor hospital.
#f10. The city should continue to receive calls from the general public
for emergency ambulance service and relay such request to the
hospital based ambulance service for prompt dispatch. Request for
transfer service should be handled directly by hospital based
ambulance service.
Comment:
Because of risk factors regarding public definition of emergency,
all calls should be handled centrally.
#12. The Mercy Hospital based ambulance should begin operation 120 days
from the time of City Council approval.
Comment:
While this recommendation is not particularly critical to the
proposal you should recognize that the hospital does
require Health System Agency and State Health Facility Council
review and approval before starting the service. This process
usually takes between 150 and 180 days to complete, if the proposal
is not controversial. It is my opinion that this proposal,which
will greatly increase the cost of ambulance services to medicare
patients, will indeed be controversial at the state level and has
a high probability of not being approved at all. In addition, the
hospital must prepare its physical plant and hire or train 20 new
Honorable Mayor and City Council
January 14, 1980
Page 4
people to meet this recommendation. The proposals from the other
institutions were based on the knowledge that it does take time
to receive an appropriate certificate of need.If the implementation
time were reduced in this regard any one of the three hospital's
proposals could be ready to go in 120 days.
Finally, I must comment on the rational given by the majority for selecting the
Mercy option which was included in your task force report. There were four reasons
stated in the report:
1. Mercy Hospital was prepared to put "up -front" approximately $350,000...
2. Mercy Hospital exhibiting best use of ambulance personnel...
3. Cost and level of service offered by Mercy Option Two significally
better...
4. Start-up date offered by Mercy Option Two superior...
In these regards you should understand the following. With regard to the
up -front application of $350,000 please be aware that the other hospital proposals
were of equivalency. Training of staff would be accomplished by any one of the three
hospitals and is an equal offset in their proposals. The building of a garage and
classroom facility was not considered a need by the Finley proposal or by the Xavier
proposal and therefore was not included. The up -front monies were also to be used
for purchasing an additional ambulance and under the Finley and Xavier proposals no
additional ambulance was required. Therefore the costs of such ambulance was not
included, -.Finally , the purchasing of additional equipment was not included in the
Finley and Xavier proposals since no additional equipment was required for two ALS
service. Neither Xavier Hospital ,norFinley Hospital indicated any willingness or
capability of providing any up -front money because lone was required in those proposals.
Under point i#2 the better use of personnel relates to -the question of "offset".
Offset is available in excess amounts by Mercy since they are utilizing registered
nurses in their proposal while the other hospitals used EMT trained personnel. In the
case of Xavier's proposal no offset was allowed because Xavier felt the need to place
ambulances at two locations. With regard to Finley an offset was at a lower level
since they were using EMT personnel and the utilization of those is more difficult
in a hospital setting. Finally, for the Mercy proposal the use of offset assumes
the use of registered nurse personnel as the backbone of their service. This is not
a concept which has met with wide popularity or success particularly when the registered
nurse riding the ambulance is one of only two attendans on the vehicle. In some areas
of the country registered nurses are utilized as the third person on the vehicle which
provides "the ultimate" in emergency care. In such a case I have no objection to the
use of registered nurses. However, the practicality of utilizing a registered nurse
as one of two members in the field causes me personal concern for the well being of
the patient not because the registered nurses are not capable of providing high quality
care,but because that care has to be delivered in the field rather than in the clinical
environment of a hospital. Under point #3 in relation to the cost and level of service
again refer to the amount of offset available to -the Mercy proposal based on registered
nurses. As I mentioned above,the task force chose —to accept this concept without study
and I have serious reservations about the practicality of the proposal. In addition
to the other problems I have with this approach please refer to the training proposed
for registered nurses which include among other things agility testing and the lifting
of 200 pound cots up and down two flights of stairs, the running of a mile in 8 minutes,
sit ups, knee bends, and the lifting of a loaded cart into the back of an ambulance.
Point #4 in the area of start-up date this I have already discussed and wish only to
point out here that Mercy's apparent superiority is based only on the assumption of a
faster certificate of need approval and should not be used as a point in distinguishing
between hospital proposals. My conclusion from the above is that the votes of the
Honorable Mayor and City Council
January 14, 1980
Page 5
majority on the proposal to select Mercy versus Finley or Xavier in the selection
process were all based on invalid facts.
In conclusion it is my opinion that the city should maintain its ambulance program
and that it should review very carefully the original proposal setforth by the
hospitals that I referred to dated August 16, 1979. Thank you for allowing me
this opportunity to comment and serve the city of Dubuque. I will be available
to answer any questions you may have of me on this matter.
Respectfully submitted,
etLL'4V
Phylli eJ. Ange/ R.N.
1006 Campbell Avenue
Galena, IL 61036
AMBULANCE STUDY TASK FORCE
SUBCOMMITTEE MEETING MINUTES - August 16, 1979
The Ambulance Task Force Subcommittee met on August 16, 1979 at
Mercy Health Center. Present were Phyllis Anger, Finley; Gary Rieniets,
Xavier; and Ken Sergeant, Mercy.
The -subcommittee was formed in order to investigate the possibility
of city/hospital shared ambulance service, as well as a' totally hospital
based service.
The subcommittee studied the hospital based services provided in the
Sioux City and Cedar Rapids areas. After lengthy discussion, the committee
arrived at the following conclusion:
There is no economic benefit to the coi:;.uunity to have the ambulance
hospital based. Even if ambulance personnel worked part of the time
in the hospitals, staffing would still have to be doubled in order
to cover• the ambulance personnel when they are on a call. Due to
economics and labor problems, the practicality of this arrangement
is not feasible.
RECO'-iMENDATIONS :
s.
1) We feel that private ambulance service should be further explored
When considering private service, we should a) have a guarantee
that the level of care will be the same as that recommended by the
Ambulance Study Task Force and b) obtain bids from interested priv-
ate services in regard to charges.
2) We see the educational activity of ambulance personnel as a speci-
fic role for hospitals, with no charge to the city.
3) We feel that the present ambulance charges should be raised:_in
accordance with the level of care provided.
The meeting was adjourned at 12:40 P.M.
Respectfully,
Phyllis Anger,