Loading...
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 Sea Height Weight Hair Eyes F 5'6" 128 BROWN GREEN 1/10/75 Issue date RECOGNIZED & USED INTERNATIONALLY The ULTIMATE in FORGERY RESISTANCE POLICE •BANK•.PRIVATE INDUSTRY• HOSPITAL -SECURITY SHERIFF •FIRE DEPT.. BUILDING INSPECTOR• DETECTIVES NO INVESTMENT in cameras, laminators, cutters etc. is required. (data does the manufacturing, not you. Your role is the delivery of signature cards, photos and applications to Idata...WE DO THE REST. IDATA. INC. 1120 GOFFLE RD HAWTHORNE. NJ 07506 (201) 423.3,335 gDATA 1 Coae No 7 on Reader Information Card JUKE, 1976 CTR-8FS Automatic Telephone/Radio Message Recorders AT LAST A SENSIBLE "LOW COST" SOLUTION TO YOUR EMERGENCY MESSAGE LOGGING NEEDS! Omnicron recorders may be used with any tele- phone, two-way radio, or monitor receiver. They start recording when a message is received and stop after the conversation has been completed. Each call is available for instant replay and future ref- erence. For more information circle reader service card or write OMNICRON ELECTRONICS Box 623 Putnam, Conn. 062EM Cfcle No. 44 on Reader Information Card _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 -10- 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 EYERGE•t)CV VFtgl"' S cei Y 1./ HTS Jr-ti �r T F Fl C FLOW [f'RCPO sEDD i E.'% ERG.n'/Jc VEHi ge. % ,ycy 1 art F 13'! EMEft VEI1ICL E GA RAGE �, 99 751 D (-7 F. 'Li 4 74./0 f 1464. '7 6/H c' " -------- / 0" IL I -4 (18K fL _ = " = '11\---•" /)=0"•/ o " _ o " s 2 1 0 1 STORAGE CA yo 0 " .11 r. - ).. 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,