The Emergency Medical Services 

Agency And Its 

Effect on Your Practice

By Karl Sporer, M.D.

The San Mateo Health Department plays a leading role in the promotion of health in our community, and some of the programs have an effect on all hospitals and physicians in our county. The Health Department has several distinct agencies that include Aging and Adult Services, Mental Health, Public Health, Environmental Health, and Emergency Medical Services (EMS). These various agencies have a number of programs such as the TIES line to aid senior citizens with medical and social problems, pandemic influenza planning, monitoring food safety in community restaurants, and monitoring the functioning of the prehospital system.

The San Mateo Emergency Medical Services Agency (EMSA) monitors the entire spectrum of prehospital care from the dispatch process, to 911 response and transport, to the care in the emergency department. The EMSA and its policies play a significant role in the destination decisions of our 911 ambulances. EMSA develops its policies and procedures with considerable help from community stakeholders in a transparent manner.

There are two committees that are the linchpin to the smooth functioning of our county system. One is the Medical Advisory Committee (MAC) made up of a group of emergency department physicians and nurses from all community hospitals as well as representatives from our prehospital system. This group, along with the medical director, is instrumental in developing the paramedic and EMT clinical protocols and policies. Because of its clinical expertise and representation from all hospitals and all aspects of the prehospital system, this group develops the necessary policies for the smooth functioning of the system. They are also advisory to the Emergency Medical Care Committee (EMCC), the second main county committee.

The EMCC is an advisory committee made up of consumers and other constituency groups from public safety. This group is tasked with aiding the EMSA in policy issues and in particular system redesign and is the group that will develop the design of the EMS system in our community each time that a request for proposal is developed. The current award-winning system, which went into effect January 1, 1999, was the result of a four-year planning process. The system is a public/private partnership between American Medical Response (AMR), the fire service agencies in San Mateo County, and the County Health Services Department’s EMS office. AMR contracts with a Joint Powers Authority, made up of 15 fire service agencies, to provide paramedic first-responder services. The system benefits patients with a faster paramedic response than the previous model and better integrates the care provided by firefighters and ambulance paramedics. A single dispatch center, San Mateo County’s Public Safety Communications in Redwood City, performs all dispatch services for fire departments within the county as well as for the emergency ambulances. The system dispatches the closest fire engine and ambulance to every medical incident regardless of local fire agency boundaries. The EMCC currently is developing a new request for proposal for the EMS system for 2009 and is in the process of creating the optimal EMS system for the next decade in San Mateo.

One of the significant EMS issues that will affect the individual physician in our community will be the 911 destination decision policy. The overarching goal of the destination policy is to transport the patient to the hospital of the patient’s choice. Certain situations can affect this decision such as a severely ill patient who should go to the closest hospital, emergency department diversion because of overcrowding, and the need for a specialty receiving facility. Specialty receiving facilities are hospitals that selectively receive EMS patients with predetermined criteria because of their ability to provide specialized care. Our trauma plan in San Mateo County is an example of a mature specialty-receiving plan. Severely traumatized patients in our community are transported each day to a level-one trauma center, either Stanford Medical Center or San Francisco General Hospital, for specialized care.

There has been a recent interest in expanding the concept of specialty receiving hospitals in our community in particular for patients with stroke or acute ST segment elevation myocardial infarction. The Medical Advisory Committee has been discussing the concept of specialty receiving hospitals and has developed some basic guiding principles to aid in future decisions. Patients will be directed to designated specialty receiving centers only on the basis of the following criteria:

• The primary medical problem can be determined in the prehospital setting.

• The need for immediate medical intervention for the patient’s condition is time-dependent, which has been shown to improve survival and prognosis.

• The specialty receiving center meets specific standards recognized by the county (e.g., California regulations, accreditation by the Joint Commission on Accreditation for Hospitals).

• A memorandum of understanding is in place between the county and the specialty receiving center.

Stroke remains the third leading cause of death in the United States and the leading cause of disability. There are more than 200,000 strokes annually in the United States, and the economic burden is estimated at $51 billion annually. Stroke results in an in-hospital mortality of 15 percent, a 30-day mortality of 20 percent to 25 percent, and half of all stroke survivors are left with a permanent disability.

Recent changes in stroke care have generated a great deal of interest in systematic improvement in the process of care from the prehospital arena to in-hospital care to rehabilitation. These changes have included the use of TPA in early thrombotic stroke, new interventions for hemorrhagic stroke, as well as a variety of neurointerventional therapies. These therapies and their indications are a rapidly evolving field that will require a systemwide approach to implement as they evolve. Multiple hospitals in our community are independently striving to become accredited by JCAHO as primary stroke centers. We believe that six out of our seven comprehensive hospitals will be accredited as a primary stroke center by the end of 2007.

The concept of specialty receiving facilities was introduced in 2005 to the Hospital Consortium, the Hospital Council, MAC, and the San Mateo County Medical Association. Follow-up reports were made to these same groups in 2006. The San Mateo County Medical Association convened a large group of neurologists, emergency physicians, and nursing leadership from our community hospitals recently to discuss these issues, and several themes emerged from this meeting. Primary stroke center designation allows for an organized systematic approach to medical care of these patients. There was significant concern about the timely availability of neurologists and radiologists to aid in making these time-critical decisions. Because only a minority of stroke patients will qualify for early therapy in a primary stroke center, there was an even stronger feeling that improved relationships and rapid transfer agreements with comprehensive stroke centers will be imperative.

Stroke patients make up about 1 percent of the total transported patients, and this translates to about four to five stroke patients transported each week. Our stroke report demonstrated that 58 percent of our EMS stroke patients called within one hour of the onset of symptoms representing a large pool of stroke patients who are within the window of effective intervention.

The Department of Health in San Mateo County, and in particular the EMS Agency, can have significant impact on various facets of your patient’s medical care. The EMS Agency develops these policies in a transparent manner with input from clinicians from all community hospitals. Our agency appreciates the guidance and expertise that we have received from members of the San Mateo County Medical Association over the years and is looking forward to continue working with the Association to improve the medical care of all of our patients in San Mateo County.