Golden Guardian 2012 Disaster Medical Response Exercise
By June Iljana, EMSA
Two days after a massive earthquake devastated his Southern California community, an earthquake victim is found in the rubble. He’s badly injured. The earthquake has collapsed the nearest hospital and roads to the next closest hospital remain impassable. The only other medical facility in the region is overrun by earthquake victims.
Photo by Brad Alexander/ Cal EMA
That’s exactly the kind of scenario the California Emergency Medical Services Authority (EMSA) was preparing for last week when more than 200 people converged on Sacramento State University for the Golden Guardian 2012 Disaster Medical Response Training and Exercise.
The federally-funded exercise, which was part of the California Emergency Management Agency’s annual Golden Guardian readiness program, is an integral part of EMSA’s grant-supported preparedness activities. This year’s objective was to validate the plan to respond to a 7.8 earthquake on the southern San Andreas Fault that runs through the most populated areas of Southern California.
“Although we plan and practice disaster response on paper, there is no substitute for putting people and equipment in action in a plausible scenario to ensure readiness,” said Dr. Howard Backer, EMSA Director.
Within 48-hours of the simulated earthquake, a 50-bed section of one of California’s three 200-bed mobile field hospitals was delivered to the affected area and set up in a large parking lot. It was staffed by a 55-member California specialized medical assistance team consisting of hospital administrators and medical personnel from Scripps, Tenet Healthcare and Stanford Health Systems. In addition, the exercise featured a mission support team and a five-vehicle ambulance strike team from American Medical Response with a disaster medical support unit.
“The goal of the exercise was to evaluate integration of state disaster medical resources and practice how the different organizations and resources coordinate to provide medical response to save lives and minimize suffering,” Dr. Backer said.
It takes 72 hours for the hospital to be fully operational, but within just two days the lights and water are on, basic equipment and supplies are available and the facility is staffed with doctors, nurses, anesthesiologists, x-ray technicians, pharmacists and administrators ready to begin treating patients.
Photo by Brad Alexander/ Cal EMA
Nursing and EMS students from Sac State’s College of Continuing Education served as the volunteer patients with simulated injuries. “Sacramento State is proud to contribute to efforts that save lives in California. Practical learning has long been a hallmark of our campus, and the readiness exercise highlights our students’ tremendous impact on the communities we serve,” said Sacramento State President Alexander Gonzalez.
Helicopters from the California National Guard, CALSTAR and Mercy Air Ambulance services transported some of the mock patients from Mather airport to the exercise site. Ambulances met the helicopters in the landing zone and transported the patients to the state-of-the art mobile field hospital where medical crews and support personnel were waiting. The patients were thoroughly briefed on the nature of their injuries to effectively play their part.
EMSA’s Chief of Administration, Rick Trussell, volunteered for the action early on. “During previous exercises I have always participated as a response team member. Volunteering as a victim allowed me to experience firsthand the actual deployment of California's disaster medical response assets and the level of care received during a disaster,” said Trussell.
The patient passes through the doors into a giant tube-shaped tent. Inside it’s a series of temperature-controlled, brightly lit tunnels leading off a main corridor. Each room has a row of rolling gurney beds and equipment for a specific purpose. Intensive care, trauma, surgery; a single patient may spend time in many of these rooms. It’s clear that organization and planning are key to an effective response, but those elements rely on training.
“With budget cuts throughout government in recent years, training opportunities have been scaled back,” explained Daniel R. Smiley, EMSA Chief Deputy Director. “The state and the federal government have made significant investments over the past decade in California’s preparedness. We’ve spent money for planning, personnel and equipment but to maintain the usefulness of those human and physical resources we must train with them.”
This was the third exercise involving the mobile field hospitals since they were purchased in 2006. They were first deployed for the Rough and Ready Exercise in August 2007 at Joint Forces Training Base in Los Alamitos. The following year, they were used in the Golden Guardian Exercise at March Air Reserve Base in Riverside.
Photo by Justin Short/ Cal EMA
Patty Skoglund is a registered nurse and Senior Director of Disaster Preparedness for Scripps Health. She has long been involved in EMSA’s disaster preparedness program and participated in developing the mobile field hospital program from the beginning.
“The first exercise was about getting to know the mobile field hospital and taking a look at the kind of capability it had. In the second exercise, we deployed a full team and developed scenarios similar to the exercise this week and worked on policy development and planning and on bringing the Cal-MAT into the exercise,” she explained.
“This time we focused on patient flow and coordinating efforts between the Mission Support Team, the Ambulance Strike Team and the Hospital Administrative Support Unit and integrated Stanford and Tenet into the hospital to test transition from one team to another. This is the first time there was significant integration of all of the teams to support the response,” Ms. Skoglund said.
Priscilla Rivera joined EMSA’s paramedic licensing unit a year ago and soon signed up for the mission support team training. During this exercise, she worked in the finance unit. “I was pleased that I got to experience the things I had learned in the class directly and through the eyes and experience of so many people who had done this before.”
“The exercise was extremely successful resulting in a lot of ideas for process improvement. It really validated to me that if I were to bring a 50-person team into the hospital and work with the teams as we did we would be very successful in treating patients during a real disaster,” Ms. Skoglund said. “I think this exercise validated the need for this kind of coordinated effort in managing casualties during a disaster.”
MaryAnn Codeglia, a registered nurse and Director of Emergency Preparedness at San Ramon Regional Medical Center, was on the Tenet Healthcare hospital administrative support unit team as deputy commander and operations chief. “We partnered with the Scripps team for the last mobile field hospital exercise and it was an honor to be asked to come back,” she said. “We had an even better experience this time because we also got to partner with Stanford. The collaboration of the three teams was outstanding and the leadership from Scripps was excellent.”
“If any hospitals were damaged even temporarily and required evacuation a mobile field hospital would provide great assistance in that,” said Scripps President and CEO Chris Van Gorder, who served as the hospital commander throughout the exercise. “Even if all hospitals are operational many of them are already operating at capacity now. The mobile field hospitals can provide surge capacity for urgent care, temporary emergency room, transfer center, triage center; they could provide all sorts of different kinds of resources because they’re so flexible.”
The exercise was managed by EMSA’s Disaster Medical Services Division, led by Division Chief Lisa Schoenthal. Lee Sapaden and Bill Campbell coordinated the participants and logistics with Sac State, while Ron Alves of Alves & Associates designed and coordinated the exercise scenarios and execution. The mobile field hospital is maintained and deployed by vendor, BLU-MED Response Systems.
“I want to thank the public and private partners who joined us this week to make the exercise a success,” said Ms. Schoenthal. “We experienced the culmination of over twenty strong partners working together to prepare California for the next major disaster.”
“Everyone recognized how important this exercise was and the need for us to continue to do this so we can get better each time,” Ms. Codeglia added, “because everyone knows it’s going to happen for real, it’s just a matter of time.”
Dr. Howard Backer, Director of the Emergency Medical Services Authority, welcomes participants to the Golden Guardian 2012 Disaster Medical Response Exercise. Photo by Brad Alexander/ Cal EMA
EMS Regulations Update
Emergency Medical Technician (EMT) Regulations
EMSA is submitting the final rulemaking file to the Office of Administrative Law for review and approval upon receiving Department of Finance Approval. The revised EMT Regulations are expected to go into effect in July 2012.
Advanced Emergency Medical Technicians (AEMT) Regulations
Following four public comment periods, the proposed changes to the AEMT Regulations will go before the EMS Commission on June 20, 2012 for approval. The five main regulation changes currently under consideration are: 1) Incorporate the National EMS Education Standards for AEMT training; 2) Increase the required minimum AEMT course hours from 88 to 160 hours (80 hours of didactic instruction, 40 hours of clinical experience, and 40 hours of field internship); 3) Amend the scope of practice to mirror the National EMS Scope of Practice Model; 4) Clean-up sections of the regulations to provide more clarity; and 5) Update sections pertaining to Base Hospital accreditation and base coordinator requirements.
The revised Paramedic regulations were open for third public comment period from May 11, 2012 to May 26, 2012. EMSA is currently reviewing the many comments in support of the proposed amendments. Specifically, EMSA is working to determine which scope of practice items will be included in the basic scope and which items will be included in the local optional scope. The three main regulation changes currently under consideration are: 1) Moving a significant number of local optional scope of practice items into the basic scope, 2) Adopting controlled substance security requirements; and 3) Adopting standards for training accreditation and scope of practice for Critical Care Paramedic (CCP). The revised Paramedic regulations will be presented to the EMS Commission on June 20, 2012 in Sacramento, for discussion, clarification of any questions, and to seek approval.
Public Safety and Emergency Medical Responder Regulations
The EMS Authority has been working with a task force to revise the existing regulations “First Aid Standards for Public Safety Personnel.” In April, 2011, the task force completed its work and released draft regulations which recommend: 1) Changing the title of this chapter to “Standards and Training for Public Safety Personnel and Emergency Medical Responder”; 2) Provisions for optional tactical first aid training for law enforcement personnel; 3) A proposed scope of practice for public safety first trained personnel; 4) A proposed scope of practice for EMR consistent with the National Scope of Practice Model; and 5) Training standards for both public safety personnel and EMR. The EMR training standards are proposed to be consistent with the U.S. D.O.T. Educational Standards and Instructional Guidelines.
However, due to significant stakeholder concerns related to implementation of the EMR provider category, these regulations are on hold pending legislative action.
Stroke and STEMI Systems Regulations
The local EMS agencies (LEMSA) continue to develop local optional Stroke Care Systems and/or STEMI Care Systems to include facility recognition, destination policy, quality improvement process, and data collection. In October 2011, the EMS Authority contracted with North Coast EMS Agency to develop STEMI and Stroke Systems regulations in California. A working group of EMS partners and other stakeholders which might be impacted by these regulations has been identified to participate in the regulatory development process. The first priority has been to create a document of data elements and benchmarks for STEMI and Stroke care systems, which took place February 6th. Each set of regulations will be on a two year timeline ending June 2013. Draft regulations for both Stroke and STEMI will be going out for pre-public comment in July.
EMS for Children Regulations
The EMS Authority and numerous EMS system participants with a special interest in pediatric EMS issues have developed draft EMS for Children Regulations were out for pre-public comment up until April 16, 2012. The EMS Authority contracted with Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center to develop regulations for destination policy, pre-hospital and hospital data collection, and quality improvement processes for children’s emergency medical facilities. After responding to pre-public comments, EMS Authority will post the draft for public comments periods in California. Draft regulations will be submitted for public comment in the near future.
For additional information relating to EMS regulation changes, visit EMSA’s Public Comment page here.
Hands Across the Bay - Training and Exercise Event
Story and photos by Brian Bolton
More than 200 Disaster Healthcare Volunteers reported to the O.Co Coliseum in Oakland, California as part of an exercise scenario involving a “massive M7.0 earthquake that struck along the notorious Hayward Fault” on the eastern side of the San Francisco Bay.
The Bay Area is fortunate to have twelve active Medical Reserve Corps Units that were able to “answer the call” from emergency officials by deploying healthcare volunteers from communities through the Bay Area. Rapid communications with this many validly licensed and credentialed healthcare professionals in the midst of chaos would have been impossible without California’s Disaster Healthcare Volunteers (DHV) Program.
“Close cooperation between EMSA and all of the healthcare and emergency officials in the counties in the Bay Area enables us to mount a significant response to medical and healthcare needs that might result from an earthquake or other major incident” stated Patrick Lynch, the Disaster Medical Services Division’s Response Personnel Unit Manager.
The fictitious earthquake event formed the basis of a scenario for a large and very ambitious two-day disaster training and exercise event held in Oakland on May 4th and 5th, 2012. A federal grant funded this full-scale event that was designed to test the functionality of the new DHV Deployment Operations Manual to deploy professional healthcare volunteers across county lines. This Homeland Security Exercise and Evaluation Program (HSEEP)-compliant exercise engaged twelve of our MRC Units and a number of DHV healthcare professionals from Alameda, Sacramento and Los Angeles counties in a deployment exercise based upon a simulated mutual aid request from Alameda County.
Many people were involved in planning this historic event. EMSA Disaster Medical Services staff in the Response Personnel Unit worked in close collaboration with several of the Bay Area’s Medical Reserve Corps Coordinators and they are deserving of our thanks and recognition: Chris Burgardt, Fremont MRC, Cathey Eide, Oakland MRC, Brian Waterbury, Marin MRC, and Dr. Michael Klass and Carol Masterson from the Coastside MRC in San Mateo County. These MRC leaders helped to design the exercise and training days and they served as team leaders and class instructors during the event. Their dedication and hard work were keys to the success of the event.
EMSA has been able to seek and receive participant feedback through the individual evaluation sheets, the input from the “Hot Wash” at the conclusion of the event, and a special internet survey that was distributed shortly after the event. It all gave us important feedback we will use in revising our deployment plans for future events and deployments. We also learned that participants felt very positive about their experience. More than 97% of the participants expressed strong interest in participating in future training and exercise events such as Hands Across the Bay.
The exercise demonstrated that EMSA, working in continued collaboration with local medical and healthcare leaders has the capacity to mobilize the energies of a large contingent of volunteer healthcare professionals during future healthcare emergencies and disasters in California. We also learned that the DHV System and our Deployment Operations Manual are useful tools in mobilizing our healthcare volunteers. In the coming weeks, the Response Personnel Unit will be making adjustments to our deployment plans based upon the input received from our partners and stakeholders. Our sincere thanks go out to all who participated in the “Hands Across the Bay” Disaster Training and Exercise.
CQI – Where Things Go Right!
By Laura Wallin, RN, Riverside County EMS Agency Stephanie Lara‐Jenkins, RN, Ventura County EMS Agency
There is a common misperception in the world of EMS that Quality Improvement (QI) is only applied when things go wrong. Further, that QI looks for the person(s) responsible for the occurrence and either remediates, or punishes, the offender.
This was demonstrated at a recent national EMS conference when a speaker pulled up a power point slide entitled, “QI – This is Where Things Go Wrong.” In the audience was one of California’s LEMSA CQI Coordinators. She subsequently brought the discussion to a general meeting of the CA LEMSA CQI Coordinators. The group agreed that QI is a hugely misunderstood program, and that the group should work to bring about a change in the way QI is perceived.
So, where does one start to change what we perceived to be a cultural myth? First we had to understand the culture we were trying to change. In an effort to do this, telephone calls were made to various groups and organizations around the state to identify QI practices. Not surprising, what was discovered was that the myth was not that at all, but instead, an unfortunate reality.
In many EMS systems, QI is indeed used primarily to identify specific calls where things go wrong. The individual involved in an unusual occurrence is typically given a remediation plan, which may consist of such things as review of policies or national standards, making a presentation to small groups on the issue, and, or writing a report on the issue; then the case is closed, and in most cases, forgotten.
While exploration of unusual occurrences in our business is one way of identifying trends and opportunities for improvement, we found that it was not being touted as such. Instead, it is often perceived as a search for the bad guy. The Japanese have a saying: "Every defect is a treasure", meaning that errors and failures are opportunities for improvement. They can help identify more fundamental or systemic root causes and ways to improve the system1, however, working on this premise can cause an adverse fear of QI.
Differences between remediation and discipline are rarely, if ever, explained, and the individual often leaves remediation feeling as if the organization is “picking” on him or her. In reality, when working with unusual occurrences, the process of QI explores the root cause of errors and attempts to correct things like equipment, policies, education and training. The hope is that process change will minimize re‐occurrence of the event. Interviewing involved personnel helps to get to the root of the error and gives EMS a greater understanding of the tools necessary to succeed. It is not the intent of QI to identify individuals, but rather processes so that we can focus on prevention and excellence, rather than individual discipline.
QI is so much more than reviewing what goes wrong; it is a formal approach to the analysis of system performance and efforts to improve it.2
QI is the process of:
- Recognizing excellence, both individually and organizationally
- Quantifying objectively what EMS does by trending, analyzing and identifying issues, concerns, and excellence based on those trends
- Setting benchmarks
- Promoting remediation rather than discipline; QI also makes a powerful distinction between the two. Remediation is education. Discipline involves licensure.
- Working hand in hand with training, education and with risk management
- Identifying system issues when possible rather than individual issues
- Promoting itself as a business standard used in corporate strategic planning
- Presenting itself as an evidence-based process equal to industry programs for education and personnel
The LEMSA QI Coordinators formed in 2007 as a subcommittee of Emergency Medical Services Administrators Association of California (EMSAAC). Each of the 56 counties in the state are represented on this committee. The first order of business was to set a mission statement and values. Our mission statement is “Through collaboration, we strive to improve the quality of patient care within California’s EMS systems.” Our values include diversity, quality, creativity and flexibility, evidence-based medicine, and patient-centered continuum of care. We have discovered that QI is a wonderful tool for discovering trends in regions or with service providers, both good and not so good.
QI often discovers that the probability of error lies in the way we do things and not the individual; in other words, systems issues. QI helps the organization focus on improving the system to promote excellence, and make problems less likely to occur.
We use the process of QI to identify best practices and recognizing excellence. Instead of telling prehospital personnel simply that they are doing a wonderful job, wouldn’t it be great to tell them exactly what they are doing so well, and exactly how much they have improved? Data collection and analysis through using the QI model not only identifies, but quantifies our successes.
The LEMSA QI Coordinators recently made a presentation to EMSAAC, asking administrators throughout the state to help us to change the culture from one of fear and resentment to one of learning and of openness, of using QI for what it truly is, a tool for improving patient care. We asked for continued education if and when they encounter those who refer to QI in a negative light. We understand that this is a cultural change we are asking for, and we also understand that culture changes take years to effect. But, if we don’t take that first step toward cultural change, it will never happen. We were happy to receive their commitment to present QI as an essential business standard.
You can learn more about the systematic way California LEMSAs are bringing about change to improve patient care, customer satisfaction, and ease in practice. Please email our group with any questions about bringing improvement and excellence to your workplace. You can reach us at: firstname.lastname@example.org.
EMSA Receives California Healthcare Foundation Program Grant
By Adam Willoughby, EMSA
EMSA was awarded a $142,670 program grant this past March from the California Healthcare Foundation, titled California Emergency Medical Services Database Development and Implementation of Core Quality Measures. Its aim is to increase the accessibility and accuracy of pre-hospital data to be used to develop policy for research, and to facilitate system evaluation and improvement.
In 2010, local EMS agencies (LEMSAs) in California began submitting pre-hospital patient care data from providers to the Emergency Medical Services Agency via the California Emergency Medical Services Information System (CEMSIS). Currently, inaccurate and incomplete data limit the potential for system analysis, quality assurance and performance improvement of pre-hospital care.
This grant will allow EMSA to improve the quality and accessibility of patient care data. It will also permit EMSA to develop and post for public review a set of core quality measures drawn from key EMS functions, including EMS Response Intervals, Trauma Care, Stroke Care, Heart Attack/Acute Myocardial Infarction Care, Cardiac Arrest, Pediatric EMS, and Skill Performance by EMS Providers.
The methods and objectives of this project are: (1) Identify and mitigate technical problems relating to collection and submission of EMS data; (2) Work with local EMS agencies and providers to improve core measure data collection; (3) Create a public interface on EMSA’s website at www.emsa.ca.gov to provide access to a subset of state-level EMS-system performance data validated by consultants and EMSA staff; and (4) Prepare EMS data from California to be submitted to the National EMS Information System (NEMSIS) www.nemsis.org.
“We are very excited to have this opportunity to partner with the California Healthcare Foundation on such an important effort,” said EMSA Director Dr. Howard Backer. “Data are considered critical in health care for performance improvement at the provider, agency, and system level. This effort will benefit all who work in EMS as well as the public in California.”
Steve Drewniany appointed to Commission on Emergency Medical Services
Steve Drewniany, 50, of Santa Clara County, has been appointed to the Commission on Emergency Medical Services by Governor Edmund G. Brown. Drewniany was nominated by the California Peace Officers association and will serve a three-year term.
Drewniany has been deputy chief of special operations for the City of Sunnyvale Department of Public Safety since 2011, where he has served in various positions since 1989. Drewniany was a paramedic for American Medical Response West from 1986 to 1989 and a paramedic for North Country Emergency Medical Services and the Yacolt Washington Fire Department in 1985. From 2009 to 2011, he was an instructor at the International School of Tactical Medicine in Palm Springs.
He is a member of the California Peace Officers Association and the California Police Chiefs Association and was previously a member of the California Fire Chiefs Association and the California Peace Officer Standards and Training Tactical Medicine Guidelines Committee.
“Steve Drewniany has had direct EMS experience as well as Peace Officer experience throughout his career and has been engaged for many years in statewide EMS issues with the Emergency Medical Services Authority. We welcome him to the EMS Commission and look forward to his input and counsel in this new role,” said Dr. Howard Backer, Director of the Emergency Medical Services Authority.
The Commission on Emergency Medical Services supports the role of EMS agencies to ensure that patients have adequate access to quality emergency medical services, and to ensure the long term stability of these services. The Commission meets quarterly at locations around the state to provide advice to the Director of the California Emergency Medical Services Authority and to approve regulations, standards and guidelines developed by the EMS Authority. For more information about the EMS Commission, please visit http://www.emsa.ca.gov.
EMSA's New Systems Division Chief
Congratulations to Tom McGinnis on his selection as the new Division Chief for the EMS Systems Division. Tom has nearly 30 years of experience in EMS including work as an EMT, Paramedic and educator. He joined EMSA four years ago, transitioning from an impressive EMS career in the private sector including working as an administrator, ambulance operations supervisor and quality improvement director. Tom has also worked as a special project coordinator for one of our LEMSAs. During his tenure at EMSA, he has developed a thorough knowledge of our programs and responsibilities and an unmatched enthusiasm for improving EMS statewide. Tom first certified as a paramedic in 1989 and maintains his license today.
The EMS Systems Division is responsible for oversight of many aspects of statewide EMS including trauma, EMS for Children, Stroke, STEMI, EMS Planning, transportation including ambulance zones, monitoring of the California Poison Control System, and prehospital EMS Data including CEMSIS. We are glad to welcome Tom into this leadership role in this very important division of EMSA.
Tom replaces Bonnie Sinz who has retired, but will continue to support the development of our statewide trauma system.
EMSA welcomes Janna Atkinson
EMSA welcomes Janna Atkinson to our team. Janna is an Office Technician in our Paramedic Licensure Unit. She comes to us from AT&T and has a background in telecommunications and business management. She will be responsible for various duties including opening mail, processing address changes, accounting processes and she will act as a receptionist for the Paramedic Licensure Unit.
In her free time, Janna enjoys spending time with her five year old son, traveling, wine tasting, baking, and hanging out with friends and family.