Travis County Commissioners Court
July 17, 2007
Item 10
>> Number 10 is to consider and take appropriate action on the following emergency services issues. A, emergency medical services second quarter sfwriewrchlts, starflight business plan outline, and c, other related issues.
>> [one moment, please, for change in captioners] . . . .hcii6r4pwp!
>> .
>> let me get a second to get on the page with you so we can rea.
>> I'm sorry, it would be page .
>> page 5.
>> okay.
>> page 6, this is a review of the revenue for fy 507 through the may the--with regards to trip date. The total budget revenue, the actual revenue into may is 1,338 000, and the projected revenue for the year is there, which is the variance. On page 7, I'll say that and return it over to heather.
>> do you want to take this one.
>> for the review.
>> this is just our performance s that we project and looks like all of our projects for patient trans ports are going to meet or exceed or numbers. One of the things we continue to see is increased volume. And requests for service. We're going to be talking about an a little bit in the performance, our business planning discussion. But all of the numbers are where we we expect them to be or exceed. Any questions, I can answer on page 7. They are there for you to review.
>> one of the questions that I think was asked more often than any question that I get is if you see that the patient out of county versus county is, you know, sometimes double or even higher than that, the question is usually, does it pay to service those out of county folks. And I guess if you really, if you get back to revenue, and I know in here you have it broken down, that it shows how many dollars are generated out of out of county. The truth of the matter is that you couldn't hit the numbers that you hit unless you do out of county transport, correct ?
>> yeah, that's correct. The last numbers that I looked at, looking at the budget for fy '08, had a mission profile of about 40 percent in county and 60 percent county. But if you look at the revenue projections it's about 62 percent out of county and 18 percent in county. That is because we charge a significantly higher rate for out of county patients that aren't paying what we call the cost of readiness, Travis County taxes that result in the helicopters and paying for the crews, so they are not paying into the program. That is one of the things during the business plan, to look at that cost and make sure the cost recoffee is adequate. But the out of county patients are paying a substantially higher rate than the Travis County residents.
>> the other question that is asked, we have two helicopters and people say, well, do you think that if you just had one helicopter, which obviously would be less operating expense, that that one helicopter would be used just for our county. Thank goodness we had two helicopters on Saturday afternoon when we had god awful wreck on 71 and b creek because without two helicopters, not that they aren't pretty quick, but pick two up, take them back to the hospital, go back and get those two. For a multitude of reasons why you have two helicopters and the need for two versus one, it's helpful to have that kind of information at hand when people start asking you about the expense of, especially, that kind of aviation, because it is very expensive, not just to basically keep in operation, but, you know, the outlay of expense that you have to buy the helicopters. So it is something that everybody needs to understand, that more than likely, you would need two helicopters , even if all we were doing is taking care of Travis County.
>> one of the things, I think it's important for folks to understand that just like the ambulances, if you have a mandatory fleet requirements, some 30 ambulances staffing the streets, we have to have an excess capacity because they have to be maintained. And so whether it's a 1.5 ratio , there's some built in capacity. The helicopter becomes even more important because of the downtime associated with maintenance. If we only had one helicopter, we would probably be available, and this is off the cuff, I can get you some figures, but probably 60 or 70 percent of the time. The other 30 to 40 percent of the time the aircraft would be down, not available because it's in maintenance. So if you're going try to have a helicopter program that's going to be in service, close to 100 percent of the time, and we run around 99 percent if you look at a calendar year, it takes two aircraft to keep one in service 24 hours a day, seven days a week.
>> when you're in the helicopter business, really minimal you have to have two helicopters to really adequately take care of the needs that you have.
>> unless you are willing to accept a certain percentage of time when the aircraft is not available. This community has the really been willing to accept that. It's been a service they have said we want to have available 24 x 7 in case it's needed. On the types of programs where maybe they share, they have a vendor and the vendor serves a large area, they can share is that point five resource between programs to maintain that availability. But with us not being able to do that, it really takes two aircraft to keep one in service.
>> when you are talking maintenance, it's not like a personal vehicle maintenance right. There are federally mandated maintenance requirements for a helicopter, right?
>> and stand widel, our director of maintenance, is in the audience and can talk to that. Both of our aircraft had to go through inspection in the last 90 days, major inspections. The aircraft is in many ways disassembled. That he was six weeks per aircraft that the aircraft was not available. And every 600 hour inspection has different requirements. They are fairly expensive. 00 hour inspection has different requirements. They are fairly expensive. It is not driving the car in and getting it back the next day. They are fairly extensive.
>> is there a fallback plan where by you may, a hypothetical example, I guess, where you have the inspections and your aircraft are down for maintenance purposes, is there a fallback where by if emergency air ambulance service is needed within this particular region, who would pick up the call at that time? In other words, the service is still needed but we aren't able to assess that need at the time. How would the region respond to that to?
>> there's been an explosive growth in the number of air ambulances operating in in the united states. That growth has also happened in central Texas. There are currently programs in san marcus, mashel false, georgetown and la grange. So in the event we would have some sort of emergency where star flight wasn't available and it was an appropriate air trans important, waiting for those programs to respond into Travis County was in the patient's business interest, we could contact any one of them and have in the past to help us manage patients in this county.
>> okay thank you.
>> let me ask you this. I don't know which page this is, the star flight performance data fiscal year second quarter performance, the interfacility transport, can you just define that, what does that refer to?
>> that is a hospital to hospital transfer versus a scene where we are going to a patient, you know, either at a residence or at a house. Interestingly enough we have seen a shift in our volume. We used do about 80 percent of the volume was scene work going directly to scenes, picking patients up. Some of that has started to switch in and county where we are starting more interfacilities, I would say probably more a 50-50 mix out of county where we are picking up patients evaluated at small hospitals and treated and now being transferred into Austin. Additionally the opening of the dell children's center has scene movement of patients from areas we have not seen in in the past now getting moved into the Austin community to be cared for.
>> are there any private air trans ports for those sorts of interfacilities that the hospital could contract with at this point in this market?
>> probably any of the private for profit companies would interested in contracting for that service.
>> I think at one time we were going through a transitional situation were we got the two new helicopters on board. We had a discussion as far as amount of money, collection of fees, da da da da, as far as persons that have used service. How is it determined when you go out of county, for an example, at a person uses a facility out of county, does that particular county pick up the responsibility for the cost of that operation? Who actually picks that cost up?
>> the patient is billed directly. The county that requests the helicopter this is true for both us and for the privates.
>> all right.
>> have no liability we bill the patients directly.
>> okay. So they are billed directly here within county and also outside of the county.
>> yes, sir.
>> okay. Okay.
>> moving on to slide 8. The ground e ms expenditures and revenue. Actually page 9 or slide 9. This is an overview of the ground ems agreement expenditures fy '07, again, through the end of may of '07 the approved budget for county page is 9.8 million through the end of may, actually expenditure was under 6.4 million. Projected expenditures for the year for the county cost is 9,745,000 which would be a variance of approximately 96,000 in savings. Ground patient fee revenue for fy '07 through may of '07, again, budget to actual regards to trip date. The fy '07 total county budgeted revenue on the ground side is two million, actual revenue collected through end of may is 1,636,000, projected is 2,553,000, which is a variance of 35,000.
>> if we have the surplus of I guess 350,000, what happens to that Monday?
>> it is returned and paid back to Travis County.
>> good news, gentlemen.
>> yes, it is.
>> okay.
>> and now, my name is heather cool. I am planner principle with Austin Travis County ems. If you turn to slide 11 we go through ground performance data. We have on this slide our total call volumes. We have actual data from last fiscal year, which you can see there. That totals out to 105,000 calls between the crit and--city and the county. We have the second year quarter year to date actuals from October to March totaling 54,000 calls. A projected total for for--for fy '07 of 110,000 calls. These are responses to 911 calls that do not include star flight. Projections for '07 were done using correlation of population data, both historical from the city as well as projected population data correlated with our actual call volumes, and that was done by our new research analyst, megan, also here in the audience today. We're happy to have her on board to have a lot more statistical fire power behind us to give you a lot more data in the future. Slide 12. Average response time. This is just for priority one through priority four calls, which are the calls that we run with lights and sirens. We have other priority calls not included in this. These are the highest priority. You can see the average response times for both the entire system as well as Travis County outside of Austin, and then within the city of Austin, and we are happy to be reporting some improvements in these response times across the board. I will now turn it over to our actinging assistant or acting director, ernie rodriguez. Sorry.
>> when you look at the times, the 8:09, 7:49, is there a benchmark that all of us need? You always hear, I mean, obviously, outside, I mean, that would vary even though probably wouldn't want to vary much since we have, you know, the system outside. Am but is that, I mean, would that be average or what would you think that people would go, how much time does it really take? And that really starts at the beginning of a call, right? Take us through real quickly.
>> that is correct. That--these response times are measuring the moment a call is received by an ems call taker from the 911 police operator. So the moment ehs communications picks up the call until an ambulance has actually arrived at the scene. It's the total time our ems staff have contacted the patient. I might add that those ems call takers are highly trained medically and can do quite a bit of intervention over the phone from cpr to delivering babies over the phone. They have done that. So the minute, this is the total time that caller is in contactin con particular with em--contact until we get there on the scene.
>> and doc--
>> I would going to add, the question is a good one and one that every e e--ems system struggles w we have struggled to measure the inant values as helgeheather described. Other systems choose to measure from the time the wheels start rolling until you get to the patient's side. The question is what is the ideal response interval. That has gone in the medical industry all the way from eight minutes to 11 minutes. Some systems include fire first response because we know that we get fire departments there much much quicker in most communities than we do the ambulance. So the current, if I were to give you a range in communities, urban, suburban and rural, it would be seven minutes 59 seconds 90 percent of the time, all the way up to 11:59. Erby, I think the system you came from was 10:59 ?
>> 9:59.
>> so it really depends on what the community, what the structure is and what the community puts in in term of ambulances. One thing that we do know, and every one in medicine would agree with this, is the, probably the most talked about, tile dependent problem is cardiac arrest that requires a shock. That is, you know, measured in seconds to minutes. And that is why the fire department's first response and public access to fibrilators has been so importantment we have been pretty aggressive in that.
>> what I am hearing you say is we don't have a really good apples to apples comparison. Some are doing 90th percentile, some are doing rubber meets the road, others are doing from a different standpoint. Looking at cardiac arrest statistics, is that perhaps a more sensitive indicator of our response time, showing our success rate in our mess critical, using ard cardiac arrest send send--essentially as a proxy?
>> that is what medicine would say is best. Regardless of response interval, if we have survival data showing x, y or z, whatever the structure is to get lives saved, more lives saved is appropriate. And if you look at our survival data,, do you want to run to that slide?
>> go ahead, that's fine.
>> it's a good question, Commissioner. If you look at our survival data.
>> slide 14.
>> the american heart association on their website survival communitiwide, the average is anywhere in the 3-7 percent range. Los angeles, new york city, have published papers in the medical literature, survival of one percent or two percent. If you look at our survival, we have broken it down into two components. What we can have an impact on in the field, meaning as hegger--heather talked about instructions from communications, fire department's first response, ambulance care and treatment and then transport, and then survival to discharge from the hospital. Obviously, we want patients to go home neurologically intact. The best thing to look at is survival. What we have an impact on is return of pulses in the field. We have broken it down into those categories. Our survival, return pulses in the out of hospital setting is systemwide at about 28 percent from last year, 30 percent this year, significant increase. We've made some changes in the past 18 months to bring that number up. You see county, 29 percent last year, 26 percent, almost 27 percent currently. Then city, 28 ish to 32. It's not surprising in any community that the longer response interval, regardless of fire department or ambulance, the lower the survival rate is going to be obviously to get the defib ril ator out to the patient. You add the dick discharge and you see the numbers there, sorry, next slide. 14.3 percent went home from the hospital. These are patients that leave the hospital alive. County is about 12 percent and city is about 15 percent. So on those measures, Commissioner, I think if you were to look and benchmark us to other communities, those are substantially above other communities our size. Certainly with the suburban rural mix that we have, those are some very good survival rate numbers.
>> looking at this slide compared to the response time slide, it's plain that there is a direct correlation between response time and success rate with cardiac arrest patients. I'm wondering if we're also measuring some of the other elements that go into it. I imagine it's not just response time. As heather was stating, also telephone contact directing people. So are we tracking, I guess what I'm saying, the cardiac arrest data probably captures that but do we have any ability to increase our success rate with some of the other elements? Are we fine-tuned enough to be capturing that ?
>> in terms of cardiac arrest, we just recently were invited to be a part of a cdc program. It's called the cares program, cardiac arrest, resuscitation, registry to enhance survival. We now entered the exact things that you just described, including was by stander cpr performed, because that would re--refrequent community education--reflect community education. In fact, we have the first community in the country to have cpr kits to every resident in the community. We track that and prearrival instructions, public access to defib rillator or public safety. We can compare ourselves to other communities, atlanta and other community to see where we do well and don't do so well and kind of tag on to other people's successes to do exactly what you talked about.
>> the reason I raise it, you mentioned credmore, I think that is an important illustration. The response times of course for reasons that are outside ems control, northwest and the southern portion of Travis County have the largest interval because of distance and also traffic issues. So anything that we can do in order to increase the likelihood of survival outside response time, not that we shouldn't keep working on response time, but oath issues as well--other issues as well, the idea of providing dfibrillators in public places, additional cpr, yesterday I met with folks saying the new cpr methods don't include mouth to mouth for instance.
>> right.
>> the push to the chess chess--chest is far more important to clear the mouth than doing the mouth to mouth. I didn't know that. I have to go back and take may class again. Any suggestions all might have in increasing survival rates in areas more far flung.
>> probably public education. I have been in traffic before. You hear the sirens. And people, it's like where do I go. Perhaps a little bit more work can be done in that area so people know exactly what they need to do. Do you just freeze where you are so they can at least know that they can pass you safely? And if you can pull over to the side. Sometimes you can't because of traffic. But it's good for people to know that. I think that also will increase the response time. It's important to let, you know, the emergency vehicles get to where they need to get in order to save lives. And people need to understand that.
>> would l.a. And new york defend themselves with that low because of the sheer inability to get to you? Like not like you can land a helicopternerman haten, I guess you can on top of a building.
>> we have had a discussion about that. Their challenges are as you describe. Vertical challenges. When patients arrest on the 2th floor--27th there are, they can get resources there. There are obviously different cultures of people getting involved in cp r. The by stander cpr rates tend to be lower in densely urban communities than they are in suburban communities. And then just not being willing to get involved. It's a struggle to see some one drop, call 911. Get involved and make that happen.
>> for comments for those, the world at large, one thing, I understand that a private doner contributed toward the defib laters. Any other private donors who want to contribute to having the appropriate equipment available in public places, please come forward. Then the other item I wanted to mention, there was an issue recently with someone being a good samaritan and providing cpr. That was a wonderful thing. We do have a little issue with the hospital bill after that regarding blood testing to make sure that they were okay after ingesting some of the blood.
>> I think they forgave the bill.
>> sorry, I was behind the times on that one.
>> no, no.
>> in any case, don't be disuaded.
>> up in Round Rock. What happens, how is the response time measured? There are some scenes that you go to where it has been brought to my attention, I understand you can't really do anything because of the nature of the event, especially if law enforcement is involved.
>> yes, we do have situations.
>> how do you handle that as far as measurement? I was always curious.
>> we include the whole time. We don't change the measurement at all.
>> okay.
>> we start the clock the minute that our dispatch personal picks under the telephone and continue it all the way through, even through the time where paramedics are waiting for law enforcement to make the scene safe. We don't alter those times. We measure exactly the same.
>> exactly the same.
>> yes, sir.
>> thank you.
>> we actually skipped over a slide to get to the cardiac stats. So if we could move back to slide 13. Heather is going to pass out a much larger map of what you should have in your backup.
>> the questions that you asked we are perfect. Think they fit right into this map. We have got a lot of questions about how we can improve response time and we're looking at everything. But it's not just response time. It's also community it grages and how we get community involvement. One of the things we believe saving a life is a community effort, not just ems or just police and fire. It's all of us that come together to do this. One of the things that we discovered as we started to look at more details information about response times in the county was what are those benchmarks, what are the times that we should be shooting for and how are we doing right now. Simple questions. So one of the things that we've done is taken the county and divided it into regions and covered this with the ems subcommittee, so you have heard it before. So what we are trying to do is to simplify the way we look at the county. With the idea being that we can then take each of the reasonables and begin to dissect what is going on in each of those areas of the county both from demographics, population, growth and density, traffic, all those issues that affect our ability to respond effectively within those areas. Then to come back with plans that we could work together towards so that we can improverg at least from ems and from our first responder component and fire component ems and police, rather, so that we can improve our piece of that. While at the same time, we're also developing a new program which is community integration. It goes beyond education. We were going to do the education things to help people learn which way to move in traffic, where to learn cpr, provide that training where we can but also integrate with the community and become partners inside those communities and become present and become persons that we actually, we increase involvement from our communities. So we're not just an ems ambulance that drives by now and then. They know our names and who we are, they know who to call, we can go to their neighborhood association meetings and provide training and do specialized things that fit within those areas of the community. So we've got this map now that we've produced that's divided into those regions. Behind that map is series of tables. The tables represent all of the different priorities that we respond to. In our communication center as soon as a person calls we begin to gather information about their situation and we use that information to determine what level of emergency they are having. We have five priorities that we track response times on. And I have provided at the very last page a definition of what all those priorities are with examples of the types of emergencies that are included in those priorities so that you can study that at bit further. The tables that are color coded that look like these on the second page behind the map, are what we call percentile response times. We have asked the simple question, how did we do most of the time in the county. What we have done is look at the 90th percentile or greater with each of those priorities. What we find is for each priority, for example priority one in the top gray box, will show that 90 percent of the time we are at the patient's residence or location between 17 and 17 and 29 seconds. That hit 92 percent of the time. That gives you a idea of where we are most of the time. The advantage we believe is important here that's better than the average response time, average typically represents about half the time, how well we do. So we think looking at the 90th percent time is a better measure for us and a higher bar to shoot for. The questions we have to answer now, what should those be 90 percent of the time and how do we get there. This is the very beginning point, the first time that we produced this bit of information and this map. Looking at this way. We hope to come back in the future and be able to not only provide you more information as we progress, but also some feedback about what we see happening demographically and population-wise and traffic-wise and kind of bring the whole thing together. So we'll be tapping into resources at the county to get information that could help us build this profile so we can continue to improve response times. All that talk to try to show a different way of looking at response times that we would like to lean you towards rather than just the average response times.
>> okay thank you.
>> we appreciate your time. If there are no further questions we'll move directly into item b.
>> okay.
>> all right.
>> item b, we want to come before you today and talk to you a little bit about getting your approval for moving forward and developing a business plan for star flight. As we start looking at our current and future requirements, the growth that we are encompassing, changes we are seeing, it's become very apparent we really need to have a good road map out there for star flight, looked at by a number of people, number of stakeholders. So we want to briefly walk you through this and ask for your approval on this. At the table we have a few familiar faces, dr. Roth earnest still here with us, willie culverson, sorry, not chief pilot. Casey ping, mark per sell, and sitting in the audience, administrative assistant and stan waddle. Did I miss anybody? Okay. We'll turn it over to ac and willie to lead it off.
>> if you turn to page 4, we want to summarize the pen fits that we see and the reasons for conducting a business plan p again, some of the stuff we already touched on during our ems presentation but star flight is an integral part of the Travis County response plan for both ems, search and rescue for law enforcement and fire. Additionally we're a region knoll--regional provider for up to 19 counties. The region continues to change since the program was developed and dispatch matrix approved. We continue to see an increase in call volume not only is that call volume increasing, missions we are being asked to assist with and manage are changing. We want to be sure the scope of work, we're adequately making sure that fits into the business plan for not only star flight but also for the county. Then additional regulations both from a faa perspective and for the team's acreditation. There's been a significant amount of review of the air medical industry nationally because of the air medical crash rate. And that has resulted in continuing regulations to address those kinds of things. So because of the cost and the safety factors, we want to be sure we're evaluating that. On page 5, we want the ensure that we are providing the best service we can for our citizens. We want to make sure that we are adequately addressing the cost and the cost recovery within this. Then looking at the appropriate service strategy. What are the services the community is going to need not now but in the future and making sure that those services are going to be available when the community needs them to the best of our amount. Again, the growth and population and service demands within Travis County. So part of that process that we have been looking at is who all needs to participate where we've been, and where are we going. We're reviewing the swat analysis that we have already conducted. So that will be under review. Then looking at, again, county vision and initiatives. On page 7 we're going to probably need to review and modify a lot of the star flight goals, missions and visions. We think we just, it's just a good time to put all of that stuff on the table and have it looked at by a group and make sure that we are setting the stage for the future. There may be on page 8, there may be some review and modifications to the organization. Again, I'm just kind of summarizing. The slides are in front of you. The organization for star flight and making sure that the organization is configured in a way that is both efficient and effective. On page 9, it is our goal, if it's approved by the court, that we would start to integrate the business plan into the fy '09 and 10 budget processes. Through those, we would be giving back quarterly reports to the Commissioners court on the status of the business plan. Basically, we know that start flight is an integral part of a lot of organizations. So if you look on page 11, there's some recommendations and approvals that would basically go from the department to the division, planning team, subcommittee, work session and ultimately to the Commissioners court. There's a list of county stakeholders that would need to be involved in the business planning process. They are all listed there. Basically, those are folks that we either provide services to or they help provide services to us and help us to do the missions that we do. Then the noncounty stakeholders, those organizations that are not directly a part of Travis County. Again, we either provide service or get service from. We're going to need to incorporate all of these folks into our business plan so that we can understand what services they need and how we would fit into that. So the next steps on page 12 --we're asking the court to approve a business plan for star flight and then would expect that we would be coming back to you on a regular basis to provide update as so where we are in the business plan and what the steps are that we see as it's coming.
>> I believe actually what we're looking for is not, we don't have the business plan done yet, we're coming to the court today and asking you to approve the process of developing this business plan, of which then you will have opportunities to review at future times.
>> so moved.
>> second.
>> discussion? Anything further?
>> that's all we have. Thank you.
>> all in favor. That passes by unanimous vote.
>> thank you all.
>> let's proceed with development of the business plan. Keep us posted.
>> thank you.
>> thank you all very much.
>> can I ask for 18.
>> beg your pardon? Depends on whether, anybody on 28? Oppninitwwihiwwwwhihihiwwwhihil ature s.s. Cuioiourur
>>
>>
>> eek k r.thth uns vovotetetete.
>> thank you all.
>> let's proceed with development of the business plan. Keep us postedst u u u es b bpmpmdede wiwiwid d d eeee development of the business plan. Keep us posted.
>> thank you.
>> thank you all very much.
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Last Modified:
Wednesday, July 18, 2007, 18:30 AM