Review Finds Flaws in County Handling of Emergency Care

A review of the county’s Emergency Medical Services program has identified “major problems . . . requiring immediate corrective action,” including a need for more consumer representation on the program’s governing board and better management of paramedical and ambulance services.

The report, compiled by a private consultant and an appointed task force over the past several months, is extremely critical of the management of the program. It points to built-in conflicts of interest on the committee that coordinates emergency services and a lack of clear authority for the program’s staff directors.

Established in 1976

“There appears to be a consensus among those most closely involved that the EMS system has a number of major problems at present,” said the report by the Cook and Associates consulting firm. “There is also fairly widespread conviction that many of these problems are insurmountable, or that there is little likelihood that they will be solved in Orange County, given the political climate that exists.”

The EMS office was established in 1976 during a time of growing state and national emphasis on reducing the number of accidental deaths. It now oversees the county’s five hospital trauma centers, ambulance service, paramedics’ training and first-aid programs--the entire range of emergency care in Orange County.

The report and a number of county officials who have looked into the issue concluded that the program is providing high-quality emergency services to county residents, but managerial controls are sorely lacking. Also, the services themselves may not be as good as they could be, it suggests.

“We may be at a point where the reputation exceeds the overall performance of the system right now,” said Robert Love, interim director of the county Health Care Agency, which oversees the EMS program.

Excellence Assumed

“Everybody assumes the system is excellent. It may or may not be. We’ve got a pretty good start in the system, and we were far ahead of most other counties. The issue now is whether we have kept pace, from a management standpoint, with different technologies and the improvements that are happening in the medical worlds.”

The report was particularly critical of the Health Care Agency’s administration of the emergency services program. It has been relegated to a relatively low level of the agency, has received much smaller budget increases than most county departments, and its requests for more staff members repeatedly have been turned down, the study found.

Love said Thursday that he would “concur with the overall thrust of the report,” but he said he has already instituted a number of changes since he took over as director several months ago. In the past few weeks, the program has been made a part of a special medical services office within the agency--effectively giving it more focused attention--and Love said he plans to ask the Board of Supervisors to expand the staff.

Dr. Greg Super, who represented the Society of Orange County Emergency Physicians on the study task force, said doctors have been frustrated because there has been no monitoring of the progress they are making in emergency medicine.

“I think the system is saving a lot of lives in the streets, and I think that’s primarily because of the strength of the paramedics themselves, the dedication of the fire agencies and the hospitals in the system,” said Super, an emergency room physician at Hoag Memorial Hospital Presbyterian.

“I think the EMS authority, the office that oversees that entire system on behalf of the county, has been understaffedZ; it has been shuffled off into a corner of county government that doesn’t give it the attention and the resources, both manpower and money that that office needs, and, because of that, there has been very little meaningful data development or analysis by that office,” he said.

“We need to have data back to know the effect of the changes we’re making: numbers of lives saved, numbers of hospital days saved, numbers of human errors prevented.”

The Board of Supervisors is expected to act on the report’s recommendations Tuesday. Board Chairman Thomas F. Riley, who had not yet seen it, said, “It’s been my observation that when the needs of a department are presented in pretty concise and urgent terms, the board responds. If the board has failed to respond to these concerns, then they probably have not been presented in the context of other priority issues.”

Committee Makeup Criticized

Riley added, “I’m sure the study has accomplished its purpose, and people will at least have to respond to the challenges of the study.”

The report cites a need for more consumer representation on the committee that coordinates emergency services, noting that the limited number of public representatives on the panel now is not backed by strong, vocal constituencies and thus carries little weight in what often becomes a process of power politics.

The committee, it notes, has been dominated by the physicians and hospitals that provide emergency care.

“Thus the EMS agency and its program office have been unduly controlled by the very providers they were supposed to regulate,” the report says, adding, “It is probably true, as one of the interviewees stated, that everybody in the system has a conflict of interest.”

It also says, “The general public has had little, if any, input into the decision-making process regarding the EMS system . . . . The critical importance of selecting strong, effective and recognized community leaders to fill the five public-member positions cannot be overemphasized.”

As an example of other potential conflicts, the report points out that the county health officer who oversees the EMS program as an administrator also serves as chairman of the review committee.

“It is often difficult, if not impossible, to clearly separate administrative matters from medical matters in EMS,” the report says. “This has created frequent conflict between the two positions. This conflict has spilled over into the community. The health officer has, on occasion, used his position as chairman of the (committee) to influence the handling of medical matters in EMS. This conflict is counterproductive and has served to undermine provider confidence in the EMS agency.”

Love, who is the immediate supervisor of the county health officer, Rex Ehling, conceded that there is conflict of interest throughout the make-up of the review committee.

“You’ve got hospitals and doctors who receive revenue from the system based upon who’s brought to their front door. You’ve got fire departments who want to keep on being the paramedic service. And you’re talking about a system that means big dollars,” he said.

Inspections Recommended

In his letter to the county administrative office, Cook noted: “The major problems identified during the study require immediate corrective action. The EMS program office should be moved to the top level of (the Health Care Agency), and the EMS program director should report directly to the director of HCA. The staff additions and upgradings should be carried out as soon as possible. The recommended staff changes are considered minimal to handle the current work load.”

In his report, Cook said a “major weakness” in the EMS program is a lack of an overall quality-assurance program.

Paramedics are evaluated only when there is a complaint. Hospitals that serve as paramedics’ bases are not being evaluated. Unannounced ambulance inspections in the field have not been carried out in five years.

During its review, the study team conducted one such inspection and found that eight out of 10 ambulances met the standards for licensing, mechanical condition, medical supplies and equipment. Study team members said most ambulance companies appeared to welcome the inspection.

According to one company owner quoted in the report: “If there are no inspections, we don’t have to worry about meeting standards. If they know there hasn’t been any for five years, there is a tendency to slack off a bit. All ambulance companies are not created equal.”

Other comments collected during the course of the study:

“The paramedic system is the single most important health-care delivery system that we have. How can we possibly shunt it off to something less than the highest priority?”

And, “Who runs the EMS system in Orange County? I don’t know. It must be God.”