Orange County officials have delayed a decision on implementing a controversial program using private paramedics to transfer patients between institutions after reports of problems with the pilot project, including questions surrounding a death.
The county’s Emergency Medical Care Committee, which advises the Health Care Agency on such issues, unanimously decided that was the best course after officials from the Orange County Fire Authority's union testified of concerns during the committee's quarterly meeting last week.
Representatives of the Orange County Professional Firefighters union cited the death and other instances where “several other patients” were “reportedly harmed” as reasons to question the pilot project, which began in April.
The union officials went so far as to accuse the lone ambulance company performing the transfers, Lynch Ambulance Service of Anaheim, of operating “a parallel 911 system” to the countywide emergency network.
The Anaheim Fire Department's coordinator of emergency services added there was confusion about when or how the paramedic transfer teams were utilized by skilled nursing and board-and-care facilities.
Regarding transfers between general hospitals, Coordinator Joelle Samsel, who is a registered nurse and a paramedic, said things were working fine.
Dr. Samuel J. Stratton, the HCA’s emergency medicine director who is on the 17-member committee, recommended approval of the interfacility program for full status, but his motion failed.
The committee then approved a motion by Wolfgang Knabe, fire chief for Fullerton and Brea, to delay endorsement until the committee received reports on the newly raised issues at its next meeting, possibly in late August.
“As we peel this onion, we have to get all the data available to make decisions,” said Knabe, who represents the Orange County Fire Chiefs Association on the committee.
The committee’s decision is advisory only, so the HCA can allow the interfacility transfer program if it wishes.
Interviews and discussions at the committee June 28 revealed the following information regarding the death:
The case involved a call May 30 regarding a 75-year-old woman from a skilled nursing facility in Santa Ana to a Lynch Ambulance interfacility team.
At some point, the woman went into cardiac arrest, requiring CPR. Per HCA requirement, a call then was made to 911 for a full paramedic unit and fire engine.
When the OCFA paramedics that serve Santa Ana arrived, the patient was in the Lynch Ambulance with paramedics administering CPR, firefighter union officials told the committee.
Union officials alleged that while other ambulance teams might be reluctant to move a patient, Lynch Ambulance is known for quickly putting a patient into its vehicle in order to ensure payment.
The woman was transported to UC Irvine Medical Center in Orange, where she died that day.
Officials from Lynch Ambulance did not respond to calls and emails for comment.
Stratton said HCA staff was aware of the death, had examined it, and initially the case “was touted as a success” of the new service.
It would be “inappropriate” to blame the Lynch Ambulance crew for the patient’s demise, Stratton told the committee, adding that he will report back after added examination.
After the meeting, Stratton said union officials brought up the incident to "blindside" him, adding that he will need to review audio tapes of the incident calls and other communications to answer committee questions.
The initial study that culminated with the report to the committee involved 121 patients. The service will continue and add cases for further review, officials say.
Historically, critical care nurses from private ambulance companies have performed the interfacility transfers, providing a higher level of assistance than paramedics.
But crowded emergency rooms, delays in clearing paramedic teams to return to field duty and associated issues prompted HCA officials to look to ambulances staffed by two private paramedics as an alternative.
This first such use of private paramedics, however, stirred a negative reaction among the fire authority's widely deployed firefighters, who see it as a degradation of the quality of service. When the countywide system was revamped as part of statewide moves to buttress emergency services, private paramedics hadn’t operated in the county in more than 30 years.
On Friday, Stratton noted that paramedic interfacility transports are expected to increase once the federal Patient Protection and Affordable Care Act, also known as Obamacare, takes affect in 2014.
Then there will be increased economic pressure on the various organized partnerships among hospitals, physicians and other providers to move patients from other systems into their contracted institutions. Today, for instance, Kaiser Permanente aggressively moves patients into its hospitals after they are stabilized after accidents or unexpected illnesses outside their network.
Health care providers are in the early stages of forming these partnership organizations, which will require regular, safe and efficient interfacility transportation services.
Already, Stattton said, the HCA is in talks with Medix Ambulance Service of Mission Viejo about soon joining Lynch Ambulance as a paramedic interfacility transporter.
And next month, he said, he will meet with a Los Angeles ambulance company that provides such service there and is seeking to expand into Orange County.
But given there are numerous questionable ambulance operators in Los Angeles County now under pressure by regulators and prosecutors for what officials say is abuse and fraud, the Orange County HCA must move carefully to license new firms here, especially since Orange County’s ambulance law has been described by many as weak and outdated.
Additionally, Stratton said the HCA expects in the future to study using a paramedic paired with a lesser-trained emergency medical technician for interfacility transportation. The technician would drive the ambulance, with a single paramedic tending the patient.
This concept is being met with considerable skepticism by both firefighter-paramedics and some chiefs, like Knabe, who consider the move a reduction in service quality.
For instance, Knabe said that on a typical 911 paramedic call, an technician would drive the ambulance and two paramedics would assist the patient on the way to a general hospital, providing care after radio consultation with a physician at a general hospital.
Lynch Ambulance vehicles typically used for the interfacility transports have no radio equipment for communications with the hospital-controlled fire authority paramedics, Stratton said.
This apparently means that during the incident in question, the Lynch Ambulance interfacility crew on scene couldn’t alert the dispatched fire authority responders that the patient had gone into cardiac arrest.
According to the HCA report on the pilot study, the program overall met performance “thresholds and parameters.”
Of the 121 cases, the HCA report states that 17 required added calls to 911 for advanced, life-support paramedic care. These were mostly for heart or respiratory failures at skilled nursing or board-and-care facilities.
The study also noted that three cases were excluded from the study conclusions, because patient vital signs were unavailable after transfer.
And there were four questioned dispatches — called “fallouts” in the committee report — of interfacility paramedic transporters. These involved two patients with acute heart attacks being transferred between general hospitals for catheterization and two patients with low blood pressure moved from skilled nursing facilities to general hospitals.
Firefighter union officials told the committee they had filed public records requests for some study records but had not received any documents.
At the meeting, Knabe said it is important that the committee learn more details of the study’s patient care and that public records requests be honored, so the committee can engage in a thorough discussion before making a decision.
Rex Dalton is a San Diego-based journalist who has worked for the San Diego Union-Tribune and the journal Nature. You can reach him directly at firstname.lastname@example.org.