A special MEETING of the board of county commissioners

APRIL 11, 2018

The Lake County Board of County Commissioners met in a special Lake Emergency Medical Services transition session on Wednesday, April 11, 2018 at 6:30 p.m., at Clermont City Hall, 685 W. Montrose Street, Clermont, FL. Commissioners present at the meeting were: Leslie Campione, Vice Chairman; Sean Parks; and Wendy Breeden. Others present were: Jeff Cole, County Manager; John Molenda, Assistant County Manager; Jerry Smith, Executive Director, Lake Emergency Medical Services; Darren Gray, Clermont City Manager; Carle Bishop, Clermont Fire Chief; Tim Bates, Clermont City Council, Ray Goodgame, Clermont City Council; Heidi Brishke, Clermont City Council; Diane Travis, Clermont City Council; and Gail Ash, Clermont City Council and Mayor.

welcome and presentation overview

Ms. Gail Ash, Clermont City Council and Mayor, asked the officials present to identify themselves for the record.

Commr. Campione stated that this was a great opportunity to answer citizen questions and explain the recent changes to improve Lake Emergency Medical Services (EMS). She indicated an intent for the County to provide emergency response times that are equal to or better than the national average, and said the organization should have the ability to adapt to changing conditions, such as road changes, new emergency facilities, and other factors that affect emergency response and patient transport times. She opined that the greatest Emergency Medical Services (EMS) system is one that is continually evaluating data, including the time required to process an initial 911 call, dispatch the first responders, arrive on scene with a paramedic, and arrive on scene with an emergency transport. She stated that the EMS system in Lake County utilizes a nationally recognized model that combines fire departments and ambulances to provide the best possible response times, and that once a paramedic arrives, a decision can be made whether to transport the patient to an emergency facility. She added that the County cooperates with each city to assist with funding to hire and train paramedics, and that the County also helps cities obtain supplies for emergency vehicles. She elaborated that ambulances and fire trucks carry the same medical equipment, that paramedics on both fire trucks and ambulances experience training under the same medical director, that Lake County follows a nationally recognized model that provides for fire trucks arriving first to an emergency scene, and that every fire truck and ambulance responding to a call carries a paramedic. She reiterated that Lake EMS’ goal was to provide response times that meet or positively exceed national benchmarks, and to perform those tasks with a high degree of professionalism. She reported that Lake EMS had undergone a number of operational audits in previous years, and that a consulting firm had been hired to conduct studies and evaluate the system with the goal of finding potential efficiencies. She commented that Lake EMS had been reviewing if response times were being measured accurately, and what benchmarks should be used in urban, suburban and rural areas. She mentioned that the consultant recommended transitioning Lake EMS into an agency directly under Lake County government to save money, as it was not previously considered a county department, and mentioned that there had been a separate Lake EMS Board that oversaw the EMS system, consisting of five County Commissioners and three elected officials from different cities in Lake County, along with one Chief Executive Officer from a Lake County hospital. She elaborated that this transition would allow Lake EMS to utilize county infrastructure already in place, such as procurement services, information technology and human resources, and that financial savings could be put back into Lake EMS, rather than other county entities such as the General Fund. She indicated that an additional benefit of transitioning Lake EMS was affording Florida Retirement System (FRS) benefits to Lake EMS employees, and explained that FRS benefits could reduce employee turnover and lengthen employment terms. She reiterated that all savings resulting from the Lake EMS transition would be kept within the system to enable improvements and strengthen monetary reserves. She commended Clermont’s fire department for its funding, staff, and response times.

presentation of lake emergency medical services transition

Mr. John Molenda, Assistant County Manager, stated that the purpose of Lake EMS is to provide countywide medical services. He said that the presentation would include the background of Lake EMS, an overview of the system, and community specific information.

Mr. Jerry Smith, Executive Director, Lake Emergency Medical Services, said that Lake EMS currently operated 22 ambulances, and stated that Lake EMS provides these items to the county: pre-hospital transport for the sick and injured; a consolidated communications center that enables dispatch service for 12 of the 13 fire departments in Lake County; a unified medical director that was on staff at the University of Florida Medical School, is board certified in emergency room medicine, and had completed a fellowship for emergency medical services; consolidated logistics supplies for fire departments; and regulatory compliance and quality assurance, due to Lake EMS being regulated as a healthcare provider. He indicated that Lake EMS affords these services to fire departments within the county: payment for state vehicle permitting; dispatch services at no cost; medication and oxygen replacement; controlled substance services; bio waste disposal; ongoing training; payment for the medical side of an online training platform for firefighters, paramedics, and emergency medical technicians (EMTs) that is certified by the medical director; and mobile data terminals (MDTs) utilized in the cabs of emergency vehicles that are linked to the Lake EMS dispatch center and provide a one button push feature to notify Lake EMS that units are responding, without adding radio traffic. He added that fire departments also benefit from these Lake EMS services: regulatory compliance; equipment retrieval from hospitals and decontamination of that equipment; assistance with equipment purchasing through the County obtaining a lower price for items such as cardiac monitors and blood pressure cuffs, and requiring vendors to sell items at that same price to fire service partners; the replacement of disposable medical supplies such as bandages and electrocardiogram (EKG) monitors; and loaning of the County’s spare equipment to fire departments. He indicated that he had served as part of Lake EMS since 1989, and that there had been many changes throughout its history.

Mr. Molenda stated that a consultant studied Lake EMS to ensure current operations were functioning as intended and to suggest potential improvements. He elaborated that a 21 month study was conducted, beginning in March 2016. He said the consultant presented three alternatives that identified efficiencies, improvements and savings, and considered the organizational structure of Lake EMS. He relayed that the consultant looked at the employment model and response times, and there were a few changes made to the methodology of analyzing these factors. He opined that the recommended alternative of transitioning Lake EMS into the County as the Office of Emergency Medical Services was best for the employees, the system, and the municipalities. He relayed that, after selecting this alternative, the County reached out to municipalities, hospitals, educational facilities, the Sheriff’s Office, other law enforcement, elected officials and the Lake EMS Board to ensure that the transition would be acceptable to them. He noted that discussions with these entities were positive, and that the County received helpful input from Fire Chiefs and elected officials. He said that on February 13, 2018, the transition was brought before and approved by the Board of County Commissioners (BCC) in a unanimous vote for a final transition anticipated by February 2019. He elaborated that these administrative changes provided cost savings that could be invested back into Lake EMS, and that the organization could save a total of $500,000 in the first year of the transition. He also noted that operating EMS under the County could increase collaboration with other County offices and agencies, reduce workloads and liability, and improve service delivery and emergency response. He said that the transition would lead to increased safety, supervision and service, enabled by the County’s ability to train together with municipal fire departments at fire stations closer to employees. He indicated that the transition would assist in disaster preparedness, stating that the consultant recommended activating, staffing, and housing personnel proactively, and collectively purchasing and reimbursing items for disaster relief. He stated that there would be no reduction in units, and that service delivery would increase as a result of the transition. He commented that the $500,000 savings would be used to enhance existing Lake EMS services without changing them, and that effective administrative practices would enable improving the operational side of the organization to meet growth and other changes in the county. He mentioned that the savings would offset existing service costs and establish an operational pooled cash budget to ensure that the money is kept within Lake EMS, and said that there would be no changes in funding or increases in billing for fire departments. He commented that Lake EMS’ computer aided dispatch (CAD) uses a nationally recognized software model that dispatches units based on the location and circumstances of the call, and that the model considers factors such as unit locations and availability. He also mentioned enhancements to these categories: zone coverage deployment; specialized units, such as those that can transport contaminated patients; child immunizations; critical care units to provide higher levels of care once a patient reaches a hospital; reduced employee turnover through FRS benefits; improved response times; elder affairs support; addressing child abuse and neglect through first responders that can identify these cases; and citizen training for first aid and cardiopulmonary resuscitation (CPR). He read the first statement of the First Response Agreement that the County has with city fire departments as follows: “Whereas, the City is a municipal corporation which operates a fire department and desires to provide first response advance life support (ALS) services on a regular basis…”, and said that the contract provides for the fire department arriving first at the scene of an emergency call. He added that the fire department responds and stabilizes the patient, with the ambulance later serving as the transport method. He explained that the first response from the fire department maximizes the use of personnel and paramedics through strategic locations of fire stations, resulting in the fastest possible response times. He commented that fire stations in the county are located according to nearby call volume, and that data is continually examined to ensure that fire stations are located in the proper areas. He noted that both the ambulance and fire truck carry the same equipment and personnel, with the primary difference being the ambulance’s transport capabilities. He said that Lake EMS uses a model that keeps ambulances on the street to more quickly arrive on scene if called, though noted that fire trucks are housed in stations that are more likely to be located near calls. He stated that every ambulance and fire truck carries an EMT, certified for basic life support (BLS), and that paramedics who are certified for ALS, are carried by every ambulance and certain fire trucks. He noted questions about dispatch practices, and said that advances in technology have positively affected deployment. He explained that the Lake EMS dispatch center receives emergency calls, that dispatchers follow guidelines to ensure they are asking the proper questions, and that dispatchers will relay the call to the appropriate agency while they are still communicating with the caller by phone. He elaborated that the dispatcher will continue gathering information which is then forwarded to fire trucks and ambulances as they are being deployed, and said that there were currently 22 EMS units and 46 fire stations in the county. He noted that the number of medical calls exceeded those for fire emergencies, but commented that the greater number of fire stations was due to those units being used as first responders. He mentioned that the number of reported fires had been decreasing due to fire prevention and improved building codes, though medical calls had risen; therefore, utilizing fire units for medical calls was cost effective. He said that the fire truck will generally arrive first at a scene and begin administering care to the patient, such as intravenous (IV) drug therapy and cardiac monitoring. He elaborated that the ambulance will arrive after treatment begins and will transport the patient; however, an ambulance may cancel its arrival due to first responders informing the crew that the patient does not want or need to be transported to a hospital. He said that, in these situations, the ambulance may divert away from the call if it is no longer needed, and that ambulances may also slow down while travelling to a scene if the first responders report the patient to be in stable condition. He said that slowing an ambulance down reduces the chance of a road accident or frees the crew to be deployed on another call, though this can negatively impact ambulance response times. He displayed a map showing the locations of the 46 total fire stations in Lake County, noting 24 county fire stations, 18 city/town fire stations, one station that the county shares with the City of Clermont, and three volunteer city/town fire stations equipped with BLS. He also displayed a map detailing deployment for EMS ambulances, stating that they are not at fixed locations, but rather they move around between hospitals, fire stations, and roads. He commented that there were a high number of ambulances at South Lake Hospital in the City of Clermont that are not assigned to the area, due to repeatedly transporting patients to that hospital throughout the day. He specified that emergency calls begin to be received in higher volumes at 8:00 a.m., with call volumes beginning to lower at around 8:00 p.m. to 10:00 p.m., and that eight ambulances operate on a 13 hour schedule due to this call pattern. He commented that transitioning a 13 hour ambulance to provide 24 hour service would be ineffective, due to call data suggesting that the ambulance would not be responding to calls for a significant amount of time.

Mr. Smith showed a chart displaying the hours of operation for the six EMS units in South Lake County, mentioning that the nearby Clermont 3 unit used a 24 hour schedule and was moved to Fire Station 1 at the end of 2014. He added that this change was due to an expanse of staffing by the Clermont Fire Department, and that Station 1 provided additional space. He explained that in Fiscal Year (FY) 2015, there was an 11 percent increase in ambulance transports, and that this was much higher than the average increase of calls per year. He said that this increase allowed for the funding for an additional 13 hour ambulance, but that response times increased due to the higher number of transports reducing overall unit availability. He noted that an ambulance was temporarily moved to Fire Rescue Station 109 in 2017, and that Lake EMS was attempting to find an area along the U.S. 27 corridor in Clermont to house it; however, there are zoning issues with housing ambulances for parking areas, unit security, and vehicle entrances and exits that need to be considered. He called attention to the considerable number of hours each day that an ambulance is waiting to be deployed from South Lake Hospital, due to ambulances transporting there from countywide locations. He noted that the ambulance locations shown on the map were where the units began each day, though they would be moving around the county for most of their service time. He showed a map of regional EMS units in Lake County, stating that resources can shift throughout the county to service call volumes. He relayed that the consultant also discussed moving ambulances from traditional fire stations to a post system throughout Lake County, and that this plan would carry forward for the current total of six ambulances for South Lake County. He specified that the ambulance posts could be moved throughout the county based on growth and call data. He showed a slide detailing revenue from the City of Clermont for the ambulance Municipal Service Taxing Unit (MSTU), and also included the amount of the reimbursement to Clermont for ALS service provided. He elaborated that the millage was not solely for Lake EMS, but also for ALS provided by all fire departments in the county. He commented that the three ambulances housed in Clermont cost up to $2.8 million annually; however, there were 20 different ambulances that responded to calls in Clermont in FY 17. He also showed a chart for Lake EMS and Clermont Fire Department response times in the City of Clermont, highlighting that there was a small spike in these times for 2015.

Mr. Molenda said he appreciated the opportunity to speak, and praised the service that Lake EMS delivers. He commented that there are daily changes within the organization, and Lake EMS meets monthly with Fire Chiefs to ensure that service is properly delivered. He commended the City of Clermont for providing some of the best response times on a national basis, and added that Lake EMS’ response times are also above the national average.

citizen questions and comments

A citizen asked about the increased amount of time that ambulances were available at South Lake Hospital.

Mr. Smith replied that ambulances are considered to be available after a transfer of care is made by taking the patient off the stretcher, cleaning the truck, and completing a report.

Commr. Campione said that an ongoing challenge is the amount of time it takes for a hospital to receive a patient from an ambulance.

Mr. Smith added that quarterly reports track hospital data for patient turnaround times, which are then presented to hospital officials and the Lake EMS board. He stated that the expected ambulance offloading time is 15 minutes, and that the Lake EMS communication center will make contact with an ambulance if 20 minutes pass and the ambulance is still not available, at which point the ambulance will inform EMS that they are either performing a transfer of care or there has been a delay. He commented that the EMS field supervisor will then contact the emergency room’s charge nurse, and said that it is expected for patients to be placed onto medical cots after 30 minutes have passed at a hospital. He also indicated a challenge with hospital diversions, and stated that information about this issue is shared with each hospital in the county.

A citizen indicated concerns from residents of the Summit Greens and Kings Ridge communities with the temporary placement of an ambulance at Fire Rescue Station 109, and the restoration of 24 hour service from an ambulance at Clermont Fire Station 3.

Commr. Campione responded that the ambulance temporarily housed at Fire Rescue Station 109 could not be housed at its original Clermont Fire Station 2 location due to a lack of available space, and that Lake EMS was considering new locations such as the Clermont Performing Arts Center and Clermont Police Station.

Mr. Darren Gray, Clermont City Manager, said that the City owned public property along the U.S. 27 corridor that could be utilized by the County to house the ambulance.

Ms. Ash asked where Lake EMS ambulances were housed in other cities.

Mr. Smith clarified that Lake EMS did not own any buildings to house ambulances, and said that 18 of the 22 ambulance stations were in city fire stations, with the remaining four housed in county fire stations. He indicated that one ambulance was housed in a building rented by the County near County Road (C.R.) 46A and C.R. 44, another was located in a building owned by The Villages, one was in a rented space in Mount Dora, and another ambulance was housed in a public works building in Minneola. He relayed that because housing is being provided for ambulances, there are no charges for the county dispatch service. He said that the challenge with the fire station near Summit Greens was that there was no available space there for an ambulance.

Mr. Molenda reiterated that Lake EMS’ model typically sees its ambulances being called while moving through the county, and that home bases of ambulance units should not affect their response times due to the units only being in the station at non-peak hour times. He added that units deployed from a station during non-peak times would still be able to arrive quickly, as there would be less traffic on the roads and the unit would already be prepared. He indicated that ambulances in stations may be moved to areas where other units are not available, to ensure quick response times throughout the county.

Ms. Ash asked if Clermont’s only 24 hour ambulance was at Fire Station 1.

Mr. Smith confirmed this, and said that another 13 hour unit posts at Clermont Fire Station 3, though it is housed at a station in Minneola. He said that the County’s numerous fire service partners providing paramedics allows for Lake EMS to utilize a lower number of ambulances.

A resident of Summit Greens noted a long ambulance response time that was previously experienced, though commended the Clermont Fire Department and Lake EMS for their swiftness in responding to calls in most cases.

A resident of Kings Ridge asked about the peak period for ambulance service, and why all ambulances are not on call for 24 hours per day.

Mr. Molenda replied that peak hours are based on demand for emergency services, and that Lake EMS has a target response time for these periods. He stated that target response times could still be met with a lower amount of available units during non-peak times, and that data is continually evaluated. He added that service changes may occur, such as transitioning a 13 hour ambulance to 24 hour service, to meet target response times. He commented that Lake EMS uses a service buffer to respond to changes in call volume before communities are negatively affected.

Ms. Ash stated that Clermont had one 24 hour ambulance that could respond to calls within the gap of time that the 13 hour ambulances are not available.

Mr. Molenda added that ambulance units at South Lake Hospital may continue to respond to calls in this period as well, and that responding ambulances are based on the unit’s current proximity to the call, rather than where the vehicle is housed.

Mr. Carle Bishop, Clermont Fire Chief, commented that the most important factor was immediately providing ALS care to patients, and that cases requiring immediate transport were rare. He mentioned that ambulances provide the same care as what is given in hospital emergency rooms, and that, barring a traumatic injury, patients will be stabilized inside an ambulance before transport begins. He explained that fire departments can also provide the same care to patients when they arrive first, and that Clermont had six fire units equipped with ALS.

Commr. Parks stated that it is important to also reinvest savings from the Lake EMS transition to enable continuing training for firefighters, as they are the first responders.

Mr. Ray Goodgame, Clermont City Council, noted that ambulances stationed in Clermont respond to calls in other parts of the county. He opined that temporarily moving the ambulance previously stationed at Fire Station 2 to Fire Rescue Station 109 had caused concern in the community due to a high volume of traffic in the area. He indicated that the presented figures of Clermont’s monetary contributions to Lake EMS considered the MSTU funds, but not insurance paid by citizens for Lake EMS transport. He opined that it is important for citizens to keep living wills in locations where first responders will be able to see them, though noted that South Lake Hospital has these records in their computer system. He stated that efforts were also being made to have paramedics stationed in emergency rooms to immediately receive patients from ambulances. He reiterated that the City of Clermont would be willing to provide its Performing Arts Center to house the ambulance that was temporarily moved to Fire Rescue Station 109.

Ms. Ash mentioned that the Clermont Fire Department always responds to calls with both a paramedic and an EMT, and that those personnel provide the same service as an ambulance. She commented that it commonly takes between 15 and 20 minutes to stabilize a patient before they can be transported to a hospital, and opined that the most important factor was if the patient was receiving treatment from either a fire or EMS unit within five to six minutes of making a call.

Mr. Goodgame said that a condition such as internal bleeding would necessitate immediate transport to a hospital, and thus a quick ambulance response time.

Commr. Breeden acknowledged concerns about the temporarily moved ambulance, and asked if the Clermont City Council could take action on this issue.

Ms. Ash responded that the Council would require more information about what Lake EMS requires to house the ambulance at another location, and noted that other ambulances around the county may arrive quickly to calls in Clermont.

Mr. Smith said that Lake EMS had already been cooperating with the Clermont Fire Department to gather information about moving the ambulance.

Ms. Ash said that Mr. Bishop had also provided her with response times for 2017, and there were 1,279 medical calls from the Legends, Kings Ridge, and Heritage Hills communities in that year. She said that the average response time for Legends was 6:30 minutes, Kings Ridge was 5:37 minutes, and Heritage Hills was 7:18 minutes. She also noted an average response time of 10 minutes for 90 percent of all EMS calls in the County, and that 1,130 patients were transported to the hospital from Legends, Kings Ridge, and Heritage Hills. She commented that the average time of patient treatment through being admitted to the hospital was 25 minutes. She said that the senior development of Heritage Hills only had 170 medical calls for that year, Kings Ridge had 589 medical calls, and the non-senior community of Legends had 520 calls.

Mr. Gray mentioned that it is agreed upon that medical calls receive service in a matter of minutes, and said the City would consider if the temporarily moved ambulance should return to the city.

Ms. Ash also asked if Clermont required the ambulance to be moved back into the city, and if this request would affect Lake EMS’ service.

Mr. Goodgame asked if there were two ambulances currently stationed at Fire Rescue Station 109.

Mr. Molenda replied that there was one ambulance housed at that station, and said that the ambulance may be called out of the station to stage itself in another location.

Ms. Ash said that an ambulance housed in Clermont can provide service to any location in the county.

Commr. Breeden stated that ambulances stationed in other cities may also service Clermont.

Commr. Parks asked about the allocation of EMS resources from Clermont’s MSTU contributions.

Commr. Campione said that Clermont’s MSTU revenue totaled approximately $1.1 million annually, and about $231,000 of that amount comes directly back to the Clermont Fire Department for ALS services, including training and equipment. She added that the remaining $728,000 goes into Lake EMS for service, though there is other revenue generated from patients paying for transport services.

A citizen asked about ambulances roving throughout the day and the benefit provided by having a unit stationed nearby.

Mr. Molenda responded that effectiveness is measured by response times, and that data is used to change EMS service in response to changing conditions, such as growth and roadwork. He indicated that Lake EMS would not have stationed the ambulance at Fire Rescue Station 109 if it would negatively impact response times, and that fire stations around the county also adjust units according to data.

Ms. Ash thanked the officials and the audience for attending.

ADJOURNMENT

There being no further business, the meeting was adjourned at 8:25 p.m.

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timothy i. sullivan, chairman

ATTEST:

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NEIL KELLY, CLERK