2023/02/27 Comm. Meieran resolution on AMR staffing (denied agenda placement)

BEFORE THE BOARD OF COUNTY COMMISSIONERS

FOR MULTNOMAH COUNTY, OREGON

RESOLUTION NO. XXX

Resolution Urging Multnomah County Chair to Exercise Her Authority to Temporarily Change Ambulance Staffing Protocol.

The Multnomah County Board of Commissioners Finds:

  1. Under ORS 682.062 (County Plan for Ambulance and Emergency Medical Services), counties are responsible for establishing plans that relate to the need for and coordination of ambulance services within their jurisdictions. Ambulance Service Plans require approval by the Oregon Health Authority (OHA).

  1. Multnomah County’s Ambulance Service Plan (ASP) was originally adopted in 1994. It established the entire County as a single ambulance service area; required that all ambulances responding to calls needing Advanced Life Support (ALS) be staffed with two Paramedics; and established the “8 minute/90 percent” standard for response times, a requirement that all ALS ambulances needed to respond to ALS emergencies within 8 minutes 90% of the time.

  1. The ASP was updated and approved by the OHA in 2016. The updated version acknowledged that emergency medical response had evolved, with more sophisticated and effective triage approaches; more evidence and understanding of medical emergency conditions such as cardiac arrest and stroke leading to more advanced treatments; improved training for medical first responders, including Paramedics and EMTs; better understanding of patient and worker safety in the context of emergency medical response; and more refined approaches to quality control and continuous improvement models for evaluating Emergency Medical Services (EMS) performance.

  1. In addition to updating the ASP, in 2016 the Multnomah County Board of Commissioners updated Multnomah County Code Chapter 21.406 to comport with the ASP. Among other things, the Code establishes duties of the EMS Director, and places authority over ambulance staffing, including any changes, under the EMS Director’s exclusive control. This includes authority to temporarily alter staffing as necessary to meet public health needs during extraordinary circumstances which overwhelm the emergency transport system or cause a shortage of ambulances.

  1. The Multnomah County Chair is the only individual on the Board with authority to direct action by Multnomah County department leadership, including the EMS Medical Director, pursuant to her role as the County’s Chief Personnel  Officer and Chief Executive Officer.

  1. Since the adoption of the updated ASP in 2016, conditions have changed dramatically in the Multnomah County service area and a confluence of unprecedented events have unmasked profound deficiencies in the County’s management, oversight and coordination of emergency medical response. The events include:

    1. The COVID pandemic that stressed all of the nation’s emergency response systems and placed tremendous strain on front line healthcare providers, particularly first responders;

    1. A national shortage of Paramedics both currently and in the education and training pipeline, exacerbated in Oregon due to uniquely restrictive rules governing Paramedic qualifications;

    1. An addiction crisis resulting in escalating rates of overdose and death, with the Governor of Oregon, the city of Portland, and Multnomah County issuing declarations of a Fentanyl emergency;

    1. A mental health crisis resulting in increased acuity and number of people experiencing serious mental illness;

    1. A homelessness crisis with escalating numbers of people living unsheltered and experiencing injury, exposure, and violence, in addition to their other underlying medical conditions;

    1. A surge in 911 calls, increasing 20% from 2018-2022; and

    1. An increase in violence, including gun violence, resulting in threat of serious injury and death for emergency first responders.

  1. The confluence of unprecedented circumstances has placed an extreme burden on medical first responders in Multnomah County.

  1. The combination of events has led to a critical ambulance shortage leading to unprecedented incidence of Level Zero (no ambulances available to respond to emergencies) and delayed ambulance response times.

  1. The unavailability of ambulances and delayed response times has had a profoundly negative impact on partner first responder agencies and workforce, particularly Portland Fire & Rescue (PFR) and Gresham Fire and Emergency Services (GFES).

  1. Residents throughout the County who call 9-1-1 with emergency medical conditions are at risk of worsening conditions and even death when they attempt to call for help but emergency medical care is delayed due to an insufficient number of ambulances available to respond.

  1. Multnomah County’s ambulance service provider, AMR, has proposed a change in ambulance staffing that would significantly increase the number of ambulances available to respond to emergencies - switching from a two Paramedic staffing model for ALS ambulances (“2PM”) to a one Paramedic and one EMT model (“1:1M”).

    1. In the 1990s, the 2PM was a well-established approach to ambulance staffing. Since then, there has been an evolution in emergency medical response systems, ambulance equipment, understanding of underlying medical emergencies, and first responder training and guidelines. For example, historically, only Paramedics could operate a defibrillator. Now, even lay people can use a defibrillator.

    1. The 2PM is still employed in some jurisdictions, but these jurisdictions all have unique features which differ substantially from Multnomah County. And all of the jurisdictions employing the 2PM in the United States are experiencing extreme challenges and are contemplating changes to their systems. Denver just abandoned the 2PM model, citing many of the factors impacting Multnomah County.

    1. For virtually all life-threatening emergencies, the time to receiving care is more important than the personnel responding to the call, assuming a baseline level of training. The 1:1M has become the national norm for responding to virtually all medical emergencies, optimizing staffing and length of time to ambulance arrival.

    1. In many jurisdictions a single ambulance Paramedic is supplemented by a Fire Response Paramedic, resulting in what is, in essence, a 2PM response to true life-threatening emergencies. This is the case in Portland and East County, as attested to by PFR and GDFES.

  1. PFR and GFES have repeatedly expressed concerns about Multnomah County’s ambulance staffing and urged Multnomah County EMS to adopt a 1:1M, at least temporarily during the current ambulance availability crisis.

  1. In response to the critical ambulance shortage, the County EMS Director and the County Chair have suggested various procurement- and contract-related reasons for not being able to change the ambulance staffing model; have fined the ambulance service provider for not meeting contract standards; have circulated information about PFR’s response to life-threatening emergencies that has turned out to be inaccurate; and have attempted a pilot alternative staffing project that resulted in incidences of mistriage.

  1. County leadership’s efforts to address the ambulance availability crisis have not led to any meaningful improvements in ambulance availability, and in some cases may have worsened the situation due to delay and the dissemination of misleading information.

  • Multnomah County is responsible for ensuring that ambulance services respond to emergencies in the most efficient, safe and effective manner possible. SUbstantial evidence suggests that a change in ambulance staffing from a 2PM to a 1:1M would increase ambulance availability without risking patient or worker safety.

  1. Providing more ambulances on the streets will improve access to timely and appropriate care and save lives.

The Multnomah County Board of Commissioners Resolves:

  1. The gravity of the situation demands urgent action to protect the well-being of Multnomah County residents and advance steps that can get more ambulances on the streets of Multnomah County in order to save lives and reduce harm.

  1. The Board urges the County Chair to exercise her authority to do the following:

    1. Direct the EMS Medical Director to order a temporary change in ambulance staffing to allow for a 1:1 staffing model while there is a critical lack of ambulances available to respond to emergencies.

    1. Require the Health Department to evaluate the impact of the change in ambulance staffing and in five (5) months report to the Board on changes in clinical outcomes, changes in response times, amount of time spent at Level Zero, and adverse events. If there are any situations resulting in significant harm to individuals being served, these should be reported immediately and consideration given to reverting to the current ambulance staffing model.

ADOPTED this ___ day of ______, 2024.

BOARD OF COUNTY COMMISSIONERS

FOR MULTNOMAH COUNTY, OREGON

Jessica Vega Pederson, Chair

REVIEWED:

JENNY M. MADKOUR, COUNTY ATTORNEY

FOR MULTNOMAH COUNTY, OREGON

By

Jenny M. Madkour, County Attorney

SUBMITTED BY: Sharon Meieran, Multnomah County Commissioner District 1