Emergency Medical Service District 2 Board Meeting

0:00 Good afternoon and welcome everyone calling to order EMS District 2 board July 13th, 2026. We'll start with the roll call. Rebecca? Board members Overholzer? Present. Belcott? Present. Thornberry? Present. Is it France? Frantz? How do you say your last name? Here. Okay, sorry. And Chair Marshall? Here. Okay, our first action item, and we have several today, is approval of the minutes of April 13th, 2026.

0:58 Are there any corrections, changes? Hearing none, I'll entertain a motion to approve. Chair Marshall, I make a motion to approve. Okay. Approved. Is there a second? Second. Okay. Thanks. Multiple seconds. Thank you for that. All in favor say aye. Aye. Motion carries. Thank you. And Deanne, I'm going to call you up because there may be some questions. We're moving on now to approval of warrants for the first quarter of 2026, and we have a few pages here, so if you want to just walk us through these things, that would be great. Good afternoon, Deanne Cordes, contract administrator. What you have in front of you today are the warrants for Q1 of 2026.

1:53 There are two supplier invoices for $5,975.62 each. That's for our medical program director services. And then also we had two internal service deliveries for $28,030.25. Those are our CRESA dispatch fees. And the total is $68,011.74. And just quickly, I'd like to touch on the second page. Rebecca, if you could advance, please. Thank you. So this is showing for Q1 both the expense and the income. And it's listed out by, sorry, the month and then in the expense column or the income column. And so the fund does receive some interest earnings, and that's what's shown there. And then also the services, those are items that we're paying out.

2:51 So those are the warrants you're being asked to approve today. I'd be happy to answer any questions. Are there any questions from the board? Okay, if not, then I'll entertain a motion to approve the warrants for the first quarter of 2026. I'll move to approve. Thank you. Is there a second? I'll second. Okay. Moved and seconded. Thank you very much. All those in favor say aye. Aye. Motion carries. Okay. Approval of the 2026 fall supplemental budget items. Okay. Again, I look to you, Deanne. Yes. Thank you. In front of you today is a graph with the approved budget.

3:48 That's the first column there in orange. And this was approved last year by the board. If you recall, throughout the rest of 2026, we'll be using the county's budget process, and the fall supplemental is coming up. And we did have a few expenses and revenue that came in after we had to submit our budget. The green column in the middle is what I'm requesting for you to approve today, to amend. We're requesting an increase in the revenue of $11,810, as well as an expense in the same amount. So those two will offset each other. The third column for the revised budget will be what the budget would look like after approval of the fall supplemental. I'm happy to answer any questions. Are there any questions? I have a question. Could you remind us of sources of revenue?

4:47 Yes. Thank you. So currently, we have a contract administration fee that AMR is providing to EMS District 2 as part of the contract. Within that amount, there's some pass-through items. So there's the CRRSA dispatch fees that we pay for, as well as the medical program director and the contract administration fee. So one of the items listed on the budget that's not being paid for by AMR is the state auditor's audit that we receive currently every other year, and we have budgeted $1,000 for that. And then also, the fund receives revenue from interest earnings. Great. Thank you. Any questions? Yeah.

5:38 Just so I understand, the $11,810, you're showing as a pass-through, that we're getting it as revenue, but then it's an expense? That is correct. So we're currently receiving that amount from AMR. We just didn't have that in the budget last year. We actually were able to negotiate that difference with AMR before we executed the contract. So we're actually already receiving that currently. And so this would align that revenue and then the expense for the budget. Great. Thank you. Great question. OK. Any other questions? If not, I'll entertain a motion to approve the proposed budget amendment. So moved. OK, thank you. Is there a second? Second. Moved and seconded. All those in favor say aye.

6:37 Aye. Motion carries. OK. We're whipping through this agenda. OK. And moving on to approval of amendment number one to EMS interlocal cooperative agreement. OK, Diane. Thank you. Last year, the board approved entering into an EMS interlocal cooperative with Clark County and the cities of Battleground, La Center, Ridgefield, and Woodland. And this is what gives EMS to the authority to enter into the ambulance service contract and administer that contract. But it also had language about using the county's budget process. If you remember from January, we talked a little bit about the board change and what that looks like. So this amendment here is actually taking out the language of using the county's budget

7:34 process and giving the process to the board entirely. So I have received approval from the county and three of the cities just waiting on the last city. And today, I'm here asking the board to approve this amendment as well. I'm happy to answer any questions. Great. I think it's a wise move to take this out of the county budgeting process. Any questions or comments? OK. I guess hearing done, I'll entertain a motion to approve. So moved. OK. Is there a second? Second. OK. You have to be quick on this. All right. Moved and seconded. All those in favor say aye. Aye. Motion carries. OK.

8:28 Then we'll move on to approval to amend the bylaws, which everybody has gotten a copy of that's marked up. Go ahead, Deanne, if you want to summarize. Yes. Thank you. At the April meeting, the board had talked about a few different items, one of them being adding a vice chair. And so that language is contained in Article 3.3. And then also with that, I added Article 4 for your consideration regarding powers and duties, and just kind of clarifying what that vice chair would be doing. And then also Article 6 is added for your consideration around the budget process and what that looks like. I'm happy to answer any questions the board might have or any suggestions or changes. Are there any questions? Yes. Go ahead, Councilor. Yes.

9:28 And what-- It's on. OK. It's on now. What brought the decision to adding the vice chair, the reason for adding the vice chair? It was just for convenience if the chair is not available. So it's not-- we don't have to make a decision on the spot who would be the chair. OK. It would be good to have a vice chair. And it's also added that if the chair and the vice chair are not available, the next ranking member would be the chair. So this comports with the county's-- Just clarifies. Yes. Mm-hmm. Any other questions? I have a question. So I agree with the Article 3 amendment. I agree with Article 4.

10:26 For Article 6 with the budget, it just states, "Staff shall prepare an annual budget proposal for the fiscal year with projected revenue and expenses. Staff shall present the budget." Just for everyone out there, who is staff? At this moment, staff is DeAnn. Correct, yes. At this moment, I left it generic because-- in case that did change. Is there a suggested edit that we should be making or considering? Or a clarification? Yeah. That would be my suggestion is clarification of the staff member or members or group that would be in charge of facilitating the preparation of the budget, whether that be our contract

11:19 administrator or if we have a financial staff member that needs to be talked about. I know we talked about this last meeting a little bit of who would prepare the financial statements, and we had talked about contracting that out to a third party. I also ran this by our financial director at the city of battleground, Megan, and talked to her a little bit about it as well as far as what that would look like. So yeah, I was just looking for clarification on the individuals that would be responsible for that preparation. Well, at this time, the county is absorbing that. That may change in the future, I'm not sure.

12:14 So maybe contract administrator, would that be an appropriate term if we were to be more specific? I think it would be better than naming an individual's name to have a more generic statement. I agree with that. Our attorney is nodding yes. Go ahead. Katie Jollma, DPA for Clark County Civil Division. I would agree with you, Chair Marshall, that naming a title for the person instead of a specific name would be ideal for a bylaws change and that at a certain point then if, because you do have the financial, the subcommittee that could, or the board, the executive committee could make a change in the future if the county doesn't want to absorb that cost.

13:12 But Dan, aren't we invoicing for your time? That will start in 2027. Okay, so that's an important factor to remember with this too is that if we list contract administrator, that would be Dan in her capacity as an employee of the county, but that the county will start to invoice EMSD2 for her services related to this specific board. And that's what was agreed to for this going forward, and unless anyone has other suggestions, we'll keep it like that in the bylaws for now. And so that contract administrator would work in both instances? Correct. Okay. Any other comments or thoughts? And would this be a group or not just one person?

14:11 Right now, Dan and myself are, Dan does, I want to give her credit. She does most of the work when it comes to EMSD2, and then I provide the legal oversight at this point, which again would be a smaller cost that would be reimbursed in the future for my services. But of course, each jurisdiction also has their attorneys, which are free to look over and approve as needed as well. But for the most part, Dan does almost all the work behind the scenes. It's mostly a group of one. Yes. Any other questions, comments? Okay. If not, I'll entertain a motion to approve the amended bylaws.

15:07 So moved. Thank you. Is there a second? Second. Moved and seconded. All those in favor say aye. Aye. Motion carries. Okay. Let me get back to my agenda somewhere here. Okay, approve the bylaws, and then I think that takes us to update discussion items. Is that correct? Okay. This financial information, and then we've got some handouts on that as well. Thank you. In front of you today is some financial information as of June 15th, 2026, and this is on the EMS District 2 fund itself.

16:02 And the top box is talking about our expenses per month, so it has it broken down from January through June. Right now our actual year to date is $96,438.60. And then the bottom smaller box is our revenue amount, and that's just broken down by the actual collected in June and then the actual year to date. So between our goods and services and the interest the fund has earned, currently year to date we've collected $128,200. And the very bottom, the working capital amount of $222,250.46, that's the fund balance in the account currently. I would like to note that it also talks about budget amounts in those columns, and that is the budget as of approved right now.

17:00 So not including the amendment that you just approved. I'm happy to answer any questions on this specifically. Okay, thank you. And this is not, this is just an informational item, so if there are any questions or clarifications the board would like? I'm not seeing any. Okay, perfect. Okay. Let's move on then to the EMS administration board report. Okay, thank you. And Chief Knorr, welcome. I know you all have been meeting and I thought it would be good to get an update. Are we on? There we go. Thank you. So the administrative board has been meeting monthly to deal with some of the issues that

18:00 are coming up with the contract and look at some of the items that you've seen over the last three months. What I'm here to talk to you about today is the quarter one report, response time report. And the reason we don't have quarter two is it just ended just a few weeks ago and the data is still coming in and getting assembled. So this is for January, February, and March of this year. And just a little bit of background, the priorities that are responded to, there are priority ones and twos, which are considered life-threatening emergencies. Priority threes and fours, which are dangerous, but not quite life-threatening. And then priority fives and sixes, which is incidents that require response and transport to the hospital, but not necessarily meeting a priority one through four. And then the last box we'll talk about is the interfacility transports. So as we talk about the priority call, that's what the first responder, the fire agencies plus the ambulance get tapped out on.

18:57 High density is the area, it's based on call density. And that has been previously defined as the area south of 179th Street with a carve out for the city of Battleground. So the city of Battleground is in high density up to the north end of the city, plus everything south of 179th Street. So then everything else is low density. High density calls require a response time of 959 or less, 90% of the time. Low density calls require a response time of 19 minutes and 59 seconds, 90% of the time or better. So as we look through that, AMR has been doing a good job on their responses in the first quarter. High density, they had a 91.13% response time or meeting the response time over 90%. You'll see that they're almost 97% in the low density areas. And those were for the life threatening critical calls.

19:57 In the priority three and four, high density was again almost 97% and low density at 95%. Then in the priorities five and six, high density areas were at 94.27% and low density was at 98.11%. So those are actually some really good response times and this is the percentages, meeting the response time a high percentage of the time and this is what we would expect from a contractor. The non-911 routine calls, those are inter-facility transports that are initiated within the EMS 2 response area. A majority of those are coming out of Legacy Salmon Creek Hospital, but there are some other places that may generate an inter-facility transport also. And the contractor, AMR, has a longer period of time to respond to those and so they are

20:53 meeting the scheduled calls 96.3% of the time and the unscheduled calls nearly 98% of the time. So overall good response times. Any questions on those? Any questions? Nope. Looks good. The next page talks about the number of mutual aid calls. So in the emergency response world, we try to staff our system in a way to handle the majority of the call types that you're going to get on a given day and sometimes it gets too busy and you must ask your neighbors for some help. So we do that a lot in the fire service. You'll hear us talk about mutual aid. Police agencies tend to do it to a certain extent also and the ambulance has to be able to do it also because there's days where there's too many calls for the resources you have staffed up. And so AMR had received mutual aid seven times in the first quarter and by the contract they

21:51 were supposed to keep that to below, and somebody had corrected me, I believe it's 3%. So they need to keep that number small. Well, you can see that it didn't even hit, it was at 0.04%. So they're doing a good job of handling their incidents themselves. If you look at the other side, mutual aid given, that is mutual aid that AMR gives to other agencies and that number skews high for a reason. I'll tell you that the agencies they give assistance to are North Country EMS if they're out of ambulances, Camas Washougal Fire if they're out of ambulances. And then in CCFR's response area, CCFR takes the first out on priority ones and twos within our response area. And if another call comes in during that time, AMR takes the call, but we classify it as a mutual aid call. But it's really an area that AMR already has ambulances in, but they step in and take that

22:51 second out call. So it makes it look like the number's quite high, but that accounts for several calls a month that CCFR's ambulance is on an incident and AMR takes the next call that comes in in that area. Any questions on mutual aid? I have a question on that. I'm just wondering of that 170, how does it break down from North Country and Camas? The majority of them are going to be in CCFR's area. So I don't have that specific number. We just talk about the mutual aid given calls and we're looking at that, but I can look into that and let you know next time around. I'm on the board of North Country, so I was just curious. North Country tends to cover the vast majority of their calls. They don't ask for mutual aid very often, but there are times when you get really busy and everyone's out.

23:50 So I'm going to guess that number would be pretty small. Okay. That's great. Good. If you need help, it's good to ask. Any other questions? I do. I have a question. Go ahead. Chief, I'm curious that a couple things you mentioned lead me to think about, in the first page, you mentioned there's a carve out for battleground for the density. Does Ridgefield not meet that criteria? We did not, and that was part of the reason why we worked with AMR to be able to have a first out ambulance for high priority calls. It would have required a kind of recalculating the whole system, and so we've seen a real change since those areas were originally designated based on data from, I believe, 2013. But Ridgefield, the center, Woodland, and the Interstate 5 corridor, where you've seen a lot of development, has not been changed to high density yet. Okay, thanks.

24:48 When would that be reconsidered? I would think the next time the ambulance contract comes up, we should look at those and ask. But really what we're asking, because we've asked AMR to provide service to the City of Vancouver and Fire 5, and a similar service to EMS 2, but they were able to move between the systems seamlessly to help them manage their call volumes and their demands. There are probably areas within far eastern Vancouver and the Fire District 5 area that they served by contract that at one time were considered low density, and call volume is picked up in Orchards and Prebsdale and out that area that would probably have a beneficial effect to look at the whole system that way.

25:42 But that would come up, I would guess, either mid-contract in 2030, or when a contract's looked at again. I can check with staff and see if there's any way to consider that mid-contract, but I think that would be a fairly significant change, requiring a deployment change by the contractor. It would probably be difficult. Thank you. Any other questions? Go ahead. The third page talks about exceptions. So we have a lot of rules that we require the contractor to abide by when answering the calls for service, and there are some exceptions they can make. So there could be something like they're responding and the only way to get to an area, there's another car crash already in the way, so they have to go around it. Or there could be construction that we didn't know about, or there could be some other items

26:38 that meet a criteria, pre-established criteria, and could give them exception. And these are calls where they would miss the time, they would have exceeded the time, but when they have good reason for that, they can turn in an exception report. So in the first quarter, AMR made 29 requests for exceptions to a response time that went too long. Those were reviewed by the contract administrator, work being done by Fire District 6 right now. And 19 of the exceptions were approved, 10 were denied. And that just gives you a little bit of a rundown on it. And I recognize after I printed it that there's some scroll downs that did not get captured down at the bottom of the page there, but it just gives you an idea. So of the approximately 3,750 calls that occurred in the first quarter, you know, AMR only asks for an exception for going over response time a small number of times, and then an even

27:38 smaller number is approved. >> I have a quick question. You mentioned the contract administrator is done by Fire District 6, could you explain that? >> Yes, though I may ask Deanne to come up and make sure I'm getting that one correct. But there were some portions of the contract data. So like this, all the data that's being collected, and some other compliance issues that needed to be taken care of, the expertise and time was not available within staff here. And so in talking with Chief Russell at Fire District 6, and Dr. Mokht, and Chief Dronan and I, Chief Dronan from District 3 and myself, we were able to weigh in on that. And Fire District 6 has taken on the work of looking at the data, making sure everything's in compliance. Would that be mostly accurate? >> Is that something they get reimbursed for? >> Yes.

28:37 >> Okay. >> Just quickly to add, that's perfect, Chief North, thank you. Not only does Clark 6 have the expertise, this was also something being done by the City of Vancouver previously. And so in 2026, this was something that the district identified, we don't have the resources, we don't have the expertise, and the board allowed us to enter into a contract with Clark 6 for those services. >> Great, I just think it's important for us to reinforce all the moving parts that make up EMS District 2, so thank you for that, go ahead. >> That's all the information I have, I'd be willing to take any further questions. >> Are there any questions? No questions? >> Thank you. >> So thank you, and thank you, Fire District 6.

29:30 Okay, then moving on to clinical report by Dr. Macht. >> Marla Macht, Medical Program Director for Clark County EMS, and so my goal with this presentation is to talk about what happens after the fire department and the ambulance get there, how we care for our patients. Next slide, please. So our mission is to provide high quality emergency care to our patients when and where they need it most. So when people ask me what I do as an EMS Medical Director, ultimately what I do is take my medical experience and use that to ensure that we build a system so that every person who calls 911 gets the kind of care that I would want for me or my family every

30:29 time, and that's the essence of this work. Next slide, please. And so what I'll talk about today, I'll give a brief report on the performance of the system. You also had received by email our annual report, and that is available to anyone who would like to review it at clarkmpd.org/quality. Chair Marshall had asked me to talk about strains or risks to the system, and we'll talk about that, and then I'll talk about our strategic approach to mitigating those risks. Next slide, please. And so first we'll go into the performance of the system. So this is our internal data about the number of patient records by month going from July of 2023 to June of 2026, so you see there's been a steadily increasing demand for EMS

31:23 services within Clark County, and so the focus of our office is ensuring that when there's that call for service, that's provided safely and with high-quality care. Next slide, please. So we use national measures, and we benchmark against what's reported on the National EMS Information System Public Measures Dashboard, and so that's where all of the national data comes from, and so we're using the same measures to benchmark here. So one measure of a high-performing EMS system is that we respond safely, and we want to respond whenever possible without lights and sirens. Why? Because one, we know that using lights and sirens roughly doubles the risk of getting in a crash on the way to the call. That risk is low, but it doubles when we use lights and sirens, and then we know that there

32:18 are absolutely calls that require a time-sensitive response, but that is a relatively small portion of our calls. From our internal data, it's roughly 14 percent of EMS calls require a time-sensitive intervention. Next slide, and go on to the next, which will show the graph as well, please. So we also mark how often we transport without lights and sirens. The reason that we monitor this is that we have set our ambulances up so that almost everything a patient needs in the first 30 minutes of their care, they can get in the ambulance. Now, there are exceptions. There are times when a patient may need a surgeon, they may need a cardiologist to open an artery. And so we use lights and sirens in those times where the benefit to the patient justifies the risk to the patient and the community, but we try to do that infrequently.

33:17 We've made steady progress on that, and we perform well above the national measure on that benchmark. Any questions about response and transport? I have a question. Here we go. The instance of accidents doubling when you're with lights and sirens, is that a driver training problem? Is that a public issue, or both? I think it's both. I do think it is. It sounds like the intent of lights and sirens is to get people out of your way. This comes from national research that it looked at across the United States, the number of crashes driving with and without lights and sirens. All of those factors are in play. And I will defer to the fire chiefs and the lead of AMR to talk about how they train their drivers to do that.

34:15 I think it is something that we can always look to improve in safety, but it is inherently difficult. And then I think anyone who has driven with lights and sirens will know that people's response to lights and sirens can be unpredictable. So I think it is a public safety issue. The state law currently does not allow us to just turn signals green without using lights and sirens. And that's another place where we could potentially improve response times while keeping the risk low. Other questions? I think we're good. Okay. Next slide, please. So one of the key measures of an EMS system is how well do we do resuscitating someone whose heart has stopped? And this is a very small percentage of our calls.

35:11 It's less than one-tenth of one percent of the calls that we respond to, but they're incredibly impactful. And so in Clark County last year, in 2025, there are 53 people who were dead, their hearts had stopped, and they are alive today because of the work of the EMS system and our partnership with the hospitals to take care of those patients. And so I'm deeply grateful to work with such dedicated individuals who are willing to respond to these calls with proficiency and excellence all hours of the day and night that are responsible for doing that. You can picture 53 people in this room here, and what a difference I would make. We compare our performance to the national benchmark, which is in the CARES cardiac arrest database. And so national performance in 2025 was 11 percent of all cardiac arrests survived to hospital discharge, and Clark County was 16 percent.

36:10 So if we had been performing at the national average, there would be 19 fewer people alive. So again, that all credit goes to the people who do the work of roughly 300 paramedics and 500 EMTs across the system who do amazing work and have an incredible impact on our community. Next slide, please. I just have a question on this. Did this also include, like, focusing on airway passages or some specific -- So we did -- so last year, as you mentioned, our key quality improvement focus was improving first-pass success without low blood pressure or low oxygen. Now, that measure was specifically for patients who had not experienced a cardiac arrest, but that is a measure that we use to ensure that when a patient is in respiratory failure, they're about to die because they can't breathe well enough, that we carry out the critical intervention, passing the breathing tube in the safest way possible.

37:10 So we go into more detail in our 2025 annual report on that, but that was an area in which we made significant improvement, and our work was featured in a national case study for the work that was done there. And in the Columbian recently, too. And how was that focusing on that -- how was that decision made, or how did that information get disseminated throughout the system? So the decision to focus on that was my decision in partnership with the EMS officers from each of the agencies. We recognized this as an area of risk, and we saw it as an area of potential improvement. And then we made the improvement by doing continuous cycles of quality improvement to plan, to do, to study, to act, to figure out how we can make it easier to provide this

38:06 really time-sensitive care in an uncontrolled environment and in challenging situations. I ask because I think it's a good example of how the collaborative system really functions to save lives, so it's commendable. Absolutely. No, I'm deeply grateful for the collaboration that we have amongst all of the EMS agencies within the system. We are very lucky, and I feel very lucky to live in a community where we have that level of collaboration. Move on to the next slide. So going deeper into cardiac arrest, the times when EMS can have the greatest impact, the people who are the most savable from cardiac arrest are those whose hearts need to be shocked. These are people who die suddenly, and what they need is for their hearts to be shocked to come back to life. So out of 50 people who experienced this in 2025, 27 are alive today.

39:05 That's included in that, the number from before of the 53 survivors, 27 were in this condition where their hearts could be shocked. That means that 54 percent of people who experienced a sudden arrest where their hearts could be shocked survived to leave the hospital. We always strive to improve, and these are smaller numbers than the previous slide. But again, we have performance that's above the national average, and it's also above the state average. And again, it's all credit to the people who actually do the work. Next slide please. And then in terms of taking care of heart disease, which is one of the biggest killers, the other things that we do are we work to identify heart attacks. So for these measures, there is not a national average performance reported. The American Heart Association has suggested benchmarks, and that's what I've reported here.

40:00 So one measure is to perform an ECG, to look at the electrical activity of the heart within 10 minutes of patient contact for a patient that's having chest pain. We hit that measure 72 percent of the time, and the AHA targeted 75 percent of the time. Next slide please. And then go ahead to show the graph as well please. And then the next measure is when we do the ECG and it shows a heart attack, an ST elevation, myocardial infarction, or STEMI, then we want to notify the hospital within 10 minutes of getting that first positive ECG. The reason that we do this is that from the EMS activation, we start all the wheels rolling to get the cardiologist, the support staff, all the people into the hospital. The ultimate goal is that from the time someone calls 911 until they get their blocked artery open is 90 minutes or less. We have imperfect data on that, but across our county we're meeting that roughly 75 percent of the time.

41:00 And this small portion of that, the STEMI notification, we get that within 10 minutes 61 percent of the time. That is a target for improvement in the coming year. I do think we can continue to improve on that, but I also want to be very transparent with where our performance is. Any questions about cardiac disease? Okay. Next, we take care of the brain. And so when someone is having a stroke, we want to ensure that we've performed an appropriate stroke screen and then we use that to notify the hospital so they can identify the appropriate teams. We perform above the national average on that benchmark. Next slide please. The other thing that we do is we treat low blood sugar or hypoglycemia. The brain can only last a very short period of time without a consistent supply of oxygen and sugar.

41:55 And patients can experience brain damage if we don't reverse their low blood sugar. And so we perform well above the national average on that measure. Any questions about neurologic emergencies? And then finally, moving on to trauma, one of the things that matters most to patients is that we improve their pain for patients that are injured. And so the national performance on that for the time with EMS is 19 percent. In Clark County, we're at 27 percent in 2025. And we've seen continued improvement in 2026 as we've introduced some other medications to help manage pain in injured patients. Next slide please. And then we also, the next thing we measure is how we capture vital signs for injured patients. The pre-hospital vital signs are critical for letting the trauma team know what to expect.

42:52 And even a brief drop in blood pressure can be an important warning to the trauma team. So we perform above the national benchmark on that measure as well. Any questions about trauma? And then you'd also ask about risks to the system. So I'm just going to give you my best assessment of the risks that exist. So just a brief review on the funding sources for EMS. So ambulance service is primarily funded by fee for service. That includes billing commercial health carriers and Medicare and Medicaid constitute the largest portion of ambulance billing in Clark County. There is some federal funding for EMS that is primarily for specialty teams such as a hazardous material team or the hazardous material team is a good example of that.

43:49 There is some state funding that's primarily given as grants to support training and some for injury and violence prevention. And then there's a local government funding, obviously what you do here and then the fire departments that are responsible for that initial response to the scene and in some cases for transport as well. But even those, the public services such as North Country or Camas Huachuca Fire and Rescue or CCFR that also provide ambulance service, they do rely on billing insurance carriers to begin to recover the cost. Next slide please. So the Washington State Institute for Public Policy recently released a review of EMS service in Washington State. And so the demand for EMS service in Washington State as I've shown you has increased and is projected to continue to increase.

44:48 Next slide. So the local risk that I see, we do have an increase in call for service and compared to the national benchmark, we are better than the national benchmark but we still have a relatively high rate of response to EMS calls with lights and sirens. As you have experienced, there are financial pressures on the current model. So in 2026, the number of uninsured patients has increased and that is projected to increase in coming years. What has happened in the past when the number of uninsured increases is that more people choose to go without coverage and so then the insurance pool is filled with sicker patients and that in turn tends to raise the rate for commercial insurance. Many of us have already experienced that increase in 2026 and there is certainly risk that it will continue to increase.

45:47 There's been a relatively low rate of growth in Medicare and Medicaid payments which constitute the bulk of payments and then as this board has discussed, ambulance rates have increased within the county. So the way -- we'll go on to the next slide, please -- so I don't want to be the doctor that prescribes something that no one can afford and isn't practical. I want to, as best I can, use my medical expertise to focus the resources on this system where they can have the most impact. And so our approach is to develop this -- to continue to refine our data-driven approach to provide care that's safe, timely, and cost-efficient. With the support of the fire districts, we're collaborating to share and analyze data and we are linking data from the dispatch center to the EMS system and we now have hospital-level data including what the diagnosis was for the patient and from the hospital, whether

46:43 they lived or died in the hospital and where they went when they left the hospital. And so my hope is that we can use this to focus our resources in the areas where they can have greatest impact. We are continuing to engage with federal partners to fund programs that are impactful. We were awarded a Safe Streets for All grant and that was awarded in December of 2025. We are still awaiting the award letter that will allow us to move forward with that. And then we are advocating for state-level change to support alternative models of care, specifically treatment in place for patients that don't require a trip to the hospital because an ambulance ride to the emergency department is the most expensive route to the most expensive care. If there are patients that can safely be cared for using alternate means, we want to do that

47:38 because I imagine your constituents want to know how this system is stewarding their financial resources and what we're doing to mitigate the risks that could make the system more expensive. Next slide, please. So in conclusion, our office prioritizes high-quality care and if I could do nothing but just make sure that patients got the best care, I would love to do that and I wish I didn't have to think about these financial issues, but I think because of the pressures on the system, I do see a need to work to focus our system so that we can continue to provide this life-saving care to the patients who need it, but we want to continue to look for opportunities to make a more cost-efficient system that delivers to your constituents the care that they want. Great.

48:34 This is really a great report and good to see how this all fits together. I think it's important for the board to understand that. Any questions from the board? No questions. I would just suggest that if there are like state-level changes that could be advocated for from a policy perspective, please bring those forward both to this board and to the county council and where we can, we could help out with that. We'll do and particularly the one that will be considered by the legislature next year is allowing the health care authority which manages Washington state Medicaid to support treatment in place. I'll make a note of that. Thank you very much. Okay, moving on to public comment. Is there anyone from the public who would like to make a comment? Anyone online? Nobody online.

49:34 Okay. Then with that, unless there are other further comments from the board, I don't see any. We've completed our agenda and without objection, this meeting is adjourned. Thank you.