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HomeMy WebLinkAboutAGENDA REPORT 1991 1002 CC REG ITEM 11I 012191 CCn'tik ° 1 MEMBERSO H BOARD .4. O F VF MAGGIE ERICKSON KILDEE • ' ? .:'0,1 ;=FT.',-4`A Chair J' r `~ V "t '1:C. SUSAN K. LACEY CO;\ .r' d� D MARIA E. VANDERKOLK � `r` VICKY HOWARD I1 Q� x JOHN K. FLYNN (',�`r.FJ�NP VICKY HOWARD SUPERVISOR, FOURTH DISTRICT (805) 582-8010 BOARD OF SUPERVISORS FAX 1805) 582-8055 INTERNAL MAIL, L #5910 COUNTY OF VENTURA 3855-F ALAMO STREET SIMI VALLEY, CA 93063 Agenda Emergency Medical Services/Paramedic Meeting September 27, 1991 3: 00 p.m. Supervisor Howard's Office During the last meeting we discussed several topics to be on the agenda for this meeting. Please review this agenda and if you have • any additions or deletions please call Linda White at 582-8010 or fax document to 582-8055. The topics are as follows: I. Response Times (Please see attached documentation) II. CAD Prioritization System A. Emergency Medical Dispatch III. Pilot Study (Status) IV. Implementation of EMT-D Program ' V. Paramedic Issue Moorpark w VI. Discussion of other topics, and scheduling of next meeting. • -- RECEIVED ..• -. SEP Z ? 1991 City of Moorpark • 6.-) RucyC/erl Paper -) Pruner Health Services, Inc. September 19, 1991 72 Moody Court Thousand Oaks CA 91360 (805)496-4664 Supervisor Vicky Howard County of Ventura 3855-F Alamo Street Simi Valley, CA 93063 Dear Supervisor Howard: , In preparation for the upcoming EMS/Paramedic meeting on September 27th, we have reviewed all of the ambulance calls Pruner received in the Moorpark area for a 3 month period ending July 31, 1991. We have enclosed a complete recap of every call received, including dry-runs and AMAs (patients that refused treatment and/or transport "Against Medical Advise") . It again becomes quickly apparent that the total number of emergency service requests in Moorpark that actually end up receiving paramedic (ALS) treatment is extremely small. ALS transports averaged just less • than 10 per month during this 3 month period. Of the 29 total ALS transports, 13 patients (45%) received only an IV line and/or cardiac monitoring as ALS treatment. This would have left roughly 5 calls each month in which all of the paramedics that would be participating in the proposed pilot program would have shared the possibility of providing, on an actual . patient, one or more of the entire remaining scope of advanced life support procedures and drug therapies that they are required to be proficient in. Dry-runs continue to represent a very high percentage (47%) of all responses occurring in Moorpark. This is approximately 17% higher than the average percentage of dry-runs occurring in our other service areas. ,l v 10, 7() .). • .. .) i1 "l!!S'Bct,on .• The summaries provide additional recap statistics along with details about patient conditions and treatments rendered for every call. Hopefully, this information will assist the meeting's participants in attaining an accurate perspective of the issues involved in providing paramedic service to the Moorpark area and in reaching effective conclusions. Sincerely, PRUNER HEALTH SERVICES, INC. Steven G. Murphy, R.N. Chief Administrative Officer U We mg ill V c e e z ° 8 a v a u 9 a '" d W w ' s z CO „'r lVOa a 3 8 3 N N 0 ._ N 'a; a co m O 0 y O N N 0 Ss• .-4w c�a w w w w W IJ < S Q Q Q w w < a Q w Q a < a Q a m m a m m Q re 0IC4 a a a o d t 1-4 ' O < L. H 0 W m + 0 3 N a 0 ° x z E . ao a '1 m 'a g •8 Q 'c i e a s + ? a. .'g W 8 e g a % . F < Eu am m as m m .0 S p a + rE ao 3 .e 8 d CO 11. 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'' _ III70 I ;< .- c9 U) O O O 0 p Cpl 1CO N T -,co I -T.� •-. 7- N rpQf A O O C C C• C• n = 7 A 0 A Fs' C D O Q D rt G O E S. m ~ 0 0 0 0 C K = o o 0 0 0 o Q o 0 0 o a a o` n n -7'4. a CD CO CD CD C) Mo Cl, 4.1) Cl) m N m I I I C) 10 p N D O CR O ;�:. O V) y' (n .y-. 3 O_ N O _ _ = C co co co —! N C) C) n fD _ -=.i o CD CD CD .-«. O 3 O n O O o o n CD O n n n ^'1 O , 0 O C> O n nO 0 N o . = co co • O \ / / ) \ 2 § ` R : } # = j \ r . \ \ Ems\ . . ' �{ � ® p� mf NJ � 0\ om0r \ m * •T x - � ; E k� &� \ � ! 0et I ; ` - [ ( ƒ ! : -C- ' 22 ! 30. , � ƒ � E • • • • • MOORPARK PARAMEDIC STUDY Background: The City of Moorpark has a desire to enhance emergency medical Services and improve response times in its City. Several options have been explored including (1) an Emergency Medical Service (EMS) Station in Moorpark, (2) a paramedic pilot program in the City's two local fire stations and (3) expansion of the County' s contract With the current ambulance company to house a paramedic unit locally (probably in a fire station) . The City, through its Budget and Finance Committee, has attempted to. identify the advantages and disadvantages of each option including the extent to which the option would improve EMS and the related cost. A report to the Moorpark City Council, dated May 10, 1991, summarized the Committee's findings as follows: 1. EMS Station in Moorpark This option would provide a paramedic ambulance in a central location with a response time in the 3 to 6 minute range. Cost for the service, as an enhancement to the County EMS System, would be approximately $270,000 per year. The EMS System would provide backup services when the local unit was busy or transporting a patient out of the area. • 2. Paramedics in Fire Stations A one-year pilot program would provide a paramedic at Stations •� 40 and 42 in Moorpark to evaluate the concept of paramedic services in the County Fire Protection District. The ,�,•'� Firefighter position on each engine would be reclassified to • Firefighter/Paramedic and the engine would be equipped with' . the necessary paramedic apparatus. Response times would also be in the 3 to 6 minute range. Cost for the one-year program was estimated at $70, 000 for the staffing and equipment. 3. EMS Station Co-Located at Fire Stations An ambulance would be located at one or both of the Fire • • Stations 40 and 42. Response times should be in the 3 to 6 minute range. No cost estimates were available. • The Committee indicated that any of the above proposals would improve response times in the City, which were estimated at 8 to 9 minutes. • ...__. ...... .. •+3 . 1 OL1, Li tis The Moorpark ,City Council took action, on May 22 , 1991, to support the paramedic pilot program (Option 2) and to place a qualified paramedic as one of the three persons assigned to each shift in both Moorpark Fire Stations. The Council also took action to finance the one-year pilot program by budgeting $75, 000 for equipment, bonuses and salary adjustments and, tentatively, up to $50,000 for other program costs . ' The City council requested the Board of Supervisors to take action on the proposed pilot program. The Fire Protection District, also conducted preliminary research on Option 2 and, while not opposed to the proposal, believed that the City's funding earmarked for the program was not sufficient to cover all program costs. The District also expressed concern over several programmatic issues. As a result, at the request of Supervisor Vicki Howard, the County Chief Administrative Office has Conducted further research on Option 2 . The purpose of this report is to present an objective program summary and cost estimate of Option 2 . The report is not intended to evaluate whether this option is the most effective or efficient program alternative, however, this report does address the logistics of the pilot-program, EMS delivery network and the programmatic concerns, some of which remain unresolved. NOTE: While this study was in progress, the City, in its pursuit to consider all viable options, also requested the Fire Protection District to research the feasibility of housing a Pruner Health Care ALS ambulance at one of the two fire stations located in the City of Moorpark (Option 3) . The District, in response to the request, has indicated that Option ` 3 is not practical or feasible. While there is adequate garage space at Station 40 to house an ambulance, the personnel quarters will not accommodate additional people. There is also adequate garage space at Station 42, however, even with relocation of Sheriff ' s deputies and station personnel the conditions would be unacceptably crowded. • 2 •:t Pilot Program- and EMS Coordination: Representatives from the Ventura County Firefighters Association, the Fire Protection District, Ventura County Public Health, Emergency Medical Services and the Chief Administrative Office met several times to discuss the composition of the proposed pilot program. There were several outstanding issues which were .:• addressed and, ultimately, consensus from all members of the review committee was achieved. • If the City decides to proceed with the one -year pilot program for enhanced paramedic service delivery within the City, it is recommended that the program will consist of the following components. The one-year pilot program should: 1. Include one Firefighter position on each shift, at each of the two Moorpark Fire Stations, who will be a trained (certified and accredited) paramedic. This position will be a modification of a currently existing position allocation (reclassified to Firefighter/Paramedic) and will not be an additional position to the engine company. Training and salary compensation are discussed below. 2. Supplement (not enhance) the current paramedic program provided by a private vendor. The private vendor will continue to provide the coverage with one EMT-D and one paramedic on each ambulance and will provide transport. 3 . Be acceptable and compatible with the Emergency Medical Service delivery system throughout the County. 4. Maintain current emergency response priorities. The two engine companies will continue to respond to all emergencies and provide back-up to other stations as required. • • 5. Include the provision of all required equipment necessary to provide paramedic service. This is discussed in detail below." 6. Be financed entirely by the City of Moorpark. 7. Retain eight certified and accredited paramedic firefighters at all times. This number should be sufficient to provide • • coverage for two positions on three shifts and provide coverage for sick days and vacation days. The Ventura County Firefighter Association has indicated that there . are a total of 13 paramedic trained firefighters currently on staff • with the Fire Protection District. Of these, all 13 have indicated a willingness to be assigned to one or either of the two Moorpark • • * Stations. There is some question as to the status of the paramedic 3 certification and accreditation of the 13 firefighters. In June, 1991, only 4/ firefighters were actually certified and accredited; uaa (A .1iL-Lv.ac�1 .�vu11 liuva uk...iFurrll.�l.o.l LI . � itl>ir. b1» lo-�+� months. The status of the 13 firefighters will be verified to insure that there are an adequate number to commence the pilot program (if and when that is the desire of the City) . -The District has expressed concern that the initial assignment of eight paramedics to the program will not be sufficient. While the District agreed to this number, the District believes that actual experience during the pilot program will show this number to be insufficient. Possible Pilot- Program Concept: Under the pilot program, the Fire Protection District would continue to be the first responder. Upon arrival of the engine company on the scene, and if warranted, the firefighter/paramedic (along with other members of the company if necessary) would provide advanced life support (ALS) medical assistance to the ill or injured party. Upon arrival of the private vendor (ambulance) the paramedic assistance and responsibility would be transferred from the engine company, as appropriate, to the private vendor. With the transition of service from the District staff to the private vendor, it is possible that some of the equipment in use would remain with the ill or injured party to be utilized by the private vendor while in transport. Also medical supplies will have been used by both the District staff and the private vendor. The District and the private vendor will cooperatively determine which entity will provide and/or replace the medical supplies and how the equipment will be returned or replaced. Any additional costs to the District for these supplies, to support the pilot program, will • be financed by the City. patient Transport: The private vendor would continue to be responsible for patient transport to the Base Hospital . If, due to circumstances, the firefighter paramedic must accompany the ill or injured party, the entire engine company will be required to travel to the Base Hospital to retrieve the firefighter paramedic, During this time, the engine company, with only 2 staff members, will be unable to respond to other emergencies until the firefighter paramedic rejoins the engine company. Since the Base Hospital could be either Simi Valley Hospital or Los Robles Regional Medical Center, this inoperable status could exist for 30 minutes or more. e. The transport and staffing arrangement under the pilot program, may require further coordination between the County EMS Agency, the 4 District and the vendor. Currently, the vendor must (according to contract) provide 2 EMT-1 ' s (BLS) in the ambulance. A current trial study allows the vendor to staff each ambulance with 1 EMT-1 and 1 EMT-P (paramedic) . The vendor is able to cover the provision of advanced life support by billing the ill or injured party for all ALS services. ' if paramedic coverage is partially provided by the District, it may change the vendor's operation and may result in a request for contract modifications specifically addressing staffing levels . In addition, the rate structure may be reconsidered. (Recommendations to revise the rates must be presented to the Board of Supervisors for approval. ) While it is not anticipated that contract modifications would result in increased costs to the County or the City for the pilot program, it may affect the ill or injured party due to potentially revised rates . Concerns have also been raised regarding the potential conflicts between paramedics from different 'agencies working the same patient. Dr. David Chase, Paramedic Liaison for VCMC, has strongly --4--r that the District personnel accompany all ALS patients y to the Base Hospital and not transfer any responsibility to another ALS provider. This arrangement would insure continuity of care to the patient and minimize the liability potential to the District. If this transport arrangement is included in the pilot program, costs to the City may increase to provide mileage (to/from the medical facility) and to reimburse the District for additional fire suppression back-up costs, if any. According to State Health and Safety Code, the proposed program is • acceptable and compatible with the EMS delivery system. As a pilot program, it is anticipated that the program will cause no or little disruption to the EMS delivery system. 4 . Other Concerns: •`'''. N. Another concern is the provision of ALS coverage, when the engine company(s) are already responding to a medical or other emergency. Back-up coverage will have to be coordinated as appropriate. • The County EMS Agency has suggested that the pilot program may have • some impact on the Base Hospitals, specifically, Simi Valley Hospital and Los Robles Regional Medical Center. This impact could include additional monitoring responsibilities for the Paramedic Liaison Nurses, but these are not thought to be significant increases . An orientation session for the "new" EMT-P' s would be :, needed to familiarize them with Base Hospital (BH) operations and expectations. The BH's have the capability to provide medical control for multiple calls. The intent is that at the end of the program year, the program will 5 be evaluated and the above items will be considered in determining whether the service should be continued in the City and whether enhanced paramedic service should be considered for other areas in the County. There is some concern that since this pilot program is being conducted in an area of limited medical emergencies due to the small population, that one year may not be sufficient to fully analyze the success or failure of the program. It has been suggested that the City may want to consider a longer period of time for its pilot program. Fire Suppression Response Coverage: As was mentioned earlier, if the engine company must accompany the patient to the Base Hospital, arrangements for another area engine company to cover the fire station area must be made . In most cases, this will be accomplished by having Stations 40 and 42 cover for each other. During this time, albeit brief, one engine company will be providing general emergency response coverage for twice the area it normally serves. In most cases, it will not mean that an additional back-up engine company will relocate to Station 40 or 42. This could increase response times by 8 minutes or more. In addition, ALS calls, on the average, take longer than Basic Life Support (BLS) calls (which are the Fire Protection District's current responsibility) . As a result, the City may find that this pilot program may actually reduce the ability of the District to provide general emergency response in order to provide enhanced emergency medical service. Also, there will be times, particularly during fire season, when either the engine company from Station 40 or 42 (probably not both) will be required to relocate to a station out of the area to provide adequate coverage. The pilot program will have to �. accommodate those times by accepting a reduced level of paramedic response coverage. ALS Designation: The Advanced Life Support (ALS) provider for any area requires Board of Supervisors designation and a contractual agreement. Currently, the private vendor for Area 4 (which includes Moorpark) has been designated as the ALS provider. If the District is to be the ALS provider, under this pilot program, the District must apply and be approved as an ALS provider for Ventura County. This will require the development of a plan to the EMS Agency, Emergency Medical Care Committee (EMCC) and the Board of Supervisors outlining the staffing, coverage, geographic area, education, training, record keeping , etc. 6 The Board's policy has been to have one ALS provider in an area to avoid confusion and provide efficient effective emergency service delivery. since the current ALS provider, a private vendor, has already been designated for Area 4 (including Moorpark) , potential conflict issues will have to be resolved. Also, it is still unclear whether, according to the State Health and Safety Code, two ALS providers can be designated for one area. This will also have ' to be determined by the EMS Agency. Trainincu Prior to program initiation, eight certified and accredited Firefighter/Paramedics will be designated for the program by the District. No training, certification or accreditation costs will be financed by the District. As indicated by the Firefighters Association, there are five additional staff members (total of thirteen) who are willing to participate if necessary. All participating Firefighter/Paramedics (thirteen) will obtain, at their own expense, the required on-going training as required during the course of the pilot program to maintain certification and accreditation. If this required training must be obtained at a time when overtime pay is earned, the City will pay the additional half-time cost. If during the course of the pilot program, it is apparent that additional Firefighter/Paramedics (in addition to the current 13) need to be made available for the program, the Fire Protection District will: 1. Review the pilot program to determine an appropriate course of action, including the option of terminating the program at an earlier date than anticipated. (If termination seems appropriate, the City of Moorpark will be contacted to participate in the decision making process . ) 2 . If the program is to be continued, the District will survey its current staff to determine if any qualified staff are available and willing to participate. If none are available, a recruitment will be conducted. This may be at the City's expense if this is a recruitment which would not otherwise have been conducted by the District. • Equipment: The Ventura County Firefighters Association and the Fire Protection District agree that the equipment listed on Attachment 1 will be necessary to implement the pilot program. The total cost for this equipment is $15, 200 per station or $30,400 for the program. This includes the upgraded, additional 7 , • defibrillators which are required to support the paramedic operation. The EMT-D defibrillators which are currently budgeted by the District for each of the Moorpark stations will continue to be purchased as was originally planned. The purchase price of the defibrillators also requires a one-year service agreement to provide repair and a replacement within 2 hours (on loan if necessary) . Therefore, no additional contingency funding for this potential expense has been included in the budget, however, if the program continues beyond the pilot program, some financial provision for these potential occurrences should be made. Also, no contingency funding has been provided for the communication equipment. The vendor has indicated that if a failure occurs within the year, loaned equipment will be provided while repairs are completed. Again, , if the program continues, a contingency fund for the repair and replacement of this equipment should be considered. tf the enhanced paramedic program is terminated during or after the pilot program, the additional program'equipment (Attachment 1) will remain the property of the City to administer: as it deems appropriate. staffing Requirements: Administrative Supervision: The Fire Protection District has indicated that its staff person, currently functioning as the Emergency Medical Services (EMS) { Coordinator, could command and supervise paramedic training, equipment, legal issues, quality control, public relations and hospital liaison, and/or assist with operations of assigned \� programs and perform related work as required. The estimated . required time for this administrative assignment would vary over the course of the pilot program but would probably include 25 hours initially and an average of six hours per week (52 weeks) . The cost for this time, computed at the Board approved rate for a Fire District Engineer, is approximately $24 , 000 . Medical Supervision: • The State Health and Safety Code; California Code of Regulations, Title 22 , Division 9; and local EMS policies and procedures, require medical direction for providers of advanced life support services. For the purposes of the pilot program, this requirement can be met by contracting with a medical firm or medical individual for intermittent program monitoring for quality assurance. Dr. David Chase has indicated that he would be able to serve in this capacity. He suggest 15 to 20 hours to establish the program and 5 hours per month thereafter. The estimated cost for this one- year contract is $7, 500. If the enhanced paramedic program is continued in the City (beyond the pilot program) and/or it is extended to other communities, it is reasonable to anticipate that this contractual approach will need to be reevaluated. Bonus Pay: Both the Firefighter's Association and the Fire Protection District have indicated that Firefighter/Paramedics with other Fire departments in other jurisdictions earn a bonus pay of 10% to 20%. It was proposed that the Firefighter/Paramedics participating in this pilot program be paid a 10% bonus (based on salary and benefits) to offset the training costs. There was some question as to how' many Firefighter/Paramedics should receive the bonus pay. The Association contends that all thirteen should be paid the bonus to. maintain their training; the District believes that the designated eight should receive the pay. For the purposes of the pilot program, it does not seem reasonable to expect the City to pay the bonus for more than eight positions actively participating. Therefore, the recommendation is to include the cost of the bonus pay for the eight designated positions as long as they are directly involved in the program. Only eight positions will receive the bonus pay at any given time. It is anticipated that the position of Firefighter will be designated for the Firefighter/Paramedic classification. Therefore, the bonus has been calculated based on the top amount of the firefighter salary range. The total annual bonus costs (based on salary and benefits) for eight positions is $41,200. (Attachment 2) In addition, the County Risk Management Office has indicated that additional liability insurance coverage will be required for the paramedics. The estimated one-year cost for this coverage is $3, 000. Total Cost: If the City determines that it wishes to initiate this one-year pilot program for enhanced paramedic service, it is recommended that the Fire Protection District administer the program and bill the City for the following amount in advance of program delivery. Upon program evaluation, the City will be notified of any overcharges or undercharges which will be corrected. 9 -';:r • .7[.1 GJ J1 10./it 1L•Jt. • The total program costs are as follows: Equipment $31, 400 Supervisorial Staff 24 , 000 Medical Supervision Contract 7 , 500 Insurance 3, 000 Bonus Pay 41,200 Possible training overtime 3 , 00Q TOTAL $110, 100 The above total does not include any cost estimates for mileage, potential firefighter/paramedic recruitment, or additional contract costs. Summary: This evaluation of the potential one-year pilot program for enhanced paramedic service in the City of Moorpark has indicated that the program is possible and is within the cost estimate initially developed by the City. There are however, some unresolved concerns which the City and, in • some cases other entities, will want to address prior to the initiation of any pilot program and modification to the EMS delivery system in the area. The concerns for the City to address are: 1. Is the City willing to potentially reduce general emergency response in order to enhance paramedic response in the area. • 2. Can the City accept reduced paramedic response delivery during times when either Station 40 or 42 are providing fire suppression service or back-up out of the area. 3. Given the number of emergency medical responses, is one year a sufficient period of time to fully analyze the success or failure of the proposed pilot program. The concerns for the County's EMS Agency to address are: 1. What operational and/or contractual needs will the private vendors propose. 2 . Can emergency medical care be transitioned from one paramedic = to another paramedic without jeopardizing the level of care. The concerns for the Fire Protection District are: 1 . Does the District currently have sufficient firefighter/ 10 paramedics who can obtain the required certification and accreditation to support a successful pilot-program. 2. Will eight paramedic firefighters initially assigned to the program be sufficient to provide complete coverage. 3 . How will the medical supplies and equipment, and subsequent billing, be coordinated with the vendor. 4. How will fire suppression response back-up be coordinated when Station 40 or 42 are providing paramedic coverage. 5. Can emergency medical care be transitioned from one paramedic to another paramedic without increasing potential liability. These concerns, along with any other items identified by affected agencies, should be addressed prior to the initiation of any pilot program by the City. 11 Attachment 1 XQUIPMENT COST ANALYSIS The following equipment is the minimum additional equipment required to support the expanded paramedic pilot program at each of the two Moorpark stations. The following costs are for one 'station. Basic Life Support (BLS)_Eclujnment Costs: Sand bags/head restraining devices (approx. ) $ 70 Backboard with straps 130 Advanced Life Support (ALS) Equipment Costs: Bio-Communication Equipment: .$ 3, 000 (A cellular telephone with telemetry capability can be used in lieu of a bio- cm radio. The telephone will cost $2, 500 plus an estimated $500 for calls. A medical radio would cost $7, 920. ) Cardiac Monitor/Defibrillator: 11, 150 (Life Pack 10 with service agreement and battery support. (This is in addition to the defibrillator previously budgeted the District. ) Laryngoscope and Equipment 250 Misc. Equipment (i.e. drug box, etc. ) • 200 Pneumatic Anti-Shock Garment 400 TOTAL $15, 200 FOR TWO STATIONS $30, 400 Defibrillator Service Contract 1,000 TOTAL EQUIPMENT COST $ 31, 400 • • 12 Attachment 2 STAFFING COST ANALYSIS Annual Firefighter Salary $ 37 , 688 10% bonus pay paid to Firefighter/Paramedic $ 3 ,768 Fringe Benefit cost (37 . 68$) $ 13 , 824 10% bonus cost to Fire District $ 1, 382 Total additional cost per Firefighter/Paramedic $ 5, 150 Total additional cost for 8 Firefighter/Paramedics $41, 200 • 13 //. L - 1 s� Pruner Health Services, Inc. October 2 , 1991 City Council 72 Moody Court City of Moorpark Thousand Oaks 799 Moorpark, CA 93021 CA 91360 (805)496-4684 Dear Councilmembers: Pruner Health Services has continued, as requested, to work with the Ambulance Sub-Committee of the City Council to locate appropriate housing which will allow the stationing of a paramedic ambulance in the City of Moorpark as soon as possible. Much time and effort was expended by both the sub- committee members and ourselves to attempt to arrange for the paramedic ambulance to be stationed in one of Moorpark's two fire stations. Unfortunately these efforts proved unsuccessful. As soon as it became apparent that co-location would not be possible at this time, other options began to be explored. We have investigated several potential locations and the related costs. Based on available options we are prepared to accept a maximum fixed dollar amount of $13,800, plus any site improvements required by the City, to meet the City's financial responsibility to provide housing for the paramedic ambulance as proposed in our letter to the City dated June 5, 1991. Adding the proposed maximum housing cost to our existing proposal would bring the total fixed cost of immediately stationing paramedic ambulance service within the City of Moorpark to $77,800. If the Council should decide to accept this proposal, Pruner continues to be prepared to finalize the details and to relocate immediately. We respectfully request your earliest consideration of this matter. Sincerely, PRUNER HEALTH SERVICES, INC. Don Pruner, President "Service is our responsibility—helping people is our satisfaction."