Minutes

Southern Nevada District Board of Health Meeting
August 23, 2007 - 9 a.m.

Clemens Room
Southern Nevada Health District Ravenholt Center
625 Shadow Lane
Las Vegas, Nevada

Chair Steven Kirk called the meeting of the Southern Nevada District Board of Health to order at 9:05 a.m. Stephen Minagil, Legal Counsel noted the meeting had been noticed in accordance with Nevada’s Open Meeting Law and that a quorum was present. The Pledge of Allegiance was held.

Board Members Present:

Steven Kirk — Chair, Councilman, Henderson
Chris Giunchigliani — Vice Chair, Commissioner, Clark County
Ricki Barlow — Councilman, Las Vegas
Jim Christensen, MD — At-Large Member, Physician
Robert Eliason — Councilman, North Las Vegas
Lon Empey — Alternate At-Large Member, Environmental Specialist
Joseph Hardy, MD — At-Large Member, Physician
Tim Jones — At-Large Member, Regulated Business/Industry
Linda Strickland — Councilmember, Boulder City

Absent:

Gary Reese — Secretary, Councilman, Las Vegas
Mary Jo Mattocks, RN — At-Large Member, Registered Nurse
Bubba Smith — Councilmember, Mesquite
Lawrence Weekly — Commissioner, Clark County
Travis Chandler — Councilmember, Boulder City Alternate
Tom Collins — Commissioner, Clark County Alternate
Susan Crowley — At-Large Member, Environmental Specialist
Frank Nemec, MD — Alternate At-Large Member, Physician
John Onyema, MD — Alternate At-Large Member, Physician
Steven Ross — Councilman, Las Vegas Alternate
Gerri Schroder — Councilwoman, Henderson Alternate
Stephanie Smith — Councilwoman, North Las Vegas Alternate
Debra Toney, RN — Alternate At-Large Member, Registered Nurse

Executive Secretary:

Lawrence Sands, DO, MPH

Legal Counsel:

Stephen R. Minagil

Other SNHD Board of Health Members/Alternates Present:

Jimmy Vigilante — Alternate At-Large Member, Regulated Business/Industry

Staff: Mike Walsh; Sylvia Claiborne; Dennis Campbell; Bonnie Sorenson; Rory Chetelat; Mary Ellen Britt; Jim Osti; Angus MacEachern; Deborah Williams; Jane Shunney; Patricia Rowley; Michael Tsai; Ann Markle; Susan Eiselt; Dan LaRubio; Dr. Joseph Heck; Jo Alexander; Veronica Morata-Nichols; Alice Costello; Jennifer Sizemore; Stephanie Bethel; Brian Labus; Leo Vega; Jeff Good; Recording Secretaries: Shelli Clark and Diana Lindquist

Attendance:

Oath of Office:
Dr. Sands indicated that the oath of office would be administered to Board members being seated today. Stephen Minagil, Board Legal Counsel, administered the Oath of Office to the following elected members: Robert Eliason – City of North Las Vegas representative and Linda Strickland – City of Boulder City representative. Chair Kirk welcomed Councilman Eliason and Councilmember Strickland to the Board and thanked them for their service.

I. Consent Agenda:
These are matters considered to be routine by the Southern Nevada District Board of Health and may be enacted by one motion. Any item, however, may be discussed separately per Board Member request before action. Any exceptions to the Consent Agenda must be stated prior to approval.

1. Approve Minutes / Board of Health Meeting: 7/26/07
2. Approve Payroll / Overtime for Periods: 6/30/07 – 7/13/07; 7/14/07 – 7/27/07
3. Approve Accounts Payable Registers: #1085: 7/05/07 – 7/11/07; #1086: 7/12/07 – 7/18/07; #1087: 7/19/07 – 7/25/07; #1088: 7/26/07 – 8/01/07
4. Petition #33-07: Approval of Revised Classification Specification for Environmental Health Training Officer, Recommended Schedule 23 ($55,974 - $78,081)

A motion was made by Member Christensen to approve all consent items; seconded by Member Hardy and was unanimously approved.

II. Public Hearing / Action

1. Variance Request to Install an Individual Sewage Disposal System (ISDS) on an Undersized Lot Served by an Off-Site Public Water Supply with a Shallow Absorption Field within Ten (10) Feet of the Property lines (APN 070-13-101-059). Petitioner: Nickolas and Esther Jones, Joint Owners, 474 Adelle Avenue, Logandale, Nevada 89021
   
   Chair Kirk declared the public hearing open.
   
   Dan LaRubio, environmental health supervisor, stated that staff recommends approval with the five conditions as outlined in the memorandum. Chair Kirk noted that the applicants were present. He asked Mr. and Mrs. Jones if they understood and accepted the conditions as outlined. They both responded in the affirmative.
   
   Chair Kirk asked if any member of the public wished to speak concerning this item. No one came forward to speak and Chair Kirk closed the public hearing.
   
   A motion was made by Member Giunchigliani to approve the variance with the conditions as outlined; seconded by Member Barlow and was unanimously approved.
   
   
2. Memorandum #23-07: Request for Approval of Initial Authorization of University Medical Center as a Pediatric Level II Trauma Center
   
   Chair Kirk declared the public hearing open.
   
   Mary Ellen Britt, regional trauma coordinator, said that NRS 450B.237 and the Southern Nevada Health District Trauma Regulations require that any hospital seeking designation by the Nevada State Health Division as a Center for the Treatment of Trauma in Clark County first seek authorization from the Board of Health. University Medical Center (UMC) submitted an application requesting authorization to pursue designation from the Nevada State Health Division as a pediatric Level II trauma center, which was reviewed by staff and unanimously approved by the Regional Trauma Advisory Board (RTAB). Southern Nevada does not presently have a pediatric trauma center; the closest verified center is Children’s Hospital of Los Angeles. UMC possess all the required elements, they currently provide the expected level of care and are committed to both pediatric patients and the community as a whole, providing trauma services from pre-hospital care through rehabilitation. UMC offers a dedicated pediatric emergency department with 21 beds; a pediatric intensive care unit with 14 beds; and 29 pediatric medical/surgical beds. The trauma resuscitation unit has 2 dedicated beds for initial resuscitation of pediatric trauma patients, but can use any of the 11 beds in the unit for that purpose. Physicians on staff are trained in all aspects of pediatric medicine and they have all necessary ancillary services. UMC is a founding member and sustained stakeholder in the Nevada Emergency Medical Services for Children Program and collaborates in prevention efforts with community organizations. UMC is working to develop new pediatric trauma resources in the community, including a pediatric trauma research agenda. UMC requested to continue to serve the currently assigned catchment area and are not requesting that patients less than fifteen years of age from any other catchment area be transported to UMC. Staff recommended approval of UMC’s application based on content of the application, their demonstrated commitment to provide trauma services to the community, their active participation in the trauma system, and their compliance with the requirements in the trauma regulations.
   
   Member Jones asked if trauma staffing was separate or combined. Ms. Britt said that additional requirements exist for pediatric trauma service, and additional resources are necessary. Member Jones asked if anesthesiologists would serve both adult and pediatric trauma patients.
   
   Dr. John Fildes commended Ms. Britt for her presentation and addressed Member Jones’ question. Dr. Fildes remarked that the trauma physician, anesthesiologist, neurosurgeon or orthopedist on call must possess additional training expertise in the care of children, which UMC has now. As a second tier, UMC has the ability to call on other more specialized pediatric surgeons and intensivists as needed. The American College of Surgeons (ACS) updated the requirements and UMC learned they were in excess of the requirements, which prompted the application.
   
   Member Jones verified that there was no conflict in having staff service two systems. Dr. Fildes said they are currently providing those services on a daily basis. UMC is seeking recognition for the work being performed currently.
   
   Member Hardy asked for clarification on the catchment area comment. Ms. Britt replied that the catchment areas were created in 2005 when Sunrise became a trauma center. All patients transported by EMS between Sahara on the north, Paradise on the west and Sunset on the south are in the Sunrise Hospital catchment area; the city of Henderson is the catchment area for St. Rose, which includes the area south of Sunset, to I-15 and the southern area of the county. As St. Rose is a Level III trauma center, only step three patients are transported there. These are patients who meet the mechanism only criteria, meaning the patient is stable physiologically and has no obvious anatomical injuries. The Sunrise catchment area was modified slightly in 2006 to increase the number of patients seen in step one (physiological) and two (anatomical) categories. Patients in Henderson meeting the step one and two criteria are transported to Sunrise. Trauma patients in the remainder of the valley are transported to UMC. Member Hardy asked if the level of care is an issue with pediatrics in the catchment areas. Ms. Britt said this will remain status quo; UMC has not asked to have pediatric patients from other catchment areas transported to their facility. Member Hardy asked if the care is consistent wherever pediatric patients are transported. Ms. Britt said the other two trauma centers have pediatric emergency departments and currently care for pediatric patients.
   
   Member Hardy asked if the other trauma centers were qualified or had made application to be designated as a pediatric trauma center. Ms. Britt confirmed they had not made application at this time. Member Hardy asked if the pediatric catchment area needs to be adjusted in some way based on the level of care. Ms. Britt replied that we are comfortable with the level of care currently provided at all trauma centers, and UMC did not request an adjustment to the catchment areas to have additional pediatric patients transported to them at this time.
   
   Rory Chetelat, emergency medical services & trauma system manager, said that Dr. Fildes implied that ACS standards changes allowed UMC to apply for designation as a pediatric trauma center. In the Clark County trauma system, all trauma centers are required to treat patients of all ages and that has not changed.
   
   Dr. Fildes said in a past RTAB meeting the requirements for pediatric Level II verification were agendized and discussion followed that showed most trauma centers were eligible to apply for this designation and achieve the same stature. He suggested this could be a community goal for all centers to demonstrate this commitment.
   
   Member Giunchigliani referenced page 5 of the memorandum and asked for clarification on diagnosis codes and patient data. Dr. Fildes said there is no integrated information system to compile the data received. The information is assembled piecemeal using a construct entitled the “injury pyramid.” The top tier is data sent directly from the coroner’s office, as the patients are not seen in a trauma center; the second tier represents seriously injured patients who require the highest level of care; the third tiers represents patients with lesser injuries seen in emergency departments. The numbers represented are blended and unmatched from the coroner’s office, the trauma centers and the inpatient admission registry. Dr. Fildes said that Clark County would like to have an integrated system; however no system that communicates at the federal or state level have been made available.
   
   Member Giunchigliani asked if segregation of child abuse data were available. Ms. Britt said that the data is similar to the national data in that automobile related injuries are the highest incidence in our community, followed by falls, bicycle-related incidents, and violent crime. Page 3 of the memorandum contains an additional breakdown of the information. Dr. Fildes said that this information was provided by the UNLV health statistics department, who collates admission record data for the entire state. The information was able to be filtered by Clark County, by age and further by ICD 9, codes that correspond to injuries. The data includes patient information for non-Clark County residents who may have been admitted to an area hospital.
   
   Mr. Chetelat said the district recently received a TIIDE (Terrorism Injuries: Information, Dissemination and Exchange) grant from CDC which should allow for more integration of data sources to provide better data much quicker.
   
   Member Giunchigliani referred back to the application and the focus on community PR campaigns, and asked if additional advertising could be aligned with the five highest incidence of injury. Dr. Fildes said that the RTAB is a resource to the prevention groups and where the county’s priorities lie. Drowning incidents are not included in the statistics; however this is very preventable. We are trying to define the problem, measure the problem, and see if interventions improve the situation in the future.
   
   Member Giunchigliani asked if pool inspections include proper fencing if young children are in the vicinity. Dr. Sands said that the district only inspects public pools. The district works with Clark County to provide community education, such as the PSA for the “A,B,C and D’s of drowning prevention.” If there is an issue with a residential pool, such as green water, the health district will intervene for mosquito abatement. Ms. Britt said that the district maintains a registry for drownings, and on average there have been 45 near drownings and 9 deaths annually since 1994 in the 0-14 age group. This data drove revisions to the pool code in 2004, where any new pool construction requires secondary barriers.
   
   Member Jones disclosed that his wife is the bureau chief for licensure and certification and will have a voice in the final decision.
   
   Chair Kirk asked if anyone from the public wished to speak to this matter. No one came forward to speak and Chair Kirk closed the public hearing.
   
   A motion was made by Member Giunchigliani to approve the application as submitted; seconded by Member Christensen and was unanimously approved.
   

III. Report / Discussion / Action

1. Memorandum #25-07: Consider/Adopt Southern Nevada District Board of Health Meeting Schedule
   
   Dr. Sands said that Board members had the results of the survey information gathered from most Board members in their book concerning meeting days and times. There seemed to be strong support for continuing meetings on the fourth Thursday. It seems that early mornings are preferred anywhere from 8:00am – 9:00am; however the meeting time could be earlier if the Board so chooses. Staff will work with the Board to coordinate meetings at the Board’s pleasure.
   
   Chair Kirk said that Thursday seems to be the choice for a meeting day, and suggested that this part of discussion be put aside to come to consensus on a meeting time.
   
   Member Jones remarked that there seems to be more public attendance at the 9:00am meeting time than at 8:00am. Member Giunchigliani suggested that evening meetings would allow for the working citizens to attend, and further suggested that rotating meetings between morning and evening would be beneficial. Member Jones said that from a restaurant standpoint, morning meetings would be better for employees.
   
   Member Hardy said that in looking at attendance, there has been similar attendance over the years. He said that earlier meetings have fewer conflicts with people missing work to attend. As it was basically split between preferences for 7:00am and 9:00am, he suggested having the meeting time at 8:00am.
   
   A motion was made by Member Hardy to hold the Southern Nevada District Board of Health meetings at 8:00am on the fourth Thursday of the month; seconded by Member Eliason.
   
   Chair Kirk asked if there were further discussion. Member Giunchigliani said that there should be evening meetings, and hoped that this motion did not permanently rule that option out. She expressed concern for those having to leave their jobs to attend morning meetings and would like to provide an opportunity to them to attend in the evenings. She agreed that meeting at 8:00am was less disruptive to work schedules; however she would like to support the working population.
   
   Chair Kirk asked Mr. Minagil how to accommodate evening meeting schedules. Mr. Minagil said it could be handled in one of two ways: 1) include in the current motion to specify a specific evening meeting rotation; or 2) when the need occurs for an evening meeting, this item could be agendized for discussion and to set a meeting date.
   
   Member Empey agreed with the option of holding evening meetings, at least quarterly, to accommodate those living in outlying areas and the long travel time.
   
   Member Hardy amended the original motion to include the opportunity to have evening meetings when specific issues arise and the Board will determine when the meetings will occur while maintaining flexibility. The motion was unanimously approved.
   
   
2. Petition #32-07: Acceptance of Delegation of Authority from State Board of Health to Develop System of Data Collection Concerning Waiting Times of Patient Transfer from Emergency Medical Services to Hospital Pursuant to Senate Bill No. 244
   
   Rory Chetelat, emergency medical services & trauma system manager, said that the district has been conducting this process since the passage of SB 458 in the 2005 legislative session. The district has been tracking the data and working with both the hospitals and EMS providers to track and report this data. There were problems in the original process under SB 458 with gathering accurate data; this information was shared with the legislature and SB 244 is a result of that process. In the process Alex Haartz, Nevada State Health Division Administrator, asked the Southern Nevada District Board of Health to accept the delegation as defined in the bill. The district has actively conducted this process for the last two years, and plans to continue this process. The district asks for the Board’s willingness to accept this delegation from the State Board of Health.
   
   Member Giunchigliani asked if the process would need to change due to the merger of the two EMS providers. Mr. Chetelat said that were no changes necessary as the data is provided by the hospitals. There have been a variety of flaws in the original data and the computer system. The district is working with EMS providers, hospitals and software developers to improve the process. The data looks at when the patient physically arrives at the hospital and is logged into the hospital; the time ends when the patient is accepted into the hospital. Other numbers are available from the EMS providers.
   
   Chair Kirk asked if there were further questions or discussion from the Board. As there was none, he called for a motion.
   
   A motion was made by Member Chris Giunchigliani to implement SB 244 which gives the Southern Nevada District Board of Health the responsibility to track the information as outlined; seconded by Member Hardy and was unanimously approved.
   
   Dr. Sands said that there is a letter attached to the petition which will be signed by Chair Kirk to send to the State Board of Health that the delegation has been accepted.
   

IV. Citizen Participation:
Citizen participation is a period devoted to comments by the general public about matters relevant to the Board's jurisdiction. Items raised under this portion of the Agenda cannot be acted upon by the Board of Health until the notice provisions of Nevada's Open Meeting Law have been complied with. Therefore, no vote may be taken on a matter not listed on the posted agenda and any action on such items will have to be considered at a subsequent meeting.

Chair Kirk invited any individuals wishing to address the Board on matters under their jurisdiction to come forward. No one came forward and the citizen participation portion of the meeting was closed.

V. Health Officer & Staff Reports

Nurse Family Partnership Conference – Bonnie Sorenson, Director of Clinic Services & Nursing
Bonnie Sorenson said that the Nurse Family Partnership (NFP) is an evidence-based home visitation program which improves the health, well-being and self-sufficiency of low-income first-time parents and their children. The program was featured on CBS news a few weeks ago. Legislative has been introduced to have this program paid for through Medicaid at the national level. The program has proven for every dollar invested yields a $2.88 return for communities who have implemented this program. The conference is state-wide an invitations have been sent to elected officials, the Nevada State Health Division and representatives from the national level. Child Protective Services is every involved in this process, as well as other key stakeholders in the community. Additional meetings will be held in the future. Gang prevention has been invited, as the program helps reduce criminal activity in the community.

Member Giunchigliani asked if Clark County Social Service would be participating. Mrs. Sorenson confirmed their participation. Member Giunchigliani asked how this home visitation program relates back to the review of the community health nursing program. As we are struggling with funding, this program can be beneficial to the community. Having this as a paid benefit through Medicaid would also be helpful. Member Giunchigliani said if funding were available we could further focus on this program, which is appreciated through the county, though it is very intensive and time intensive. Mrs. Sorenson said that we are trying to find ways to sustain the program; however this is a very specialized model and requires more technical assistance and training provided by NFP.

Member Jones asked if this required a home health license. Mrs. Sorenson said this falls under the scope of public health.

Health Status Report Volume II – Michael Tsai, Chronic Disease Epidemiologist
Dr. Sands invited Michael Tsai to speak about the health status report, volume II, which was given a few meetings ago.

Mr. Tsai provided a detailed description of chronic disease indicators in Clark County focusing primarily on cardiovascular disease and cancer (attachment #1 (PDF 478 KB)). The data is taken from several sources, including the behavioral risk factor surveillance system (BRFSS) and the risk behavior survey; cancer statistics are obtained from the national cancer registry and Nevada interactive health database system.

Cardiovascular disease is the leading cause of death for men and women in the United States. This also affects the work place and lost productivity. Conditional risk factors include high cholesterol levels, elevated blood pressure, physical inactivity, obesity and diabetes. Behavioral risk factors include smoking, and having a poor diet and improper nutritional habits. The second leading cause of death in America is cancer. Leading cancer types in Clark County include prostrate, breast and lung caner. Unfortunately, even with community efforts and wellness education, many of the Healthy People 2010 goals for Clark County have not been met. Mr. Tsai recognized Jing Feng, Biostatistician and Dr. Juan Zevallos, former CDC Assignee to SNHD for their efforts in analyzing the data and compiling the report.

Member Giunchigliani asked if the report differentiated between type I and II diabetes. Mr. Tsai replied the data was combined. She also inquire about tobacco use and if the information including chewing of tobacco. Mr. Tsai said that the survey resulted in the BFRSS data and the data specific only to smoking is the data contained in the health status report itself; however the survey did ask about specific types of tobacco use.

Member Giunchigliani asked if school lunch programs were observed in Clark County. She expressed concern about the unhealthy food choices given to children. Dr. Sands said that the Office of Chronic Disease Prevention & Health Promotion has been working with the school district and providing education, as developing projects for physical activity. Schools are required to develop wellness plans and the district is assisting with development of the policies and intervention. Member Giunchigliani suggested that we look at increasing the physical education component of education and encourage additional activity. She said that we need to start with the youth and teach them proper physical fitness and nutrition.

Nevada Clean Indoor Air Act (NCIAA) – Stephen Minagil, Legal Counsel
Mr. Minagil updated the Board relative to NCIAA enforcement. He said that there are currently three local district court cases regarding enforcement of NCIAA. The case with the retail tobacco store in a local mall with a patio where smoking is permitted is proceeding to trial in January. Discovery is being conducted and experts retained, and the hope is that the district will receive an order enabling enforcement of the Act there. The second case involves the bar & grill owner who refused to remove ashtrays. A temporary restraining order was obtained by the district. A motion was filed to return to court to ask that the bar owner be held in contempt of court for refusal to comply with the order as the establishment is now using other glass receptacle devices as ashtrays. The third case involves another local bar & grill and the prohibition against food service in a stand alone bar. Stand alone bars can provide no service of prepared food where smoking is not prohibited. A resolution has been reached and the court will sign a temporary restraining order setting forth the prohibitions against delivery and service of prepared food in a stand alone bar.

Mr. Minagil traveled to Reno and met with the drafters of NCIAA. Information and clarity was provided regarding the intent and language of the Act.

The district is also working on a process whereby individual smokers can be cited for violating the Act. Judge Herndon’s decision in December eliminated the criminal component and left the health district as the lone enforcement agency. Currently there is no process in our court systems to accept a civil citation issued by the health district. Mr. Minagil met with the court administrator of the local court system and presented a proposed citation form, and asked they accept the citation form and to reserve a date and time certain for recipients to appear in court. An additional meeting is scheduled for September to finalize the process. If the process is accepted, the next step is to seek cooperation with local law enforcement in the event inspectors require assistance in the field when issuing citations. Again, in order to move forward the court system must accept the proposed plan; following that the district’s request for law enforcement assistance needs to be met with a positive response.

Stroke Destination – Rory Chetelat, EMS & Trauma System Manager
Dr. Sands invited Rory Chetelat to come forward to discuss activities with the Medical Advisory Board (MAB) and centers being approved as stroke centers and other specialized centers. EMS staff held a community meeting where EMS providers and hospitals were invited in an open meeting to discuss the standard to determine if a hospital is able to provide stroke care. This would allow the MAB to designate that hospital as a transport center for stroke patients. JACHO is the only body able to designate a stroke center. Currently one center is currently JACHO certified and another is moving in that direction. From that last meeting a number of individuals suggested reaching out to our community partners, such as Phoenix and Orange County, and bring in their experts to help us in this process. The American Heart Association is lending support to fund that process in bringing in individuals for discussion.

VI. Informational Items - Duly Noted

VII. Adjournment

There being no further business to come before the Board, Chair Kirk adjourned the meeting at 10:04 a.m.

SUBMITTED FOR BOARD APPROVAL

Lawrence Sands, DO, MPH, Chief Health Officer
Executive Secretary

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