(a) A licensed general acute care hospital with an emergency department shall, by September 1, 2024, develop, in consultation with its emergency department staff, and its exclusive employee representatives, if any, an ambulance patient offload time reduction protocol that addresses all of the following factors:

1. (1) Notification of hospital administrators, nursing staff, medical staff, and ancillary services that the local EMS agency standard for ambulance patient offload time has been exceeded for one month.
2. (2) Mechanisms to improve hospital operations to reduce ambulance patient offload time, which may include, but are not limited to, activating the hospital’s surge plan, transferring patients to other hospitals, suspending elective admissions, discharging patients, using alternative care sites, increasing supplies, improving triage and transfer systems, and adding additional staffing.
3. (3) Systems to improve general hospital coordination with the emergency department, including consults for emergency department patients.
4. (4) Direct operational changes designed to facilitate a rapid reduction in ambulance patient offload time to meet the local EMS agency standard adopted pursuant to subdivision (b) of Section 1797.120.5.