1 2018

NATIONAL EMS SCOPE OF

2 PRACTICE MODEL
3 WORKING DRAFT
4 FRONT NARRATIVES
5 THIS VERSION CONTAINS FRONT NARRATIVES ONLY

6 Note to all reviewers: content regarding EMS levels and skill sets is still under discussion and
7 will be addressed in future versions. It is important to note that the content of this document is
8 currently a DISCUSSION DRAFT that is under review; it is not binding, and should not be
9 considered as a final recommendation at this time. Considerations may or might not appear in
10 the final document.

11 v. 2017.08.01

12 Please provide your comments via this link:

13 https://nasemso.wufoo.com/forms/scope-of-practice-model-draft-1/

14

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
15 Table of Contents
16 Executive Summary - Revision Pending .................................................................................... 3
17 I. BACKGROUND....................................................................................................................... 4
18 Overview of the EMS Profession ........................................................................................................... 4
19 The Evolution of the EMS Agenda for the Future............................................................................... 5
20 Implementation of the 2007 National EMS Scope of Practice Model ................................................ 6
21 Approach to Revising the National EMS Scope of Practice Model.................................................... 8
22 The Role of State Government............................................................................................................... 9

23 II. UNDERSTANDING PROFESSIONAL SCOPE OF PRACTICE .................................. 10

24 Overview ................................................................................................................................................ 10
25 The Interdependent Relationship Between Education, Certification, Licensure, and
26 Credentialing ......................................................................................................................................... 11
27 Scope of Practice versus Standard of Care......................................................................................... 15
28 A Comprehensive Approach to Safe and Effective Out-of-Hospital Care ...................................... 16

29 III. SPECIAL CONSIDERATIONS ........................................................................................ 17

30 Liability in EMS Licensing .................................................................................................................. 17
31 Scope of Practice for Special Populations ........................................................................................... 17
32 Scope of Practice During Disasters, Public Health Emergencies, and Extraordinary
33 Circumstances ....................................................................................................................................... 18
34 Scope of Practice for EMS Personnel Functioning in Nontraditional Roles ................................... 18
35 Specialty Care Delivered by Licensed EMS Personnel ..................................................................... 18
36 Military to Civilian EMS Transition ................................................................................................... 19
37 IV. GENERAL DISCUSSION .................................................................................................. 20
38 1. Use of opioid antagonists at the BLS level .................................................................................... 20
39 2. Therapeutic hypothermia following cardiac arrest ......................................................................... 20
40 3. Pharmacological pain management following an acute traumatic event ....................................... 21
41 4. Hemorrhage control ........................................................................................................................ 21
42 5. Use of CPAP/BiPAP at the EMT level .......................................................................................... 21
43 6. Nomenclature and the use of international models to advise the SOP Model ............................... 22
44 7. Additional topics currently under consideration ............................................................................ 22
45 8. Comments received for exclusion from the SOP Model: ............................................................... 22
46 Appendix I ................................................................................................................................... 23
47 History of Occupational Regulation in EMS ...................................................................................... 23
48 Appendix II .................................................................................................................................. 26
49 Legal Differences Between Certification and Licensure ................................................................... 26
50

51

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
52 Executive Summary - Revision Pending
53 The National EMS Scope of Practice Model (Practice Model) is a continuation of the
54 commitment of the National Highway Traffic Safety Administration and the Health Resources
55 and Services Administration to the implementation of the EMS Agenda for the Future. It is part
56 of an integrated, interdependent system, first proposed in the EMS Education Agenda for the
57 Future: A Systems Approach that endeavors to maximize efficiency, consistency of instructional
58 quality, and student competence.

59 The Practice Model supports a system of EMS personnel licensure that is common in other allied
60 health professions and is a guide for States in developing their Scope of Practice legislation,
61 rules, and regulation. States following the National EMS Scope of Practice Model as closely as
62 possible will increase the consistency of the nomenclature and competencies of EMS personnel
63 nationwide, facilitate reciprocity, improve professional mobility and enhance the name
64 recognition and public understanding of EMS.

65 The Practice Model defines and describes four levels of EMS licensure: Emergency Medical
66 Responder (EMR), Emergency Medical Technician (EMT), Advanced EMT (AEMT), and
67 Paramedic. Each level represents a unique role, set of skills, and knowledge base. National EMS
68 Education Standards will be developed for each level. When used in conjunction with the
69 National EMS Core Content, National EMS Certification, and National EMS Education Program
70 Accreditation, the Practice Model and the National EMS Education Standards create a strong
71 and interdependent system that will provide the foundation to assure the competency of out-of-
72 hospital emergency medical personnel throughout the United States.

73 Add summary of key points with completion of the draft.

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
 74 I. BACKGROUND
75 Overview of the EMS Profession
76 The Practice Model provides a resource for defining the practice of Emergency Medical Services
77 (EMS) personnel. EMS clinicians are unique health care professionals in that they provide
78 medical care in many environments, locations, and situations. Much of this care occurs in out-
79 of-hospital settings with little onsite supervision. Medical oversight is provided through
80 physician medical direction and protocol development based on evidence based treatment
81 standards and resources such as this document. EMS personnel are not independent clinicians,
82 but are expected to execute many treatment modalities based on their assessments and protocols
83 in challenging situations. They must be able to exercise considerable judgment, problem-
84 solving, and decision-making skills.

85 Most EMS personnel work in career or volunteer emergency medical organizations that respond
86 to emergency calls. Emergency response is often provided by local government through publicly
87 operated fire or EMS departments, or contracted to a private entity by local government. In the
88 vast majority of communities, residents call for EMS by dialing 9-1-1 when they need
89 emergency medical care, and the appropriate resources are dispatched. EMS personnel respond
90 and provide care to the patient in the setting in which the patient became ill or injured, including
91 the home, field, work, industrial, and recreational settings. Too many of these are in high-risk
92 situations, such as on highways and freeways, violent scenarios, and other unique settings.

93 Many EMS personnel provide medical transportation services for patients requiring medical care
94 while enroute to or between medical facilities, in both ground and air ambulance entities. These
95 transport situations may originate from emergency scenes, or may be scheduled transports
96 moving patients from one care facility to another. In many cases, EMS personnel provide
97 critical care level medical care during interfacility transfers of very high acuity patients.

98 Medical care at mass gatherings (e.g., concerts or sporting events)) and high-risk activities (e.g.,
99 fireground operations or law enforcement tactical operations) have become an expectation of
100 EMS personnel. EMS personnel sometimes serve in an emergency response or primary care role
101 combined with an occupational setting in remote areas (e.g., off-shore oil rigs and wildland
102 fires). EMS pesonnel also work in more traditional health care settings in hospitals, urgent care
103 centers, doctors offices and long-term care facilities. Finally, EMS personnel are involved in
104 numerous community and public health initiatives, such as working with healthcare systems to
105 provide non-emergent care and follow up to certain patient populations, as well as providing
106 immunizations, illness and injury prevention programs, and other health initiatives.

107 EMS is a local function and organized in a variety of ways. Common models are municipal
108 government (fire-based or third-service) or a contracted service with a private (profit or
109 nonprofit) entity. Multiple levels of licensure/certification exist for EMS personnel, each
110 offering different levels of scopes of practice. EMS personnel may function at any of these

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
111 levels in career settings with typically larger fire and/or EMS departments, or they may be
112 volunteers, providing a level of care to communities for no, or very little, remuneration. EMS
113 personnel provide medical care to those with emergent, urgent, and in some cases chronic
114 medical needs. EMS is a component of the overall health care system, and delivers care as part
115 of a system intended to reduce the morbidity and mortality associated with illness and injury.
116 EMS care is enhanced through the linking with other community health resources and integration
117 within the health care system.

118 The Evolution of the EMS Agenda for the Future

119 The 2007 Practice Model was developed as one part of the National Highway Traffic Safety
120 Administrations commitment to the EMS Agenda for the Future. Released in 1996, the EMS
121 Agenda for the Future established a long-term vision for the future of EMS in the United States.
122 According to the Agenda,

123 EMS of the future will be community- based health management that is fully
124 integrated with the overall health care system. It will have the ability to identify
125 and modify illness and injury risks, provide acute illness and injury care and
126 follow-up, and contribute to treatment of chronic conditions and community
127 health monitoring. This new entity will be developed from redistribution of
128 existing health care resources and it will be integrated with other health care
129 professionals and public health and safety agencies. It will improve community
130 health and result in a more appropriate use of acute health care resources. EMS
131 will remain the publics emergency medical safety net.

132 As a follow-up to the EMS Agenda for the Future, The EMS Education Agenda for the Future: A
133 Systems Approach (Education Agenda), released in 2000, called for the development of a system
134 to support the education, certification and licensure of entry-level EMS personnel that facilitates
135 national consistency.

136 The Education Agenda established a vision for the future of EMS education, and a
137 called for an improved structured system to educate the next generation of EMS
138 personnel. The Education Agenda built on broad concepts from the 1996 Agenda
139 to create a vision for an educational system that will result in improved efficiency
140 for the national EMS education process. This was to enhance consistency in
141 education quality ultimately leading to greater entry-level graduate competence.

142 The Education Agenda proposed an EMS education system with five integrated components:
143 National EMS Core Content, National EMS Scope of Practice Model, National EMS Education
144 Standards, National EMS Certification, and National EMS Education Program Accreditation.
145 The National EMS Core Content, released in 2004, defined the domain of out-of-hospital care.
146 The 2007 Practice Model divided the core content into levels of practice, defining the minimum
147 corresponding skills and knowledge for each level. Our nation has made great progress in
148 implementing these documents.

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
149 Now in 2017, it is time to update several of these landmark documents. A process to update the
150 original EMS Agenda for the Future is underway (http://emsagenda2050.org/.) The 2007
151 Practice Model also needs review. Several forces have combined to make this need a reality:

152 1. As states have widely implemented the Practice Model, many have chosen to add skills
153 to their authorized scopes of practice beyond the floor called for in the national model.
154 2. EMS research is providing new evidence about the effectiveness of interventions in the
155 out of hospital setting.
156 3. Our nation is facing new health problems including explosive growth in opiate abuse,
157 threats of violence and terrorism, and new challenges related to a growing population
158 over the age of 65.
159 4. The National EMS Information System is maturing to provide information about what
160 levels of EMS personnel are performing which skills and interventions.

161 The development and publication of the Practice Model represents a transition from the
162 historical connection between scope of practice and the EMS National Standard Curricula. The
163 Practice Model is a consensus document, guided by data and expert opinion that reflects the
164 skills representing the minimum competencies of the levels of EMS personnel.

165 This update of the Practice Model is a natural and expected activity in assuring that our EMS
166 personnel are prepared to meet the needs and expectations of the communities they serve.

167 Implementation of the 2007 National EMS Scope of Practice Model

168 EMS crews today are better equipped than ever for the worst kinds of emergencies, from cardiac
169 arrests and gunshot victims to car crashes and other life-threatening emergencies. In its Future
170 of Emergency Care series, the National Academies of Science, Engineering, and Medicine
171 (formerly known as the Institute of Medicine) envisioned high integration of the emergency and
172 trauma care systems to function effectively. Operationally, said the NASEM, this means that
173 all of the key players in a given region...must work together to make decisions, deploy resources,
174 and monitor and adjust system operations based on performance feedback. A system that
175 attracted a generation of emergency care personnel depicted in the popular 1970s television
176 series, Emergency, is now faced with the realities of providing care in a fragmented health care
177 system with limited resources, overcrowded emergency departments, inadequate mental health
178 resources, a nationwide opioid epidemic, escalating domestic and street violence, hazardous
179 material risks and exposures, high consequence infectious disease, an aging population with
180 complex needs, increasing threats from terrorism and other mass casualty events that require
181 24/7 operational readiness along with constant non-urgent social, medical, and transport requests
182 that were not fully contemplated in the 2007 Practice Model. These competing concerns
183 illustrate a crucial need to find innovative strategies to improve EMS care delivery inside and
184 outside the boundaries of an ambulance. The licensure of EMS personnel, like that of other
185 health care licensure systems, is part of an integrated and comprehensive system to improve
186 patient care and safety and to protect the public. The challenge facing the EMS community

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
187 including regulators is to develop a system that establishes national standards for personnel
188 licensure and their minimum competencies while remaining flexible enough to meet the unique
189 needs of State and local jurisdictions.

190 According to the 2011 National EMS Assessment, 826,111 licensed EMS personnel encounter
191 nearly 37 million patients a year in the United States and reflects a multi-billion dollar enterprise.
192 Implementing the 2007 Practice Model required consideration of funding, reimbursement,
193 transition courses, grandfathering of current personnel, development of educational and
194 instructional support materials, workforce issues, labor negotiations, impact on volunteerism, and
195 other important issues. The majority of states required legislative and rulemaking changes but
196 the effort resulted in four nationally recognized levels of EMS clinicians as described by the
197 2007 Practice Model compared to at least 44 different levels of EMS personnel certification
198 reported in the United States in 1996.

199 According to data collected by the National Association of State EMS Officials in 2014, 100% of
200 states use the SOP Model as the minimum allowable psychomotor skill set at the EMT and
201 paramedic levels. 76% of states are using the Practice Model as the minimum allowable
202 psychomotor skill set at the EMR level and 88% of states are using the Practice Model as the
203 minimum allowable psychomotor skill set at the AEMT level. Several states are still
204 transitioning the Intermediate-85 level to AEMT, with an estimation that this effort will be
205 completed by March 2018.

206 According to data collected by the National Association of State EMS Officials in 2014, 90% of
207 states effectively require National EMS Program Accreditation at the Paramedic level.

208 As of June 25, 2017, the Commission on Accreditation of Allied Health Education Programs
209 (CAAHEP), the largest programmatic accreditor in the health sciences field lists accredited EMS
210 programs at the paramedic level in ALL 50 states. 537 paramedic programs have successfully
211 completed the accreditation process and are fully accredited, a 92% increase in the number of
212 nationally accredited paramedic programs from 2007. Another 153 paramedic programs hold a
213 Letter of Review (LoR) from CAAHEP (meaning that they are actively engaged in the
214 accreditation process.)

215 According to real time data available from the National Registry of Emergency Medical
216 Technicians as of June 30, 2017:

217 24 States and the District of Columbia require National EMS Certification as a basis for
218 initial state licensure at the EMR level. An additional 4 States utilize National EMS
219 Certification as an optional or alternate entry process at the EMR level. 22 States do not
220 license EMRs.
221 43 States and the District of Columbia require National EMS Certification as a basis for
222 initial state licensure at the EMT level. An additional 4 States utilize National EMS

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
223 Certification as an optional or alternate entry process at the EMR level. 4 States maintain
224 a state-based or combination process for certification and licensure at this level.
225 37 States and the District of Columbia require National EMS Certification as a basis for
226 initial state licensure at the AEMT level. An additional 4 States utilize National EMS
227 Certification as an optional or alternate entry process at the AEMT level. 10 States do
228 not license AEMTs.
229 46 States and the District of Columbia require National EMS Certification as a basis for
230 initial state licensure at the paramedic level. An additional 3 States utilize National EMS
231 Certification as an optional or alternate entry process at the paramedic level. 2 States
232 maintain a state-based process for certification and licensure at this level.

233 Approach to Revising the National EMS Scope of Practice Model

234 Since the original 2007 Practice Model document, the evidence for which interventions and
235 treatments are useful and effective in an EMS setting has expanded significantly. Similarly,
236 growing interest in EMS research is putting a sharper focus on how specific interventions are
237 affecting the care and outcomes of patients in the out of hospital setting.

238 This 2017 document makes use of a Patient, Population, or Problem, Intervention, Comparison,
239 and Outcome (PICO) Model to examine five clinical topics relevant to EMS treatment. The
240 topics were selected for a systematic review of literature for consideration as high priority issues
241 requiring analysis due to the frequency or need of the interventions being provided at different
242 levels from the 2007 Practice Model in some States. These are:

243 1. Use of opioid antagonists by all levels of EMS personnel

244 2. Therapeutic hypothermia in cardiac arrest (i.e. Targeted temperature management)
245 3. Pharmacological pain management following an acute traumatic event
246 4. Hemorrhage control (i.e tourniquets and hemostatic dressings)
247 5. CPAP/BiPAP at the EMT level

248 Two limitations on using evidence to establish an EMS scope of practice are:

249 1. While evidence may tell us what is or is not effective, it generally does not suggest what
250 level(s) of EMS personnel are appropriate to perform a specific intervention, and;
251 2. There are still limitations on the evidence base for much of what is included in an EMS
252 scope of practice.

253 As the 2017 National EMS Scope of Practice Model has been developed it has relied upon
254 extensive literature review, systematic analysis of policy documents regarding health care
255 licensing and patient safety, the input of a subject matter expert panel, and extensive public
256 input.

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
257 Analysis and research on patient safety, scope of practice, and EMS personnel competency must
258 remain a priority among the leadership of national associations, Federal agencies, and research
259 institutions. When EMS data collection, subsequent analysis, and scientific conclusions are
260 published and replicated, later versions of the Practice Model should be driven by those findings.

261 The Role of State Government

262 Insert FARB paper/SCOTUS case describing this broadly about health care professions.

263 Each State has the statutory authority and responsibility to regulate EMS within its borders, and
264 to determine the scope of practice of State-licensed EMS personnel. The Practice Model is a
265 consensus-based document that was developed to improve the consistency of EMS personnel
266 licensure levels and nomenclature among States; it does not have any regulatory authority.

267 The Practice Model will continue to serve EMS in the future as it is revised and updated to
268 include changes in medical science, new technology, and research findings.

269 The Practice Model identifies the psychomotor skills and knowledge necessary for the minimum
270 competence of each nationally identified level of EMS personnel. This model will be used to
271 develop the National EMS Education Standards, national EMS certification exams, and national
272 EMS educational program accreditation. Under this model, to be eligible for State licensure,
273 EMS personnel must be verifiably competent in the minimum knowledge and skills needed to
274 ensure safe and effective practice at that level. This competence is assured by completion of a
275 nationally accredited educational program and national certification.

276 While each State has the right to establish its own levels of EMS personnel and their scopes of
277 practice, staying as close to this model as possible, and especially not going below it for any
278 level, will facilitate reciprocity, standardize professional recognition, and decrease the necessity
279 of each State developing its own education and certification materials. The National EMS
280 Education Standards, national certification, national educational program accreditation, and
281 publisher-developed instructional support material provide States with essential infrastructure
282 support for each nationally defined EMS licensure level.

283 The adoption of skills and roles beyond those proposed in this model will diminish national
284 consistency and may impede interstate mobility and legal recognition for EMS personnel.
285 Additionally, content in future national EMS education standards, national certification
286 examinations, and curriculum-focused aspects of national education program accreditation
287 standards will continue to be consistent with the Practice Model and may not be appropriate for
288 State use if there is significant State deviation from the Model. This will necessitate States
289 developing and implementing State-specific educational content, education program approval,
290 certification examinations, credentialing processes, and quality assurance procedures.

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
291 Some States permit licensed EMS personnel to perform skills and roles beyond the minimum
292 skill set as they gain knowledge, additional education, experience, and (possibly) additional
293 certification (See also Section III Specialty Care Delivered by Licensed EMS Personnel.) Care
294 must be taken to consider the level of cognition necessary to perform a skill safely. For instance,
295 some skills may appear simple to perform, but require considerable clinical judgment to know
296 when they should, and should not, be performed.

297 II. UNDERSTANDING PROFESSIONAL SCOPE OF PRACTICE

298 Overview
299 Scope of practice is a legal description of the distinction between licensed health care
300 personnel and the lay public and among different licensed health care professionals. It describes
301 the authority vested by a state in individuals that are licensed within that state. In general, scopes
302 of practice focus on activities that are regulated by law (for example, starting an intravenous line,
303 administering a medication, etc.). This includes technical skills that, if done improperly,
304 represent a significant hazard to the patient and therefore must be regulated for public protection.
305 Scope of practice establishes which activities and procedures that would represent illegal activity
306 if performed without a license. In addition to drawing the boundaries between the professionals
307 and the layperson, scope of practice also defines the boundaries among professionals, creating
308 either exclusive or overlapping domains of practice.

309 Scope of Practice is a description of what a licensed individual legally can,

310 and cannot, do.

311 This Practice Model should be used by the states to develop scope of practice legislation, rules,
312 and regulation. The specific mechanism that each State uses to define the States scope of
313 practice for EMS personnel varies. State scopes of practice may be more specific than those
314 included in this model and may specifically identify both the minimum and maximum skills and
315 roles of each level of EMS licensure.

316 Generally, changing a law is more difficult than changing a regulation;

317 changing a regulation is more difficult than changing a policy.

318 Scopes of practice are typically defined in law, regulations, and/or policy documents. Some
319 states include specific language within the law, regulation or policy, while others refer to a
320 separate document using a technique known as incorporation by reference.. The Practice
321 Model provides a mechanism to implement comparable EMS scopes of practice between states.

322 Scopes of practice need not define every activity of a licensed individual (for example, lifting
323 and moving patients, taking a blood pressure, direct pressure for bleeding control, etc.). The

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
324 Practice Model includes suggested verbiage for the state scopes of practice in the section entitled
325 EMS Personnel Scopes of Practice. The interpretive guidelines (Appendix A) include a more
326 detailed list of skills discussed by the National EMS Scope of Practice Subject Matter Expert
327 Panel. These skills, which generally should not appear in scope of practice regulatory documents,
328 are included to provide the user with greater insight as to the deliberations and discussion of the
329 group.

330 The Interdependent Relationship Between Education, Certification, Licensure, and

331 Credentialing
332 The Practice Model establishes a framework that ultimately determines the range of skills and
333 roles that an individual possessing a State EMS license is authorized to do on a given day, in a
334 given EMS system. It is based on the notion that education, certification, licensure, and
335 credentialing represent four separate but related activities.

Trained
336 Education includes all of the cognitive, psychomotor, and affective
337 learning that individuals have undergone throughout their lives. This to Do

338 includes entry-level education, continuing professional education,

339 formal and informal learning. Clearly, many individuals have extensive
340 education that, in some cases, exceeds their EMS skills or roles.

341 Certification is an external verification of the competencies that an Trained Certified As

Competent
to Do
342 individual has achieved and typically involves an examination process.
343 While certification exams can be set to any level of proficiency, in
344 health care they are typically designed to verify that an individual has
345 achieved minimum competency to assure safe and effective patient care.

346 Licensure represents permission granted to an individual by the State to Trained Certified As
to Do Competent
347 perform certain restricted activities. Scope of practice represents the
348 legal limits of the licensed individuals performance. States have a
349 variety of mechanisms to define the margins of what an individual is
State
350 legally permitted to perform. Lic ensed
to Practice

351 Credentialing is a local process by which an individual is permitted by a Trained Certified As

to Do Competent
352 specific entity (medical director) to practice in a specific setting (EMS
353 agency). Credentialing processes vary in sophistication and formality.
Credentialed State
354 by Medical
Director
Licensed
to Practice

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
355 For every individual, these four domains are of slightly different relative sizes. However, one
356 concept remains constant: an individual may only perform a skill or role for which that person is:

357 educated (has been trained to do the skill or role), AND

358 certified (has demonstrated competence in the skill or role), AND
359 licensed (has legal authority issued by the State to perform the skill or role), AND
360 credentialed (has been authorized by medical director to perform the skill or role).

361 This relationship is represented graphically in Fig. 1.

362 Figure 1: The Relationship among education, certification, licensure, and credentialing.

363

364

365 The center of Fig 1, where all the four elements overlap, represents skills and roles for which an
366 individual has been educated, certified, licensed by a State, and credentialed. This is the only
367 acceptable region of performance, as it entails four overlapping and mutually dependent levels of
368 public protection: education, certification, licensure, and credentialing.

369 Individuals may perform those procedures for which they are educated, certified, licensed, AND
370 credentialed.

371 A significant risk to patient safety occurs when EMS personnel are placed into situations and
372 roles for which they are not experientially or educationally prepared. It is the shared

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
373 responsibility of medical oversight, clinical and administrative supervision, regulation, and
374 quality assurance to ensure that EMS personnel are not placed in situations where they exceed
375 the States scope of practice. For the protection of the public, regulation must assure that EMS
376 personnel are functioning within their scope of practice, level of education, certification, and
377 credentialing process. Figure 2 illustrates the interconnections among education, certification of
378 baseline competency, licensing by a regulating body, and credentialing by an agency and its
379 medical director.

380 Figure 2: Skill and role situations not covered by all four elements for protection of the public.

381

382 Region A: represents skills and roles for which an individual has received education,
383 but is neither certified, licensed, nor credentialed. For example, an EMT in a paramedic
384 class is taught paramedic level skills; despite being trained, the EMT cannot perform
385 those skills until such time that he is certified, licensed, and credentialed by the Local EMS
386 Medical Director.

387 Region B: represents skills and roles in which an individual has been educated and
388 certified, but are not part of the State license and credentialing. For example, a
389 Paramedic is educated and certified in needle cricothyrotomy. Should he be functioning in a
390 State in which that skill is prohibited for Paramedics, it would now be out of his scope of
391 practice, and cannot be performed in that setting

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
392 Region C: represents skills and roles for which an individual is educated, certified,
393 and licensed, but has no credentialing. For example, an off duty Paramedic arriving at
394 the scene of an incident outside of his jurisdiction usually is not credentialed to perform
395 advanced skills. In this case, performing an advanced skill would represent a violation of his
396 scope of practice.

397 Region D: represents skills or roles the State has authorized (licensed) but which
398 also require local entities to assure the education, competence, and provide medical
399 direction. For example, rapid sequence intubation (RSI) in some States is legally
400 permitted, but usually not taught as part of the initial education, nor is it part of the certification
401 process, and most medical directors do not credential individuals to perform RSI. Some
402 individuals (for example, flight paramedics) may perform RSI; however, the local medical
403 director assumes a larger responsibility for training, competency verification, and medical
404 direction.

405 Region E: represents skills or roles which a medical director wants an individual to
406 perform but for which he has not been educated, certified, or licensed. There is
407 considerable State-to-State variability in dealing with this situation. Most States have
408 regulations that restrict licensed individuals from functioning beyond their scope of practice, and
409 may take action against an individual who performs a skill or role for which they are not
410 licensed. In contrast, some States have regulatory mechanisms that enable a local physician to
411 assume complete responsibility for the performance of skills and roles performed by an
412 individual. Most States fall somewhere between these extremes and have mechanisms by which
413 local medical directors can appeal for an expansion/waiver of a scope of practice if they can
414 demonstrate need and appropriate mechanism to reasonably assure patient safety.

415 In many States, day-to-day clarification of scopes of practice, management of the appeal
416 process, or otherwise assuring the adequacy of medical direction is the role of the State EMS
417 Medical Director. Some States have licensure boards, often consisting of medical directors,
418 administrators, peers, and public representatives that help adjudicate and clarify scope of practice
419 issues.

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
420 Scope of Practice versus Standard of Care
421 Scope of practice does not define a standard of care, nor does it define what should be done in a
422 given situation (i.e., it is not a practice guideline or protocol). It defines what is legally permitted
423 to be done by some or all of the licensed individuals at that level, not what must be done. Table 1
424 describes some of the differences between scope of practice and standard of care.

425 Table 1: Relationship between scope of practice and standard of care

Scope of Practice Standard of Care

Purpose Deals with the question, Are
you/were you allowed to do
it?
Legal implications Act of commission is a
criminal offense
Variability May vary from individual to
individual. Does not vary
based on circumstances.
Defined by Established by statute, rules,
regulations, precedent, and/or
licensure board interpretations
Miscellaneous It is difficult to regulate
knowledge through scope of
practice.
426
Deals with the question, Did
you do the right thing and did
you do it properly?
Acts of commission or
omission not in
conformance with the
standard of care may lead
to civil liability
Situational, depends on many
variables
Determined by scope of
practice, literature, expert
witnesses, and juries
Used to evaluate the totality
of circumstances. What
would a reasonable EMS
person do in the same or
similar circumstances?

427

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
428 A Comprehensive Approach to Safe and Effective Out-of-Hospital Care
429 Scope of practice is only one part of health care regulation, and regulation is only one component
430 of a comprehensive approach to improved patient care and safety. The primary goal of state
431 regulation of EMS personnel is to protect the public from harm by ensuring they possess a
432 minimum level of competency and professional behaviors. Safe and effective EMS care is the
433 cumulative effect of a cascade of many individual decisions involving every level of EMS
434 leadership, medical direction, supervision, management, and regulation. Safe and effective
435 patient care is the first priority and shared responsibility of everybody within an EMS agency
436 and the EMS system. Safe and effective care cannot be accomplished through any single activity,
437 but is best accomplished with an integrated system of checks and balances. All components of
438 this comprehensive approach to safe and effective patient care are mutually supportive of and
439 dependent upon each other.

440 Figure 3: A comprehensive approach to safe and effective out-of-hospital care.

441

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
442 III. SPECIAL CONSIDERATIONS
443 Liability in EMS Licensing
444 A license is the official or legal permission to engage in or perform a regulated activity. In the
445 United States, state governments generally hold the authority to issue licenses including EMS
446 licenses. This is important because states ultimately need to be in a position to halt EMS people
447 from performing in ways that are dangerous or harmful to the public.

448 Licensing differs from certification in that certification is an affirmation of competence while
449 licensing is the authorization to perform the regulated health care activity. EMS personnel most
450 commonly function on behalf of some volunteer or career organization that acts in a supervisory
451 relationship as the persons employer.

452 EMS personnel have functioned in a supervisory medical direction relationship by physicians
453 since the 1960s. This physician oversight has been invaluable in assuring and improving the
454 quality of care provided by EMS personnel. The close relationship of EMS personnel and
455 physicians in this evolving healthcare discipline and descriptions of medical direction in early
456 EMS curricula has led to the impression and belief by some that medical direction physicians are
457 extending their licenses to authorize EMS practice. The logic of that belief would be that if an
458 EMS person acted incompetently or dangerously, the state would take an action on the medical
459 direction physicians license. Not only would that be ineffective in halting the EMS persons
460 practice, it would put at risk the physician who might be in a position to help correct whatever
461 the problem with the EMS persons practice is.

462 The concept that EMS personnel are somehow practicing under the physicians license is
463 simply not accurate. The umbrella of physician supervision and collaboration can never be used
464 to replace the certification, scope of practice and individual responsibility of the licensed EMS
465 person. EMS personnel need to hold their own license so that the relevant state authority can
466 restrict or remove to stop incompetent practice.

467 Scope of Practice for Special Populations

468 EMS personnel are expected to meet the urgent health care needs of all patients with
469 consideration to age, race, gender, cultural, religious, and ethnic considerations consistent with
470 their defined scope of practice. Recognized special populations include, but may not be limited
471 to, children, older patients, lesbian, gay, bisexual, and transgender (LGBT) patients, bariatric
472 patients, patients with disabilities, and patients with limited access to health care due to
473 geographic, demographic, socioeconomic, or other reasons.

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
474 Scope of Practice During Disasters, Public Health Emergencies, and Extraordinary
475 Circumstances
476 The Practice Model is intended to cover a range of situations and circumstances where EMS
477 personnel may provide emergency care. It is virtually impossible to create a scope of practice
478 that takes into account every unique situation, extraordinary circumstance, and possible practice
479 situation. In some cases, EMS personnel may be the only medically trained individuals at the
480 scene of a disaster when other health care resources are overwhelmed. This document cannot
481 account for every situation, but rather is designed to establish a system that works for entry-level
482 personnel under normal circumstances. States may wish to modify or expand the scope of
483 practice of EMS personnel in times of disaster or crisis with proper education, medical oversight,
484 and quality assurance to reasonably protect patient safety.

485 Scope of Practice for EMS Personnel Functioning in Nontraditional Roles

486 The delivery of health care has been transformed over the last half-century by exponential and
487 significant advances in medicine, research, and technology. The increasing portability and
488 affordability of diagnostic and treatment equipment and the demand to increase care quality
489 while reducing the cost of providing it has changed the demand for health care services in ways
490 that were not envisioned with the passage of the National Highway Safety Act in 1966. EMS
491 personnel are identifying volunteer and employment opportunities in a range of nontraditional
492 settings that fulfill an important public health, public safety, and patient care need, such as large-
493 scale concerts, sporting events and festivals, industrial, frontier and wilderness environments,
494 wildland fire settings, community health, and more. Enabled by progressive rulemaking,
495 occupational partners and innovative health care systems have been successfully utilizing
496 educated, experienced, and licensed EMS personnel in patient care settings, such as health clinics
497 and hospitals, for the past several years and they have become recognized as an invaluable
498 member of the health care team. States with practice restrictions based on location are
499 encouraged to review existing laws, regulations, and policies to identify barriers that prevent
500 EMS personnel from functioning at a level they have been educated, certified, licensed, and
501 credentialed by the state, and develop solutions that allow them to function in any setting to the
502 full extent of their education and training.

503 Specialty Care Delivered by Licensed EMS Personnel

504 Specialization of EMS personnel continues to be an evolving area of interest to the national EMS
505 community. This reflects a broader specialization trend that has occurred in medicine for over a
506 century as well ongoing specialization in nursing and other allied health fields. In general,
507 specialization occurs in response to an identified need for an expanded body of knowledge and
508 skills that are best served by a formal supplemental educational and credentialing process. In
509 many instances throughout healthcare the development and oversight of a specialty recognition
510 process is lead by health professionals through specialty boards and implemented in conjunction
511 with state regulators. This approach effectively combines national consistency achieved through
512 the specialty certification process with the legal authority to practice.

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
513 Specialty recognition, credentialing, or endorsement is the outcome of a formally defined
514 process and mechanism for actively assessing that an individual possesses and has mastered a
515 unique body of knowledge over and above entry-level cognitive, affective, and psychomotor
516 domains and that they can apply this knowledge and related skill set to improve care provided for
517 patients. Numerous health care and non-healthcare professions regulated by states have one or
518 more specialty certification areas that have been defined, in part, by members of the profession
519 itself. Several EMS specialties have emerged since the 2000 release of the National Highway
520 Traffic Safety Administrations (NHTSA) EMS Education Agenda for the Future: A Systems
521 Approach.

522 Integration of specialty care requires appropriate educational preparation, a rigorous certification
523 process, integration with state scope of practice regulations, and local credentialing by the
524 medical director and EMS agency.

525 The legal authority for personnel to practice is established by state legislative action. Licensure
526 authority prohibits anyone from practicing a profession unless they are licensed and authorized
527 by the state, regardless of whether or not the individual has been certified by a nongovernmental
528 or private organization.

529 States often approach specialization policy though two mechanisms. The first is development of
530 an additional licensure level beyond those described in this model. The second is to enact scope
531 of practice regulations at the state level that allow for additional practice, often called an
532 endorsement, in addition to an existing license level. This second approach is used extensively in
533 the medical and nursing professions. Both approaches benefit from ongoing cooperation and
534 coordination with non-governmental specialty boards.

535 Military to Civilian EMS Transition

536 Military corpsmen face combat wounds in some of the harshest conditions that the majority of
537 civilian EMS personnel will likely never see and they are undoubtedly well qualified to serve a
538 domestic mission to achieve zero preventable deaths in the war on trauma (#ZPD2025). While
539 support for military to civilian EMS transition is broad, the cognitive, affective, and psychomotor
540 coursework for medical corpsmen is variable depending on the individual service members
541 military assignment, which makes determining related equivalency and awarding experiential
542 credit for military service across five armed services branches somewhat complex. Much work
543 has been done to identify pathways for military corpsmen to transition to civilian EMS positions:

544 The U.S. Department of Defense has consolidated health care specialist training across
545 the armed services branches to a single operational center via the Medical Education and
546 Training Campus (METC) at Fort Sam Houston, TX. METC is working to ensure that
547 more service-required education and training programs satisfy the ever-increasing course
548 completion requirements of the civilian sector.

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
549 EMS programs are increasingly providing advanced placement evaluation and
550 assistance to separating service members, particularly at the AEMT and paramedic levels.
551 States have developed an updated model for conducting EMS personnel licensure
552 evaluations including the integration of EMS licensees from other states and from the
553 military setting.

554 Course completion of a program that meets or exceeds the National Emergency Medical Services
555 Education Standards (NEMSES) documents that an individual has fulfilled entry-level education
556 requirements that leads to National EMS Certification provided by the National Registry of
557 Emergency Medical Technicians (NREMT). Active NREMT Certification has been
558 demonstrated to be the most expeditious path for military personnel to seek EMS licensure with
559 the states.

560 IV. GENERAL DISCUSSION

561 An EMS Subject Matter Expert Panel, seated to consider the revision of the Practice Model,
562 convened its first in person meeting on June 1-2, 2017 in Washington, DC. The expert panel has
563 been encouraged to use an evidence-based approach to revising the SOP Model, specifically:

564 1. Is there evidence that the procedure or skill is beneficial to public health?
565 2. What is the clinical evidence that the new skill or technique as used by EMS personnel
566 will promote access to quality healthcare or improve patient outcomes?

567 While the discussion and conclusions are not binding and should not be considered as a final
568 recommendation at this time, the value of providing the context of ongoing discussions to the
569 EMS community is desired. The expert panel received a systematic review of literature on five
570 priority topics at their recent meeting and summaries are provided as follows:

571 1. Use of opioid antagonists at the BLS level

572 The expert panel reached consensus that the use of opioid antagonists was appropriate by EMRs
573 and EMTs if the individual possesses the necessary educational preparation, experience and
574 knowledge to properly administer an opioid antagonist via unit-dose, premeasured, intranasal or
575 autoinjector routes and suggest that the execution of the procedures shall include the
576 identification and discrimination of expected and unexpected human responses and the post-
577 treatment management of administering opioid antagonists to EMS patients with suspected
578 opioid overdose. Because the implementation of this practice serves an urgent patient care need,
579 a change notice (i.e. recommendation) has been transmitted to NHTSA for consideration.

580 2. Therapeutic hypothermia following cardiac arrest

581 Upon the review of literature, the expert panel reached consensus that the American Heart
582 Association and others suggest that there is no demonstrated benefit on patient outcomes with
583 implementing this procedure, and therefore, should not be included in the Practice Model.

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
584 3. Pharmacological pain management following an acute traumatic event
585 2,086 articles were extracted to evaluate pain management practices in the EMS environment but
586 they were inconclusive to answer the PICO question: (P) In patients requiring pain management
587 following an acute traumatic event in the prehospital setting, (I) can EMT and AEMTs
588 administer pharmacological pain medications (C) compared to paramedics (O) safely and
589 effectively? The panel discussed a variety of options and issues including alternatives to opioids,
590 the use of nitrous oxide at the AEMT level, intranasal administration of fentanyl at the EMT
591 level, diversion and accountability issues, pain management practices in the military
592 environment, the use of approved medication lists (i.e. does this practice limit flexibility or
593 enhance definitions), and the use of over-the-counter medications by EMTs. The topic is still
594 under review by the expert panel.

595 4. Hemorrhage control

596 The Hartford Consensus advocates TKTs for use by immediate responders to include
597 tourniquets (TKTs) when indicated. The national Stop the Bleed campaign includes
598 hemorrhage control education specifically for non-medically trained individuals and this training
599 addresses proper TKTs use. TKTs are already in the SOP for EMTs and the use of this device
600 should be expanded to include all levels of prehospital personnel.
601 Direct pressure for control of active bleeding is already a component of the SoPM for
602 hemorrhage control at all levels. The discussion surrounding this topic, therefore, focused on the
603 role of wound packing with and without hemostatic agents to address junctional (axilla, neck and
604 groin) wounds. Evidence supports wound packing when combined with application of direct
605 pressure to control active bleeding. Hemostatic-impregnated gauze has been shown to be more
606 effective than plain gauze for this purpose, although both can effectively control bleeding.
607 Hemostatic-impregnated gauze is currently included in many publicly-available bleeding control
608 kits. It was also noted that hemostatic dressings are available to the general public in many forms
609 for purchase over-the-counter and without prescription. Wound packing is an important
610 component of the training offered to immediate responders as part of the national Stop the
611 Bleed campaign and it is a skill that should be available to all personnel levels within the SoPM.

612 Because the implementation of hemorrhage control, including wound packing, serves an urgent
613 patient care need, a recommendation by the expert panel for an expedited update to the SoPM is
614 currently being considered.

615 5. Use of CPAP/BiPAP at the EMT level

616 The literature with regard to this topic was extensively reviewed. Although the data supporting
617 this practice at the BLS level was minimal, several panelists reported good outcomes in State
618 pilot projects evaluating the practice at the EMT level. Discussion included the impact on
619 intubation rates, risk of mortality, inclusion criteria, PEEP vs. CPAP, and
620 consideration/comparison of other respiratory therapies (such as bronchodilators). The topic is
621 still under review by the expert panel.

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
622 6. Nomenclature and the use of international models to advise the Practice Model
623 Over the last several years, a conversation has begun among national organizations in support of
624 EMS to consider updating the nomenclature relating to EMS personnel and the provision of out-
625 of-hospital care in the U.S. It is noted that there are models for nomenclature used in other
626 countries' EMS systems that may prove to be of value in these discussions. The expert panel
627 supports the need for continued national dialogue in this regard.

628 7. Additional topics currently under consideration

629 The expert panel reviewed several suggestions that have been submitted by the EMS community
630 via an on-line form. After participating in a brainstorming session and nominal group process,
631 the panel identified several priorities for moving forward. While this is not a comprehensive list
632 of all elements the expert panel is currently reviewing, key points include:

633 Spinal motion restriction at the EMT level

634 Blood glucose monitoring, bronchodilators, CPAP, and epinephrine at the EMT level
635 Ultrasound at the paramedic level
636 Need and criteria for licensure level above paramedic
637 Definitions for critical care
638 Calculating drug doses/use of vials and syringes by EMTs
639 Patient transport at the EMR level
640 I/O for adults
641 Blood administration by paramedics
642 High flow nasal cannula
643 Oral OTC meds
644 Capnography

645 8. Comments received for exclusion from the Practice Model:

646 Endotracheal intubation
647 PASG/MAST
648 Spinal Immobilization
649 Cricoid Pressure
650 Carotid Massage
651 Sub-q Epinephrine
652 Demand Valve
653 Jaw Thrust for Trauma
654 PEEP -Therapeutic

655

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
656 Appendix I
657 History of Occupational Regulation in EMS
658 The development of modern civilian EMS stems largely from lessons learned in providing
659 medical care to soldiers injured in military conflict.

660 Building on these lessons, a number of rescue squads and ambulance services emerged in the
661 civilian sector, often community based in nature. Hospitals and funeral homes were also
662 common sources of nascent response and transportation systems. While well intentioned, most of
663 these personnel were untrained, poorly equipped, unorganized, and unsophisticated. The systems
664 were unregulated, and no state or national standards existed. By the 1960s, prehospital care in the
665 United States had evolved into a patchwork of well intentioned but uncoordinated efforts. This
666 all changed in the mid-1960s.

667 In 1960, the Presidents Committee for Traffic Safety recognized the need to address Health,
668 Medical Care and Transportation of the Injured to reduce the nations highway fatalities and
669 injuries.

670 In 1966, the National Academy of Sciences published a white paper report titled Accidental
671 Death and Disability: The Neglected Disease of Modern Society. This report quantified the
672 magnitude of traffic-related death and disability while vividly describing the deficiencies in
673 prehospital care in the United States. The white paper made a number of recommendations
674 regarding ambulance systems, including a call for ambulance standards, State-level policies and
675 regulations, and adopting methodology for providing consistent ambulance services at the local
676 level (National Academy of Sciences National Research Council, 1966).

677 The Highway Safety Act of 1966 required each State to have a highway safety program that
678 complied with uniform Federal standards, including emergency services. This provided the
679 impetus for the National Highway Traffic Safety Administrations early leadership role in EMS
680 system improvements. Initial NHTSA EMS efforts were focused on improving the education of
681 prehospital personnel such as the writing of the National Standard Curricula (NSC). Funding was
682 also provided to assist States with the development of State EMS Offices. Subsequent NHTSA
683 efforts were oriented toward comprehensive EMS system development and included, for
684 instance, model State EMS legislation (Weingroff and Seabron, circa 2003).

685 The genesis of State EMS systems can also be traced to the early 1970s, when an unprecedented
686 level of funding from the Federal Government and the Robert Wood Johnson Foundation
687 prompted the establishment of regional EMS systems and demonstration projects throughout the
688 country. The Emergency Medical Services Systems Act of 1973 Pub. L. 93-154 87 Stat. 594-
689 605. 16 November 1973 (enacted by Congress as Title XII of the Public Health Service Act),
690 yielded eight years and over $300 million of investment in EMS systems planning and
691 implementation. The availability of EMS personnel and their training were two components that

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
692 eligible entities were required to focus on, resulting in the first generation of legislation and
693 regulation of EMS personnel levels (National Highway Traffic Safety Administration, 1996).

694 Insert brief NHTSA NSC history here, how they and the textbooks were the primary drivers of the
695 scope of practice, especially once states starting incorporating the NSC into state laws and rules.

696 One function of State EMS offices was to ensure the competence of the States EMS personnel.
697 States employed a number of strategies to help assure safe and effective EMS practice, including
698 licensure and certification. Unfortunately, these terms developed multiple connotations in EMS.
699 In some cases, the meanings differed from other disciplines, causing confusion and inconsistency
700 at the national level.

701 Cover the effect of the 1981 Omnibus Reconciliation Act and how it left states with local and
702 regional EMS systems with very different levels of personnel competency and scopes of practice.

703 By 1990, EMS in the United States had enjoyed many successes. Not only did EMS systems
704 grow, but EMS became a career and volunteer activity for hundreds of thousands of talented,
705 committed, and dedicated individuals. Emergency medical care was available to virtually every
706 citizen in the country by simply dialing 9-1-1 from any telephone. Despite this progress, EMS
707 was affected by a number of factors in the broader health care system.

708 In 1992, the National Association of EMS Physicians (NAEMSP) and the National
709 Association of State EMS Directors (NASEMSD) saw a need for a long-term strategic
710 direction for EMS, and the EMS Agenda for the Future was initiated with support from the
711 National Highway Traffic Safety Administration and the Maternal and Child Health Bureau
712 (MCHB) of the Heath Resources and Services Administration (HRSA). Published in 1996,
713 the EMS Agenda for the Future proposed a bold vision for greater integration of EMS into the
714 U.S. health care system.

715 In 1993, the National Registry of EMTs (NREMT) released the National Emergency
716 Medical Services Education and Practice Blueprint. The Blueprint defined an EMS
717 educational and training system that would provide both the flexibility and structure needed
718 to guide the development of national standard training curricula and guide the issuance of
719 licensure and certification by the individual States.

720 In 1998, the Pew Health Professions Commission Taskforce on Health Care Workforce
721 Regulation published Strengthening Consumer Protection: Priorities for Health Care
722 Workforce Regulation (Finocchio, Dower et al., 1998). The report recommended that a
723 national policy advisory board develop standards, including model legislative language, for
724 uniform scopes of practice authority for the health professions. The report emphasized the
725 need for States to enact and implement scopes of practice that are nationally uniform and
726 based on the standards and models developed by the national policy advisory body.

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
727 Also in 1998, demonstrating their commitment to the EMS Agenda, NHTSA and HRSA jointly
728 supported a two-year project to develop an integrated system of EMS regulation, education,
729 certification, licensure, and educational program accreditation. The result was the EMS
730 Education Agenda for the Future: A Systems Approach, which recognized the need for a
731 systematic approach to meet the needs of the current EMS system while moving toward the
732 vision proposed in the 1996 EMS Agenda for the Future. The EMS Education Agenda called for
733 a more traditional approach to licensing EMS personnel.

734 A coordinated national EMS system continues to be in the best interest of States, EMS
735 personnel, and the public. State EMS offices, while working in cooperation with their
736 stakeholders, should implement scope of practice regulations that are as close as possible to
737 those described in the National EMS Scope of Practice Model. This will help with professional
738 recognition of EMS personnel, facilitate reciprocity, decrease confusion, and enable the
739 development of high quality support systems to benefit the entire system.

740

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
741 Appendix II
742 Legal Differences Between Certification and Licensure
743 Used with permission: National Registry of Emergency Medical Technicians

744 https://www.nremt.org/rwd/public/document/certification_licensure

745 Although the general public continues to use the terms interchangeably, there are important
746 functional distinctions between certification and licensure.

747 Certification
748 The federal government has defined certification as the process by which a non-governmental
749 organization grants recognition to an individual who has met predetermined qualifications
750 specified by that organization.1 Similarly, the National Commission for Certifying Agencies
751 defines certification as a process, often voluntary, by which individuals who have demonstrated
752 the level of knowledge and skill required in the profession, occupation, role, or skill are
753 identified to the public and other stakeholders.2

754 Accordingly, there are three hallmarks of certification (as functionally defined). Certification is:

755 1. voluntary process;

756 2. by a private organization;
757 3. for the purpose of providing the public information on those individuals who have
758 successfully completed the certification process (usually entailing successful completion
759 of educational and testing requirements) and demonstrated their ability to perform their
760 profession competently.

761 Nearly every profession certifies its members in some way, but a prime example is medicine.
762 Private certifying boards certify physician specialists. Although certification may assist a
763 physician in obtaining hospital privileges, or participating as a preferred provider within a health
764 insurers network, it does not affect his legal authority to practice medicine. For instance, a
765 surgeon can practice medicine in any state in which he is licensed regardless of whether or not he
766 is certified by the American Board of Surgery.

767 Licensure
768 Licensure, on the other hand, is the states grant of legal authority, pursuant to the states police
769 powers, to practice a profession within a designated scope of practice. Under the licensure

1
U.S. Department of Health, Education, and Welfare, Report on Licensure and Related Health Personnel
Credentialing (Washington, D.C.: June, 1971 p. 7) .
2
NCCA Standards for the Accreditation of Certification Programs, approved by the member organizations of the
National Commission for Certifying Agencies in February, 2002 (effective January, 2003).

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.
770 system, states define, by statute, the tasks and function or scope of practice of a profession and
771 provide that these tasks may be legally performed only by those who are licensed. As such,
772 licensure prohibits anyone from practicing the profession who is not licensed, regardless of
773 whether or not the individual has been certified by a private organization.

774 What if my state certifies, not licenses, EMS professionals?

775 Confusion between the terms certification and licensure arises because many states call their
776 licensure processes certification, particularly when they incorporate the standards and
777 requirements of private certifying bodies in their licensing statutes and require that an individual
778 be certified in order to have state authorization to practice. The use of certification by the
779 NREMT by some states as a basis for granting individuals the right to practice as EMTs and
780 calling the authorization granted certification is an example of this practice. Nevertheless,
781 certification by the National Registry, by itself, does not give an individual the right to practice.

782 Regardless of what descriptive title is used by a state agency, if an occupation has a
783 statutorily or regulatorily defined scope of practice and only individuals authorized by the
784 state can perform those functions and activities, the authorized individuals are licensed. It
785 does not matter if the authorization is called something other than a license; the
786 authorization has the legal effect of a license.

787 In sum, the NREMT is a private certifying organization. The various State EMS Offices or like
788 agencies serve as the state licensing agencies. Certification by the NREMT is a distinct process
789 from licensure; and it serves the important independent purpose of identifying for the public,
790 state licensure agencies and employers, those individuals who have successfully completed the
791 Registrys educational requirements and demonstrated their skills and abilities in the mandated
792 examinations. Furthermore, the NREMTs tracking of adverse licensure actions and criminal
793 convictions provides an important source of information, which protects the public and aids in
794 the mobility of EMS providers.

795 CONTENT BEYOND THIS MARK WILL BE INCLUDED IN NEXT DRAFT FOR
796 COMMENT

It is important to note that the content of this document is currently UNDER REVIEW; it is not
binding, and should not be considered as a final recommendation at this time. Considerations
may or might not appear in the final document.