Broadly defined, the scope of practice defines the healthcare services that a pre-hospital provider is authorized to perform by virtue of professional licensure. The scope of practice in Emergency Medical Services (EMS) is under the regulation of state-level licensure. To become licensed, an EMS provider must provide evidence of satisfactory completion of an accredited education program, a certification examination, and state licensure. For clarity, certification verifies a knowledge or experience base. Licensure bestows permission to perform specific duties/skills.
Each level of EMS provider has a defined scope of practice that gets delineated in the National Highway and Traffic Safety Administration (NHTSA), The National EMS Scope of Practice Model. This scope was developed based on a uniform educational curriculum and included knowledge and skills critical to each level of care, meaning any provider with that level of certification and licensure should be equipped to perform these skills. The formal definition given by NHTSA of the scope of practice is as follows, “Defined parameters of various duties or services that may be provided by an individual with specific credentials. Whether regulated by rule, statute, or court decision, it represents the limits of services an individual may legally perform.”
However, states may choose to expand or limit the scope of practice regarding specific skills. This expansion would require additional training and certification beyond the standard curriculum before licensure. Other training courses may be completed for certifications that allow for expanded scope of practice as well, although this is still often regulated by states individually.
Issues of Concern
The education, examination, and process for licensure are often state-dependent despite efforts to ensure national uniformity.
In 1996, the EMS Agenda for the Future was published with the intent to provide principles to guide the continued development of EMS by obtaining input from a broad range of stakeholders. This document contained fourteen key components necessary for the growth and progress of prehospital care. A system of uniform education was one of the key elements; this led to the publication of “EMS Education Agenda for the Future” in 2000, which recommended evidence-based education, medical direction for all levels of training, and accreditation by a national accrediting agency.
The education agenda specifically delineates a goal to promote national uniformity, thus increasing state reciprocity, while still allowing and meeting local needs. Within the agenda are five specific components, including the National EMS Scope of Practice Model. The other components include National EMS Core Content, National EMS Education Standards, National EMS Program Accreditation, and National EMS Certification. Leaders in the development of these components included physicians from the National Association of EMS Physicians (NAEMSP) and the American College of Emergency Medicine (ACEP), the National Association of State EMS Officials (NASEMSO), and the National Association of EMS Educators (NAEMSE) among other stakeholders.
The National EMS Core Content defines the content base and educational standards for various EMS providers. This component is outlined to mimic a physician education program defining a specialty scope of practice. The National EMS Education Standards outlines more specific content for curriculum development. The National Registry of Emergency Medical Technicians (NREMT) developed the initial education plan for prehospital practitioners in the 1980s and has continued to provide the national certification exam and sponsor the standard curriculum. To ensure adherence to the national curriculum endorsed by the above organizations, the National Registry has a formal accreditation policy, which requires advanced level education (paramedic) to be conducted by institutions accredited by the Committee on Accreditation of Educational Programs for the EMS Profession (CoAEMSP).
The previously mentioned National EMS Scope of Practice Model published by NHTSA was developed based on the educational core content. The National Scope model outlines the recognized “levels” of EMS practitioners eligible for licensure after successful completion of an accredited educational program, certification exam, and state licensure requirements. NHTSA recognizes four levels of care, each with a unique scope of practice and associated skills. These levels of care include Emergency Medical Responder (EMR), Emergency Medicine Technician-Basic (EMT-B), Advanced Emergency Medical Technician (AEMT), and Paramedic (EMT-P).
The education and skills competency is demonstrated via a certification exam. Most states utilize the National Registry of EMT standardized written and psychomotor examinations to ensure educational standardization and competence. Each state will then determine, based on certification, if a license to practice may be issued. Credentialing is done at the individual agency level by the system medical director.
Remember that scope of practice is not equivalent to the standard of care. The scope of practice defines what skills or procedures a prehospital practitioner is allowed to perform. Standard of care defines properly performing the correct skill in the appropriate setting. Performing a skill outside of the defined scope of practice can be considered a criminal offense. Commission or omission of a skill that is not defined as the correct skill or for the appropriate circumstances may constitute malpractice with civil liability. The scope of practice is determined by the level of care and does not vary between individual practitioners or clinical circumstances. Standard of care is often more variable and may be case dependent. Concerning EMS, the scope of practice is defined by state statutes, rules, regulations, or licensure board interpretations. The standard of care, in particular cases, is determined by considering the defined scope of practice, existing literature and evidence, as well as expert witnesses. The use of expert witnesses should be limited to physicians with working knowledge of and relationships with EMS practitioners, preferably those who provide medical direction services.
A recent example that outlines the changes required to expand the scope of practice would include the movement in states to allow intranasal naloxone administration by BLS providers in cases of a suspected opioid overdose. Intranasal naloxone is not typically part of the national curriculum or outlined in the national scope of a basic EMT. Due to the increase in opioid-related deaths, this skill has been added to the scope of practice by individual states. This change has been particularly impactful in rural communities, where deaths related to opioid overdoses are often higher than in urban communities. Naloxone was previously limited to ALS providers (paramedic, AEMT), and BLS (EMT-B) providers constitute the majority of responders. One institution in Nevada has promising data showing the utility of naloxone administration by BLS providers. Rural EMTs received training regarding naloxone administration. They received both didactic and motor skills education. All participants completed pre and post-testing. Following training, there was a statistically significant increase in scores on the post-test and increased comfort in administration.
Similarly, in New England, patient outcomes were studied after administration of intranasal naloxone following administration by either basic life support (BLS) or advanced life support (ALS) providers. No significant difference in the improvement in GCS score after naloxone administration between BLS and ALS providers. BLS providers were also able to identify patients in whom the administration is appropriate.
Specific certifications will also allow for expanded scope of practice relative to the levels of care outlined by NHTSA. Wilderness EMT certification, as well as critical care paramedic certification, are two common examples. Flight paramedics receive training beyond the core curriculum to prepare the paramedic primarily to manage interfacility transfers. These transfers involve complex patients who have already received significant medical interventions and often require transport with multiple advanced pharmacologic agents or advanced hemodynamic monitoring. More recently, interfacility transport of patients with cardiac devices such as balloon pumps or extracorporeal membrane oxygenation (ECMO) has become common. The National Flight Paramedic Association has a specific training program and exam. Upon successful completion, paramedics are “certified flight paramedics” with an expanded scope. This expanded scope is recognized in state statute as most state EMS protocols have specific protocols for air medical transport programs.
Due to the unique nature of providers operating in the wilderness or austere environments, the National Association of EMS Physicians Wilderness Medicine Committee, with the assistance of other stakeholders, attempted to better define core educational content and levels of care regarding wilderness medicine. Operating in these conditions often requires prolonged field care, less readily available medical direction, and specific equipment constraints. The curriculum builds on the National EMS Education Standards as well as the National Scope of Practice Model. Four specific levels of care and certifications were recognized and completion of the wilderness emergency medical responder (W-EMR), wilderness emergency medical technician-basic (WEMT-B), wilderness advanced emergency medical technician (WAEMT), and wilderness paramedic (WEMT-P) allows for the performance of specific skills when practicing in an austere environment.
Disaster situations and critical events often raise the question of EMS operating outside the defined protocols or scope. NHTSA does recognize that protocol-driven care and specifically defined scope of practice may not apply to every unique situation. The National Scope of Practice Model does allow for modification due to critical or disaster events. A classic example provided is during public health emergencies. Although the traditional scope does not include vaccine administration, ALS providers receive training in drawing up medicine and administering IM injections. They would be able to assist in mass vaccination protocols.
Conversely, an agency medical director may choose to limit scope at a lower level than state or regional protocols, which occurs via agency-specific credentialing. Common themes have been identified based on geographic service area, fire-based service, volunteer, or professional services. EMS agencies in urban areas were less likely to authorize specific interventions at any level of care when compared with rural agencies. Fire-based services were more likely to authorize optional interventions/skills for EMT-B and EMT-intermediate. Volunteer agencies were more likely to authorize EMT-B interventions. Greater medical involvement led to an increased likelihood of any intervention for both EMT-B and EMT-P.