At the August 29, 2012 meeting of the National Emergency Medical Services Advisory Council (NEMSAC), an “Education Agenda Workgroup” was empaneled by the Chair, Aarron Reinert, and charged with the task of reviewing the proceedings of the March 12, 2012 Roundtable on the EMS Education Agenda for the Future: A Systems Approach (the Education Agenda), and answering a series of questions proposed by the NEMSAC at its May 30, 2012 meeting regarding a potential revision of the Education Agenda.
After due consideration, conducted by the Workgroup by teleconference on January 22, 2013, and in person meeting on January 29, 2013, and by the NEMSAC at its meetings of January 30, 2013, and May 16-17, 2013, it was determined it would be inappropriate to recommend major changes to the Education Agenda at the present time, since a number of emerging issues had come to the fore since publication of the foundational document, the EMS Agenda for the Future (the Future Agenda), that could alter the fundamental structure and function of the EMS professions—issues that could necessitate revision of the Future Agenda before any changes in the Education Agenda could be contemplated. The issues cited include, but are not necessarily limited to, the impact of the Patient Protection and Affordable Care Act (PPACA) on EMS, as well as the evolving roles of specialty care transport, provider specialty certification, aeromedical services, disaster paramedicine, community paramedicine and public health, physician extenders, tactical support, and patient and provider safety in EMS. However, two of these issues, disaster paramedicine and patient and provider safety, were deemed to be of such import, given their impact on public health and provider wellbeing, that they needed to be emphasized within the scope of EMS education set forth in the Education Agenda as soon as possible, and could not wait for the lengthy process of revising the Future Agenda to be completed.
It was additionally determined that incomplete understanding of the original intent of the Education Agenda, and insufficient assessment of the current state of implementation of the Education Agenda, also weighed against major changes in the document at present.
As such, the NEMSAC recommends a triphasic approach to review and revision of the Education Agenda at this time. First, the NEMSAC recommends that a process be initiated as soon as practicable to review and revise the Future Agenda. Second, the NEMSAC recommends that the minor changes to the Education Agenda cited above should be made as soon as possible, based upon expeditious review by the NEMSAC. Third, the NEMSAC recommends that efforts should be made to reeducate the national EMS communities of interest regarding the history and intent of the Education Agenda.
In addition, the NEMSAC has also provided detailed answers to the specific questions on the Education Agenda it proposed at its August 29, 2012 meeting, based on review of the proceedings of the March 28, 2012 NEMSAC Roundtable on the Education Agenda.
Submit Comments to NEMSAC@dot.gov by May 10, 2013
1) Should the Education Agenda be revised or updated or both?
The statements made by those participating in the March 28, 2012 NEMSAC Roundtable on the Education Agenda collectively suggest that it should be updated, but not revised. Most participants expressed the sentiment that insufficient time had elapsed between publication of the Education Agenda and the documents it called forth, the National EMS Core Content (the Content), the National EMS Scope of Practice (the Scope), and the National EMS Education Standards (the Standards), to permit meaningful analysis of their impact at this time. Therefore, wholesale revision did not seem to be warranted by those present, since insufficient data are currently available to substantiate such revision. As previously stated above, the NEMSAC agrees with these sentiments. However, the NEMSAC also believes that systematic assessment of the current state of implementation of the Education Agenda is needed, since unforeseen consequences of its implementation may have arisen in some locales. This could be undertaken by national organizations representing EMS physicians, regulators, educators, providers, and managers, and the results of their efforts used by the NEMSAC to identify any gaps in implementation.
2) Are there gaps in the document compared to current practice? Is there a need to expand the document?
While there may be significant gaps in the document compared to current practice, there are no known gaps between the document and the Scope or the Standards, neither of which directly addresses any of the emerging issues cited above. Once again, a limited update of the Education Agenda could emphasize the importance of education in disaster paramedicine and patient and provider safety. As soon as possible after such an update, the Content, the Scope, and the Standards should be correspondingly updated as needed.
3) Are there barriers to implementing the Education Agenda that should be studied and addressed (ceilings, nomenclature, etc.)?
The main barrier to full implementation of the current Education Agenda continues to be imperfect consensus within the national EMS community regarding the role of national EMS education program accreditation and national EMS individual provider certification. Although substantial progress has been made toward their adoption in most states and territories, and there is broad support for the concept of third party education program accreditation and individual provider certification, the best mechanisms to achieve these goals remain the subject of debate in some locales, particularly for educational program accreditation below the Paramedic level. The issues involved in this debate are complex, and will likely require focused discussion among key stakeholder groups. The efforts of currently existing national EMS program accreditation and EMS provider certification bodies toward full inclusivity of all EMS provider sectors may facilitate this discussion. Ceilings and nomenclature could also be impeding full implementation of the Education Agenda in some locales, but again, such issues could be studied by national organizations representing EMS physicians, regulators, educators, providers, and managers, and the results of their efforts used by the NEMSAC to address any such barriers perceived.
4) Are there changes to the environment that would necessitate a revision of the Education Agenda? What is the process by which each of the components are revised?
While the current economic climate poses major challenges to the EMS community, and the steadily increasing numbers of natural and human made disasters pose grave threats to individual and public health, these should not by themselves lead to revision of the current Education Agenda. Rather, it should be revised based only on the contemporary needs of the national EMS community. Since the collective sentiment of those present at the March 28, 2012 NEMSAC Roundtable on the Education Agenda, the Workgroup, and the NEMSAC, was that only a limited update, not a wholesale revision, was needed, and since the time and effort required to make the minor changes cited above would be minimal, the NEMSAC, based upon expeditious review by the Workgroup, could assume primary responsibility for recommending these changes to the Education Agenda to the NHTSA. Corresponding changes to the Content, the Scope, and the Standards, if needed, should follow as soon as possible thereafter, by their respective communities of interest.
5) How do we keep that process sustainable?
Given the vital role of EMS in timely and effective resuscitation from cardiorespiratory failure and arrest, which necessitates periodic revision of the evidence-based Consensus on Science the Treatment Recommendations (the CoSTR) of the International Liaison Committee on Resuscitation (ILCOR), and the resulting Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (the Guidelines) of the American Heart Association (AHA) Emergency Cardiovascular Care (ECC) Committee, the NHTSA could convene roundtables or workgroups to address the need for potential changes in the Education Agenda, the Content, the Scope, and the Standards, as needed, as soon as possible after each periodic revision of the AHA ECC Guidelines is published. The NEMSAC should be fully involved in advising the NHTSA as the revision process is created. If a need for potential changes to any of the Education Agenda documents is identified, including but not limited to those necessitated by either the Guidelines or the “Evidence-Based Guidelines for Prehospital Emergency Care” project sponsored by the NHTSA, the NHTSA should take the lead in convening, or causing to be convened, a broadly representative group of subject matter experts to recommend these changes.
6) Should the Education Agenda review process include a comparison analysis of EMS systems internationally, to include a) scope of practice, b) regulatory structure, c) education standards, d) others?
Yes. This is particularly true of EMS systems in North America from outside the United States, since in the event of a truly catastrophic disaster, North American EMS personnel from outside the United States might be called upon to assist their American colleagues. However, comparative analysis of EMS systems internationally may provide valuable insights regarding the structure and function of EMS professions in the United States, particularly with respect to the proposed revision of the Future Agenda. This analysis should be considered by the NHTSA as a priority topic for a future EMS white paper.
7) What is the scientific basis of the current Agenda and evidence for future revisions?
The scientific basis for the current Education Agenda is well described in its introduction. Future revisions or updates to this document should be evidence-based, and follow upon advances in the science of EMS education. Experts in EMS education should therefore be asked to participate any time a full revision of the Education Agenda is contemplated. As set forth above, evidence based processes for revision or update of the Content, the Scope, and the Standards should follow immediately upon revision or update of the Education Agenda. Given the increasing role that medical simulation is taking in health education, the NHTSA should consider convening a panel, or contract with a recognized expert in the field, to examine the potential role of medical simulation in EMS education.
8) What would be the impact of proposed revisions? State law and regulation? Economic impact? Impact to localities, particularly rural areas?
Although difficult to say with certainty, the impact of a limited update to the Education Agenda on state law and regulation is hoped to be minimal. The same is true regarding economic impact. Those participating in the March 28, 2012 NEMSAC Roundtable on the Education Agenda felt that only limited changes to the document could be justified at the present time, and further expressed their sentiment that any such changes should be considered in light of potential effects on state law and regulation and the economic impact on EMS provider agencies. Still, education of EMS personnel in out-of-hospital disaster medicine and patient and provider safety is clearly needed, and must be offered. The impact on localities, especially rural areas, must be seen in this same context. Recent experience with both natural and human made disasters confirms that disasters can afflict urban, suburban, rural, and frontier areas alike, while a culture of safety is paramount.
9) What are the most appropriate immediate next steps for the NHTSA?
The most appropriate short term next steps for the NHTSA are to support the proposed limited updates of the Education Agenda, Content, Scope, and Standards as described above. Each of the updates should be reviewed and endorsed by the NEMSAC and the national communities of interest, prior to consideration and adoption by the NHTSA. The most appropriate medium term next steps for the NHTSA are to initiate a process to review and revise the Future Agenda. An EMS white paper charged with comparative analysis of EMS systems internationally should therefore receive priority consideration.
10) What are the most appropriate immediate steps for the FICEMS?
The most appropriate immediate next steps for the FICEMS are to work to ensure that all participating Federal agencies endorse the Education Agenda and its resulting documents, and to implement their recommendations with all deliberate speed if not yet doing so.
A letter from National Emergency Medical Services Advisory Council Chair Aarron Reinert