The commonly accepted role of EMS, in public health speak, is secondary prevention: to mitigate the impact of an injury or medical emergency once it has occurred by immediate and appropriate emergency intervention.
The repurposed role envisioned by the 1996 EMS Agenda for the Future expands to include primary prevention, which is preventing the injury or medical emergency from occurring in the first place, and tertiary prevention, which is preventing reoccurrence of injuries and medical emergencies through rehabilitative management of the underlying disease or other issues that may have caused them.1
Community paramedicine (CP) has evolved as the embodiment of these expanded roles for EMS providers. Leaders of the CP movement in the United States maintain that CP represents additional roles and practice settings for EMS providers without requiring scopes of practice expanded beyond current state EMS licensure.
A soon-to-be-published National Association of State EMS Officials (NASEMSO) survey of state EMS offices finds that only three of 49 respondents (6%) allowed CP scope beyond current scope of practice. One example is a state that allows suturing by community paramedics with appropriate supplemental training.
Scope of Practice Considerations
In its ongoing support for implementation of the EMS agenda, the National Highway Traffic Safety Administration (NHTSA) sponsored the development of The EMS Education Agenda for the Future: A systems approach in 2000. The education agenda envisioned a new model for delivering and updating education for EMS personnel—one that more closely paralleled other allied health disciplines. It also sought to answer some fundamental questions about EMS: Where does EMS fall in the spectrum of other healthcare professions like nursing or respiratory therapy? How many levels of EMS do we need and what should the scope of practice be for each level? How can we assure the competency of people entering and working in EMS?
Community paramedics typically rely on comprehensive care plans developed by nurse case managers, mid-level practitioners or physicians to provide episodic care to patients. PHOTO COURTESY MEDSTAR MOBILE HEALTHCARE
As one step toward implementing the education agenda, an effort was undertaken to establish theNational EMS Scope of Practice Model (SOP model), which was published in 2007. This initiative was also supported by NHTSA and the federal Health Resources and Services Administration. It was led by NASEMSO with participation by educators, employer groups, physicians, the National Registry of EMTs, the Committee on Accreditation of Educational Programs for the EMS Professions, and private citizens. Establishing the SOP model was crucial for EMS as it reversed the orientation from education driving practice to first defining practice and then building the education necessary to prepare EMTs and paramedics to function.
The SOP model was built on several foundational elements. As its name implies, it is just that: a model. States bear the responsibility for licensing EMS personnel who deliver services within the state. States also have the responsibility for establishing the scope of practice associated with that license. The SOP model is intended to be a floor, not a ceiling, supporting the mobility of the EMS workforce between states by clarifying that an EMT or paramedic knows at least this much and can do at least this much.
The SOP model states that “the primary focus of the EMT is to provide basic emergency medical treatment and transportation for critical and emergent patients who access the emergency medical system,” and that “the Paramedic is an allied health professional whose primary focus is to provide advanced emergency medical care for critical and emergent patients who access the emergency medical system.” In describing the settings where EMTs and paramedics work, the SOP model suggests both may work at emergency scenes and during transportation, “or in other healthcare settings.”2
As EMTs and paramedics take on new and different roles in providing community healthcare, EMS systems need to keep asking whether something outside their scope of practice is really just a new place or role where they’re applying education they already have.
The National EMS Education Standards were created to help EMS educators prepare candidates for the EMS profession at the four levels in the SOP model (EMR, EMT, advanced EMT and paramedic). This document describes “depth” of knowledge, which relates to the amount of detail a student knows about a topic. It also discusses “breadth” of knowledge, which refers to the number of subjects a student needs to learn in a particular competency. In ascending levels from EMR to paramedic, each of the levels contains the full depth and breadth of information in the lower level(s) while adding to each category.3
The scope of practice, particularly for paramedics, is far broader than many people realize. For example, the SOP model describes psychomotor skills including: inserting an intraosseous cannula, enteral and parenteral administration of approved prescription medications, accessing indwelling catheters and implanted central IV ports for fluid and medication administration, collecting and testing blood samples, administering medications by IV infusion, and maintaining an infusion of blood or blood products.2
Pharmacology is another example. The education standards describes paramedic competence as “complex depth and comprehensive breadth for names, actions, indications, contraindications, complications, routes, side effects, interactions, (and) dosages.”3 Neither the education nor scope document includes a list of authorized medications a paramedic can administer. This was purposeful so that the documents don’t become outdated as clinical practice changes and advances are made in pharmacological treatments.
As interesting for CP as what the SOP model and education standard includes is what they don’t mention. Is it a scope issue for EMS to visit the home of a patient and provide education on fall prevention? Could EMS compare a prescription medication list provided by a patient’s physician with the medications found in the home to determine if the patient has had their prescriptions filled and is taking them as intended by the physician? As an assessment technique, could an EMS person weigh a patient at their home to monitor potential weight gain related to fluid retention? Some of the tasks that EMS may be well-positioned to take on in a CP realm are things a non-clinical support person could do.
Although EMTs and paramedics use their education, skills, protocols, standing orders and direct medical oversight to establish “care plans” for their patients, these plans for the next minutes of emergency care are very different from comprehensive care plans for managing chronic conditions encountered by community paramedics. As a result, some say community paramedics provide “episodic” assessment, care, intervention and care recommendations based on care plans developed by nurse case/care managers, mid-level practitioners, or physicians with whom they’re clinically integrated. They maintain that responsibility for establishing the care plans themselves is outside the community paramedic’s scope.
Medication reconciliation, as opposed to simply reviewing medications as discussed above, is another area of uncertainty. Paramedics are within their scope to understand the indications, contraindications, mechanisms, interactions and precautions for the administration of a wide range of medications and to use reference materials to access related information they may not know. The CP role may have them helping a recently discharged hospital patient reestablish themselves at home. As a part of this, a “medication reconciliation” may be done to make sure that medications brought home don’t cause problems with medications found at home. Some systems have the community paramedic simply listing or taking pictures of all meds for review by a physician or pharmacologist, while others may require more assessment responsibility on the community paramedic’s part. What is the scope limit here, if any?
Community paramedicine was conceptually based on using EMS resources to address unmet health service and access needs in a given community. By definition, then, CP in one community may look very different from CP in another community. As CP matures, however, it’s incumbent upon its leaders to encourage standardization of practices and their scope, and the education, medical oversight and other system components required to carry out those practices. There have been productive efforts to create such standardization through the development of a national consensus curriculum for community paramedics. It’s perhaps time, though, to turn to the scope and education documents and processes for the purpose of further development in the CP realm.
Dan Manz is executive director of Essex (Vt.) Rescue and the former director of Vermont EMS.
Kevin McGinnis is program manager for community paramedicine, mobile integrated healthcare and rural EMS for the National Association of State EMS Officials.
1. National Highway Traffic Safety Administration. (1996.) Emergency medical services agenda for the future. Retrieved July 6, 2015, from www.ems.gov/pdf/2010/EMSAgendaWeb_7-06-10.pdf.
2. National Highway Traffic Safety Administration. (2007.) National EMS scope of practice model. Retrieved July 6, 2015, fromwww.nhtsa.gov/people/injury/ems/EMSScope.pdf.
3. National Highway Traffic Safety Administration. (January 2009.) National emergency medical services education standards. Retrieved July 6, 2015, from www.ems.gov/pdf/811077a.pdf.