From Fragmentation to Unity: How to make the transition to the national EMS scope of practice model

In the recently released National Academy of Sciences, Institute of Medicine (IOM) report Ë™Future of Emergency Care: Emergency Medical Services at the Crossroads,à“ Ë™fragmentationà“ was listed as a major problem in”žEMS. Across the”žU.S.,”žEMS provider titles, and the associated patient interventions, differ from state to state.”ž

Most states have five provider levels of”žEMS providers: First Responder (FR), Emergency Medical Technician-Basic (EMT-B), EMT-Intermediate/85 (EMT-I/85), EMT-Intermediate/99 (EMT-I/99) and EMT-Paramedic. It would take an entire article to cover the differences between state provider levels, but EMTs who_ve moved between states know them all too well. These differences cause complications, increase provider frustration and ultimately prevent the public from receiving a consistent level of care across the country.

But between 2010 and 2014, the nation_s EMS agencies will transition to meet the goals outlined in the IOM-supported National EMS Scope of Practice Model (SOP), which was designed to reduce fragmentation and provide greater uniformity to the certification and licensure of”žEMS providers. Under the SOP, education for each level will be based on practice, rather than National Curricula Standards, resolving the disconnect between what_s taught in class and the care we actually provide to patients.”ž

The justification for this transition has been outlined in the documents Ë™National EMS Education Agenda for the Future: A Systems Approachà“ and the Ë™National EMS Scope of Practice Model.à“ (Both are available on the U.S. Department of Transportation NHTSA Web site at A thorough understanding of the SOP and its benefits are critical to successfully making the transition, so”žEMS professionals and other stakeholders should familiarize themselves with these documents.

The SOP calls for all EMS systems to recognize four standard levels of”žEMS care providers: Emergency Medical Responder (EMR), Emergency Medical Technician (EMT), Advanced-Emergency Medical Technician (A-EMT) and Paramedic. Implementation of these new”žEMS provider levels will require a lengthy transition, the details of which are important to comply with in order to maintain your agency_s level of service.

The National Registry of Emergency Medical Technicians Board of Directors is very early in the process of implementing the SOP and hasn_t made any decisions regarding the formal process at this time. However, the board is committed to following the recommendations in the EMS Education Agenda and, because it_s aware the transition will require advance planning and resources, has developed some basic information to prepare you for the transition.”ž

Much of the SOP provider levels transition can be accomplished by simply changing the focus of existing continuing and refresher education to target the Ë™gapsà“ between old and new levels. When the gaps are filled, provider education validated and competencies verified, new levels of certification can be earned and new patient interventions begun.”ž

From Five to Four
Beyond education targets, some states may have to change their EMS rules and regulations, and some states may even need to change their laws, an especially difficult task for state legislatures that meet only once every two years.”žEMS medical directors may need to be updated on the skills and expectations for each of the four levels. New protocols may need to be developed. Textbooks and transition courses will have to be written.”ž

At the individual level, the NREMT currently plans to transition only providers who are nationally certified. If a provider is state licensed, but not nationally certified, that individual_s transition will be managed by their state and may vary considerably from the NREMT plan. The transition timeline may vary significantly from state to state.”ž

National certification indicates competence of providers in their ability to deliver”žEMS throughout their careers. Therefore, during transition to one of the new levels, the NREMT isn_t planning to assess previously acquired knowledge. It will verify education and weigh competency over the knowledge gap between a provider_s current and prospective level.”ž

The NREMT won_t require any provider to complete a transition until the gap material has been determined and the transition Ë™toolboxes,à“ which can be customized to fit educational needs, have been disseminated. The toolbox will comprise the new material to fill the gap between current National Standard Curriculum and the new National EMS Education Standards. Different states can select the materials they_ll need to transition their”žEMS providers. In some states, the gap may be extensive and more education will be necessary, whereas in other states, only a few simple educational tools will be necessary.

Transition materials (i.e., textbooks) won_t be developed until after the National EMS Education Standards are completed in late 2008, when educational gaps between the levels will be better defined.”ž

Although we don_t have a specific timeline for when the transition toolboxes will be available to state”žEMS agencies, educators and training officers, we anticipate it will occur during the second half of 2009. After the new educational materials are available, the NREMT hopes to announce a more definitive timeline and strategy, at which time some transition procedures may change.”ž

How It Will Affect You
First Responder (FR) to Emergency Medical Responder: The 2004 EMS Practice Analysis indicated most FRs in the nation are already authorized to deliver the interventions that will be required by newly licensed EMRs. The SOP calls for EMRs to know self-administration of medication with a Mark-1 kit, and some splinting techniques that may be new to many FRs.”ž

However, some states continue to follow the 1996 First Responder National Curriculum. In those states, such interventions as AED, BP measurement, oxygen therapy and some additional techniques will also have to be included in transition courses. So the length of an FR-to-EMR transition will vary depending on the existing competencies of the FR.”ž

The NREMT will accept the education covering this information in place of current refresher courses; nationally registered FRs can use transition course completion to meet all of the NREMT recertification requirements. Because the gap between FR and EMR knowledge won_t be extensive in most cases, the NREMT will issue current FRs the new EMR certification when the appropriate transition materials have been completed.

EMT-Basic (EMT-B) to Emergency Medical Technician (EMT): This transition doesn_t include a lot of new educational material. In some states, transition toolbox material may cover pulse oximetry, new approaches to patient assessment, automatic transport ventilators, administration of aspirin and other minor techniques. Therefore, the NREMT will apply the transition course toward the current NREMT two-year recertification requirements, with all of the transitional education recognized as part of the recertification process. When an EMT-B receives a transition course certificate and produces that as part of their NREMT recertification requirements, an Emergency Medical Technician National EMS Certification will be issued.”ž”ž

EMT-Intermediate/85 (EMT-I/85) to Advanced-EMT (A-EMT): The gap between the I/85 and the new A-EMT level is the largest under the SOP in terms of knowledge and skill. Although the 2004 Practice Analysis indicated much of the A-EMT material is already known by many I/85s, the NREMT has never measured the A-EMT material on any I/85 examination.”ž

For example, in many states, I/85s already administer nebulized beta 2 drugs to patients. However, the NREMT has never measured current I/85s_ ability to accomplish this task. Because of the large gap, the new material will most likely have to be tested to be evaluated by the NREMT. I/85s will most likely have to complete a transition course, which can be applied toward NREMT requirements (72 hours), and then take the new NREMT A-EMT National EMS Certification examination in order to validate their competency.”ž

EMT-Intermediate/99 (EMT-I/99) to Paramedic: One of the most difficult decisions facing SOP developers was whether to discontinue the EMT-Intermediate (I/99) as a national level. Currently, the NREMT has about 3,000 I/99s on the registry rolls. Although I/99s are certified to perform many of the same interventions as paramedics, educators and supervisors have reported that I/99s lack the depth of knowledge of a Paramedic. Because the gap is about knowledge and a few additional drugs, which can be covered in a classroom experience, the NREMT believes the gap between the I/99 and Paramedic levels can be effectively bridged via a transition course without clinical or field internship.”ž

Personally, I don_t see why a competent, practicing I/99 needs an internship to become a Paramedic. However, educational subject matter experts have indicated the knowledge gap between these levels is substantial. This may be true for some I/99s, depending on how much continuing education they_ve obtained, what education was included in their original I/99 course, and what their state requires for curriculum and competency. Because of these discrepancies, the transition toolbox will be all-inclusive, but not all I/99s moving toward the Paramedic certification will need all of the material.”ž

Although the gap of material between the I/99 and Paramedic levels hasn_t yet been identified, it appears this transition course may run over two or even three recertification cycles. Therefore, the I/99-Paramedic transition may take a number of years to implement. The bottom line is that I/99s must show completion of a transition course that makes up the knowledge gap, however broad the gap is. Once that transition course is completed, an I/99 can take the NREMT Paramedic examination up to six times. The NREMT does not plan to test I/99s for practical skills because its I/99 practical exam is nearly identical to the Paramedic practical exam.

EMT-Paramedic to Paramedic: This transition will replace the Paramedic refresher process. After an EMT-P completes the transition course, the NREMT will issue the new National EMS Paramedic Certification.”ž

The National Association of State EMS Officials (NASEMSO) has an implementation team ready to visit with your state or stakeholder organization to explain the agenda and the SOP. You can learn more about this option by

It_s time that”žEMS is recognized by other health-care specialties as a true profession and not a trade. Implementation of the SOP will reduce fragmentation, lead to better patient care across the nation and help us obtain this recognition. With adequate planning, cooperation and general supportÆ’which come easily when a transition is for the greater goodÆ’we can accomplish a successful transition as a unified group. JEMS

William E. Brown Jr. is the executive director of the National Registry of Emergency Medical Technicians.

Learn more from William E. Brown Jr. at the EMS Today”žConference & Expo, March 2à6 in Baltimore.

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