Updated Scope of Practice: What It Means for Fire-based EMS

The National Highway Traffic Safety Administration’s recently released National Scope of Practice Model 2019 has a number of crucial areas that could affect EMS operations in your fire department. This document provides a clear and concise report on how the scope of practice was developed and is a great reference on the history of EMS. It is one of the key reports for EMS and is a part of the process followed by the EMS community for making changes and improvements. 

Section I
provides an overview of the EMS profession and the history of the Agenda for the Future. It includes a report on the 2007 Scope of Practice Model and explains the approach that was taken to update the Scope of Practice Model. 

Section II
is about understanding the scope of practice and explains the interdependent relationship between education, certification, licensure, and credentialing. This section explains the difference between the scope of practice and standard of care. 

The scope of practice is not a practice guideline or operating procedure. The speed of changes in medicine dictates a need for more frequent changes in the standard of care. As the scope of practice sets the entry-level or floor of EMS education, medical directors in conjunction with EMS agencies, have the flexibility to add skills or services they need. Even state regulations could be determined based on the addition of a needed practice. 

Section VI provides an overview of the interpretive guidelines for each of the four levels. It illustrates the differences in the skills and practice between those levels, but the skills list is not all-inclusive. 

Appendix II deserves close attention; note that there was an attempt to insert the term paramedicine, but it was not successful. In fact, you can see in the definitions that this term is not present. There wasn’t support among the key organizational representatives to consider making a change, primarily because there is no need, no requirement, and no direct evidence that paramedicine is a better term than emergency medical services. 

There was also an attempt to require all new paramedics graduating from an accredited paramedic program to complete an associate degree. This was not considered a part of the scope of this project, and this change also failed to have majority support. The current requirement for paramedic education is to prepare entry-level-competent providers. Since there is no direct evidence for the need for a degree to achieve this competency, many of the representatives felt this addition was not needed. 

There was a recommendation that accreditation for AEMT programs is implemented by 2025. Implementing that recommendation will require a change in the current process. This would likely start as a voluntary method to determine the scope of the need before a mandatory requirement is implemented. 

The appendix also took a look at attendant qualifications of an emergency medical responder (EMR) and found no scientific evidence of this as a best practice. The level of medical training for attending to or riding in an ambulance to the hospital remains at a minimum of EMT. 

The deletions and updates section summarizes the areas that were either deleted or changed to a more current practice application. The following were deleted: 

  • Military antishock trousers (MAST)/pneumatic antishock garment (PASG) 
  • Spinal immobilization (this terminology has been revised) 
  • Demand valves 
  • Carotid massage 
  • Automated transport ventilators at the EMT level (deferred to a decision by the medical director) 
  • Modified jaw thrust for trauma

The expert panel recommended adding the following: 

EMR 

  • Spinal motion restriction using cervical collars 
  • Basic splinting for suspected extremity fractures 

EMT

  • Administration of beta agonists and anticholinergics 
  • Oral over-the-counter (OTC) analgesics for pain or fever 
  •  Blood glucose monitoring 
  • Continuous positive airway pressure devices (CPAP) 
  • Pulse oximetry 

AEMT

  • Monitoring and interpretation of waveform capnography 
  • Additional intravenous medications (such as epinephrine during cardiac arrest and ondansetron) 
  • Parenteral analgesia for pain 

Paramedic

  • Addition of high-flow nasal cannula 
  • Expanded use of OTC medications 

Please note that the changes suggested in this report would not take effect until adopted by your state’s EMS authority. 

The process to create the National Scope of Practice Model 2019 took many months, and several individuals were involved in the meetings and discussions. This was not developed without input from all interested parties and was, in fact, open to comment. Please keep that in mind when you see other groups or individuals trying to change how EMS is delivered in the United States; if something seems radical, it probably is. The fire service is the largest providers of EMS in the United States and needs to be involved in the future for the sake of the communities we protect every day. 

You can find the National Scope of Practice Model 2019 at EMS.gov

Chief David S. Becker (retired), EFO, is the immediate past chair of the EMS Section. He’s been a member of the IAFC since 1991.

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