National Ems Scope Of Practice Model

National EMS Scope of Practice ModelA Western Perspective

For the National EMS SoPM Task Force and the National EMS SoPM National Review TeamJune 13, 2005

by Nikiah Nudell, NREMTP2

SF Collaborative Presentation

Nikiah Nudell, NREMTP, CCEMTP– EMS Agency Specialist, San Francisco EMS Agency– Member of NAEMT, NEMSMA, NRHA, NNAEMSA,

CSRHA, and Advocates for EMS– Instructor of AHA, AAP, NAEMT & DHS programs

Niels Tangherlini, NREMTP, BA– Paramedic Captain, San Francisco Fire Department– Organizer of SFFDs “Homeless Outreach & Medical

Emergency Team”


California EMS Systems

State EMS Authority licenses paramedics, regulates Local EMS Agencies and provides statewide disaster support functions

San Francisco EMS Agency regulates EMS, EMT Licensure and Paramedic Accreditation in the County

– Similar in perspective to many State EMS Agency roles

SF DPH provided ambulance transport beginning in 1867

– Now regulates the EMS System, not an operational entity


"Computers in the future will weigh no more than 1.5 tons."

Popular Mechanics 1949

The NHTSA Vision for Our Future: – Community-based health management– Fully integrated with health care system– Identify & modify illness & injury risks– Provide acute/follow-up care for illness/injury– Contribute to treatment of chronic conditions &

community health monitoring– More appropriate use of acute health care resources


EMS Education Agenda

For the Future? In 2010…– Provide basic competencies for EMS to serve the

needs of the population– Educate Injury & Illness Prevention, risk modification,

chronic treatment, and community/public health– Significant flexibility for local needs– Entry level competence managed nationally– Facilitate adaptation as CH/PH needs and roles

evolve


What EMS models are in place?

25% cross trained FD 20% third service 19% “other” 12% private service 8% Public utility model

Source EMS Magazine 2nd Annual EMS System Survey


The Community/Public Health Model

Using EMS resources to monitor, respond, prevent and modify community/public health

The Vision describes a CH/PH focus for EMS– Describes the future EMS entity as:

“New” or reborn from its prior existence Continuing as the public’s ‘safety net’

The SoPM should support the Vision– Focus of the EMS Education Agenda is competency

based national licensure and local accreditation


Competence defined

”The ability to perform work to a set standard… the emphasis is not on knowledge or skills”

Rowanhill Consultants


Proven Competence is…

Judged by what people produce in the course of their work, not what they put into it

Focuses on the outputs from activities, not inputs

Measured by Quality Improvement programs integral to Risk Management


Adaptive Competence is…

Defined as the ability to read a new situation and adapt or apply appropriate competencies

About asking the right questions and developing the means to resolve problems

Seen as “learning to learn” or “thinking outside the box”

Exemplified by independent practice providers


Draft 2.0

Does not address the Vision– APP may be a critical role

Legal definition of “certification” may be inconsistent with SoPM use

“Evolving” population=Baby Boomers Layperson skills should be included for all levels

– Auto-injectors (i.e. EpiPen, Narcan)– Glucose check, administer oral glucose and Rx glucagon– Oral pain medications (i.e. ASA for ACS, NSAIDS for trauma)– Beta agonist MDI (Rx)


EMR Scope– Tourniquet

EMT Scope– Monitor/maintain IV infusions– Insert multi-lumen & esophageal airways

Paramedic Scope– Initiation of synthetic volume expanders– All airways (i.e. RSI, surgical, retrograde, etc)– Simple central venous access (i.e. single lumen)

Draft 2.0 continued


Education requirements

Minimum competency to graduate– No specific hour requirement mandated– Flexibility for course design, student population and

instructor base– Immediately sets the minimum to acceptable level– Supports the Vision

Current CE courses do not assure continued competence– Ineffective remediation


Advanced Practice Paramedic

DEA licensing, CMS-NPI, Mid-Level Graduate level education & competency

– Primary Care Paramedic Antibiotics, prescriptions Suture removal & simple suturing Wound care

– Mental Health Paramedic Module Involuntary holds Medication management

– Critical Care Paramedic Module Invasive management


Acute Care Paramedic Module

Emergency Surgical Procedures– Field amputations– C-Sections– Chest tubes– Escharotomy– Cross clamping

Research based care for the future


“Improvise. Adapt. Overcome.” USMC

Does the SoPM encourage “learning to learn”?

Is it fully integrated into healthcare delivery systems?

Does it serve Special Needs populations? Does it contribute to treatment of chronic

health conditions? Does it provide more appropriate use of

acute health care resources?


2005 Gap Analysis

Significant gap remain unaddressed:– Provide basic competencies for EMS to serve the

needs of the population– Injury & Illness Prevention, risk modification, chronic

treatment, and community/public health– Significant flexibility for local needs– Entry level competence managed nationally– Facilitate adaptation as CH/PH needs and roles

evolve


Who are the providers?

43% career paid providers only 26% volunteer providers only 31% mixed providers

77% serve populations under 50,000



Suggested EMS Scopes

EMR– First Responder competencies similar to today

EMT Basic– Basic competencies similar to today

Advanced EMT– Competencies similar to ‘Paramedic’ of today– First Response ‘ALS’ Level– Focus on BLS skills with ‘basic’ advanced skills

Paramedic– Professional medical provider, advanced by today's standards

Advanced Practice Paramedic (multi-tiered) Primary Care Paramedic (i.e. Alaska/IHS CHA Program) Mental Health Paramedic (i.e. MH Technician, LCSW) Critical Care Paramedic (i.e. CCT Mid-Level provider) Acute Care Paramedic (i.e. EM Mid-Level Provider)


“Role Creep…” Protect the Status Quo!

Prevents “integration” of healthcare delivery systems– Freezes progress for EMS Professionals trying to

realize the potential of integration

Does not encourage “learning to learn” Who does this statement benefit? EMS providers regulated by SoPM should

define their ‘new’ role in healthcare


The EMS role of today

49.4% respond to Emergency Requests 50.6% respond to Emergency & Transfers

73% ALS transport 64% BLS transport

28% ALS first response 36% BLS first response



EMS Roles

EMR– First Responder in rural/wilderness/mass gathering

EMT Basic– Routine transports

Advanced EMT– First Responder in Fire Based or non-transport EMS– Non-transport sole provider– 1 on 1 partner for Paramedic

Paramedic– 1 on 1 or dual paramedic– Essential/minimum ALS level provider

Advanced Practice Paramedic (multi-tiered) Primary Care Paramedic- Underserved populations, treat/release, etc Mental Health Paramedic- Crisis management, disaster support, liaison Critical Care Paramedic- Specialty Care Transport for all age groups Acute Care Paramedic- EM for high acuity responses & standby


EMS Competence Management is…

A systematic framework within which the regulators and administrators manage all the competencies needed

Ineffective if based on the least common denominator

Does the SoPM encourage adequate Competence Management for the Vision?


National Scope of Practice Model

Is a necessary project, however:– Cannot be separated from the future roles of

NHTSA, FICEMS, DHS or others– Should support

EMS System design Quality Control

– Should not negatively impact community based interventions


"Why not go out on a limb? That's where the fruit is."

Will Rogers, 1879-1935

Improved advertisement of project– Periodicals (JEMS, EMS Magazine, Internet)– Direct Mail (NREMT, NAEMT, NAEMSD)– Target other regions, not just state EMS

Welcome future invitation for [email protected]

(415) 254-5821

National Ems Scope Of Practice Model

Health & Medicine

healthcare

mental health

acute care

primary care

ems education

critical care

advanced practice

provide basic