The EMS Scope of Practice: Then and Now

How has the EMS Scope of Practice changed since the first EMS Week was celebrated 50 years ago? Let’s take a look at the past, present and future.

National EMS Scope of Practice Model

First developed in 2007, the National EMS Scope of Practice Model defined the knowledge and skills necessary to achieve competence for each of the four levels of EMS clinician: EMR, EMT, AEMT and paramedic. It described the levels of EMS personnel and gave us a model for states to follow in terms of what EMS professionals can do. The 2019 revision marked the first significant update and impacted the education, credentialing and licensure of EMS clinicians.

Previous practices that were eliminated from the current Scope of Practice Model include:

• Military Antishock Trousers 
• Spinal “immobilization” 
• Demand valves 
• Carotid massage 
• Automated transport ventilators (for EMTs) 
• Modified jaw thrust 
• “Assisting” patients with own medications

Practices that were added to the current Scope of Practice Model include:

• For an EMR:
  • Administration of narcotic antagonists 
  • Hemorrhage control (tourniquets and wound packing) 
  • Spinal motion restriction 
• For an EMT:
  • Providing assistance to higher levels 
  • Administration of beta agonists and anticholinergics 
  • Oral OTC analgesics 
  • Blood glucose monitoring 
  • CPAP 
  • Pulse oximetry 
• For an AEMT:
  • Monitoring and interpretation of waveform capnography 
  • Additional intravenous medications (such as epinephrine during cardiac arrest) 
  • Parenteral analgesia for pain 
• For a Paramedic:
  • High-flow nasal cannula 
  • Expanded use of OTC medications 
• For immunizations:
  • Required education 
  • Credentialing by the EMS medical director 
  • States retain authority to determine role 

Evidence-Based Guidelines

Just like other areas of the medical field, what we thought would work in emergency medicine in the past, based on our knowledge of physiology and pharmacology at the time, may not have actually been the best for patients. We may have saved lives, but our practice was not backed up by evidence-based guidelines (EBG). Evidence-based guidelines give us increased access to data to improve patient safety. The creation and following of EBG is the biggest shift in EMS to happen over the last few decades.

Data and scientific literature related to prehospital has become plentiful, but there was not always an established process for how to create guidelines based on this information and how to implement change. This led to great variability in the content of prehospital protocols. When the Federal Interagency Committee on Emergency Medical Services (FICEMS) and the National EMS Advisory Council (NEMSAC) approved a National Prehospital Evidence-based Guideline Model Process for the development, implementation and evaluation of EBGs, things became more standardized. The use of established guideline development tools such as Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) has helped EBGs to become consistent across the country. 

What Does the Future Look Like?

Changing Roles

EMS of the future may look more like community healthcare. As more EMS calls are for non-emergencies, and may not even involve transport, clinicians are stepping into new roles.

Fewer Transports and More Telehealth

Many factors are coming together to equal fewer transports by EMS. Telehealth is on the rise in all areas of healthcare and EMS agencies are exploring funding for this growing segment of medicine. 

Managing Mental Health Calls

Mental health issues are on the rise in the country and law enforcement is handling an increasing number of mental health calls. It’s likely that a lot of those calls for service will end up in the hands of EMS in the coming future. 

Social Services Will Be Integrated with EMS