National EMS Scope of Practice Model A Western Perspective For the National EMS SoPM Task Force and the National EMS SoPM National Review Team June 13, 2005

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” by Nikiah Nudell, NREMTP

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 by Nikiah Nudell, NREMTP

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 by Nikiah Nudell, NREMTP

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 by Nikiah Nudell, NREMTP

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 2 nd Annual EMS System Survey by Nikiah Nudell, NREMTP

25% cross trained FD

20% third service

19% “other”

12% private service

8% Public utility model

Source EMS Magazine 2 nd 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 by Nikiah Nudell, NREMTP

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 by Nikiah Nudell, NREMTP

” 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 by Nikiah Nudell, NREMTP

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 by Nikiah Nudell, NREMTP

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) by Nikiah Nudell, NREMTP

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 by Nikiah Nudell, NREMTP

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)

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 by Nikiah Nudell, NREMTP

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 by Nikiah Nudell, NREMTP

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 by Nikiah Nudell, NREMTP

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? by Nikiah Nudell, NREMTP

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 by Nikiah Nudell, NREMTP

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 Source EMS Magazine 2 nd Annual EMS System Survey by Nikiah Nudell, NREMTP

43% career paid providers only

26% volunteer providers only

31% mixed providers

77% serve populations under 50,000

Source EMS Magazine 2 nd Annual EMS System Survey

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) by Nikiah Nudell, NREMTP

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 by Nikiah Nudell, NREMTP

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 Source EMS Magazine 2 nd Annual EMS System Survey by Nikiah Nudell, NREMTP

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

Source EMS Magazine 2 nd Annual EMS System Survey

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 by Nikiah Nudell, NREMTP

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? by Nikiah Nudell, NREMTP

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 by Nikiah Nudell, NREMTP

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 involvement [email_address] (415) 254-5821 by Nikiah Nudell, NREMTP

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 involvement

[email_address]

(415) 254-5821