Introduction

The Emergency Medical Services Systems Act of 1973 was the first formal national initiative supporting and endorsing EMS in the United States [1]. The Act defined 15 components of an EMS system, and this led to the development of the Department of Transportation’s national standard curricula (NSC), in an attempt to standardize the training of prehospital personnel: the first responder, the emergency medical technician-ambulance (EMT-A, which evolved into the EMT-Basic in 1994), the EMT-Intermediate (1985, revised in 1999), and the EMT-Paramedic (1989, updated in 1999).

These curricula essentially evolved from the existing practices of EMS providers in the 50 states. It was not until 2005, almost ten years after the publication of the Emergency Medical Services Agenda for the Future in 1996 [2], that an educationally sound, scientifically based scope of practice process was implemented. The EMS Education Agenda for the Future: A Systems Approach was released in 2000 and called for the development of a system to support the education, certification, and licensure of entry-level EMS personnel that facilitates national consistency [3].

The Educational Agenda is a vision for the future of EMS education, and a proposal for an improved structured system. To educate the next generation of EMS professionals, The Educational Agenda builds on the broad concepts from the 1996 Agenda to create a vision for an educational system that will result in improved efficiency for the national EMS education process. The system will enhance consistency, education, [and] quality and ultimately lead to greater entry level graduate competence [3].

The Education Agenda proposed an EMS education system that consists of five integrated components: national EMS core content, National EMS Scope of Practice Model, national EMS education standards, national EMS certification, and national EMS education program accreditation. In 2004, the national EMS core content was released and defined the complete domain of out-of-hospital care [4]. In 2005, the National EMS Scope of Practice Model divided the core content into four “levels” of practice, defining the minimum corresponding skills and knowledge for each level of EMS provider, and established four levels: emergency medical responder (EMR), emergency medical technician (EMT), advanced emergency medical technician (AEMT), and the paramedic [5]. Each level represents a unique role, set of skills, and knowledge base for which the National EMS Education Standards define educational content [6]. The Education Standards define the minimal terminal objectives for entry-level EMS personnel to achieve within the parameters outlined in the National EMS Scope of Practice Model. Although educational programs must adhere to the Standards, its format allows for diverse implementation methods to meet local needs and evolving educational practices.

The above five integrated components are intended to establish an educational system that, when fully implemented, provides the foundation to ensure the competency of out-of-hospital EMS personnel in a way that parallels other allied health care disciplines, as well as consistency from state to state. Note that the evolution and establishment of subspecialty recognition for EMS physicians intentionally and explicitly built on the same general structure [7].

A survey published in November 2011 noted that there were 826,111 credentialed out-of-hospital care personnel in the United States [8]. Until recently, there has not been a national system to aid states in the evolution of their EMS personnel scopes of practice and licensure. In 1996, there were at least 40 different levels of EMS personnel certification in the United States [2], with, for example, a number of different “EMT-Intermediate” definitions and scopes of practice used by various states, many of which did not match either the 1985 or the 1999 NSC. This diversity and patchwork of EMS personnel licensure and certification created several problems, including public confusion, reciprocity challenges, limited professional mobility, and decreased efficiency due to duplication of effort. The National EMS Scope of Practice Model supports a system of licensure that can be recognized across all states, establishes a platform for reciprocity, allows for professional mobility, and reduces public confusion.

The authors of the National EMS Scope of Practice Model recognized the responsibility of the state regulatory process to help ensure the protection of the public. Part of a state’s regulatory responsibility includes the authority to establish the scope of practice for EMS personnel. Although this model is not intended to force standardization, it encourages national consistency of EMS licensure levels and their minimum competencies, while still accommodating some degree of state flexibility.

“Scope of practice” is a legal description of the distinction between licensed health care personnel and the lay public, and also among different licensed health care professionals, creating either exclusive or overlapping domains of practice. It describes the authority, vested by a state, in licensed individuals practicing within that state. Scope of practice establishes which activities and procedures represent illegal activity if performed without licensure.