Individual states regulate the education, certification, and licensure of their EMS providers. Historically, the federal government has support EMS development at the state, regional, and local levels. The EMS Systems Act passed by Congress in 1973 created a categorical grant program to support developing state and regional EMS systems and led to the distribution of more than $300 million for EMS research, planning, operations, and improvement.¹ While the act identified 15 essential elements of EMS systems (communications, training, manpower, mutual aid, transportation, accessibility, facilities, critical care units, transfer of care, consumer participation, public education, public safety agencies, medical records, independent review and evaluation, and disaster linkage), it did not set national standards how these elements were to be enacted. In 1974, the Robert Wood Johnson Foundation contributed an additional $15 million to 44 regional EMS project, marking one of the largest private grants for EMS. Without a unified EMS model, states’ EMS systems became significantly different from each other and customized to their needs.

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  Discuss common types of providers within EMS systems, including firefighters and first responders, EMTs, flight nurses, physician assistants, and physicians.

  
  
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  Discuss national standard EMS provider certifications, as well as regional and state-specific designations (eg, EMT-D, EMT-I99, EMT-CC, licensed paramedic, critical care paramedic).

  
  
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  Discuss types of other medical personnel involved in prehospital care and transport.

  
  
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  Discuss state versus NREMT certification and reciprocity issues.

  
  
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  Discuss some occupational health concerns for EMS providers.

The Omnibus Budget Reconciliation Act of 1981 folded federal EMS funding with preventative health block grants to states.² States determined how these grants were divided and distributed, leading to a significant reduction in total funding for EMS across the Unites States. Differences between licensure levels and scopes of practice persisted. In 1996, a minimum of 44 levels of EMS certifications existed across the United States.³ In 2005, a survey of 30 states found 39 different licensure levels still existed.⁴ Even with the same title, providers’ scopes of practice varied between states. This disparity created four specific obstacles for EMS personnel:

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   Public confusion

   
   
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   Reciprocity challenges

   
   
3. 
   

   Limited professional mobility

   
   
4. 
   

   Decreased efficiency due to duplication of efforts

In 1996, the NHTSA and HRSA published a consensus document, the EMS Agenda for the Future, outlining a vision of EMS fully integrated with health care and supporting the health of their communities.³ Designed to help all levels of government guide planning, decision making, and policy regarding EMS, the Agenda addressed 14 attributes requiring improvement including education.

Building on the Agenda, the EMS Education Agenda for the Future: A Systems Approach released in 2000 by the NHTSA proposed a nationally consistent system of education, certification, and licensure for all levels of EMS professionals.⁵ The Educational Agenda outlined five primary components: national EMS core content, national EMS scope of practice, national EMS educational standards, national EMS education program accreditation, and national EMS certification.

In 2004, the National EMS Core Content defined the domain of out-of-hospital care.⁶ In 2005, the National Scope of Practice Model ­recommended dividing the core content into four levels of EMS ­providers: emergency medical responders (EMRs), emergency medical technicians (EMTs), advanced EMTs (AEMTs), and paramedics.⁴ In addition, the Scope outlined the minimum education preparation and designated the appropriate psychomotor skills for each licensure level. While the Scope had no regulatory authority, it provided a framework that states could use to model their licensure levels and to facilitate a national consistency for EMS personnel between states. Adopting this national structure offered states’ EMS systems and personnel several benefits:

1. 
   

   National standards for the minimum psychomotor skills and knowledge of EMS personnel

   
   
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   Consistency among states’ scopes of practice

   
   
3. 
   

   Facilitation of reciprocity

   
   
4. 
   

   Improved professional mobility

   
   
5. 
   

   Consistency of EMS personnel titles

   
   
6. 
   

   Better name recognition and public understanding of EMS personnel

Even if all states adopted the recommendations in the Scope, some variation in scopes of practice and skills for each licensure level would remain. States require the flexibility to expand or customize their EMS providers’ scopes of practice to address unique local needs. While states may add to each licensure level, states are urged not to fall below its ­recommended scopes of practice.

Scope of practice is a legal description of the distinction between licensed health care personnel and the lay public and between different licensed health care professionals. Scopes of practice, defined by individual states, establish the activities and procedures that are illegal if performed without a license and what level of licensure is required to perform them. A standard of care is not the same as scope of practice. A standard of care is defined by what should be done in a given ­situation. Scope of practice defines what activities and procedures a licensed ­provider may do.

There are a number of different types of prehospital personnel operating in the field. These include firefighters (with first aid, CPR, and AED skills), certified first responders, EMT (basic), advanced EMTs, paramedics, critical care/flight paramedics, nurses, and physicians. There are still a number of locations that have other types of providers that fit somewhere in-between the various EMT types (eg, EMT-CC, EMT-I99). National standards exist that are now widely recognized and are discussed below. Almost every state provides providers with a document that allows EMS providers (nonnurse, nonphysician) to perform their skills. Many states refer to this as EMS provider certification. However, certification should only refer to a certificate stating completion of a course or qualification in a certain set of skills. When a state provides a document that allows an individual to do something that would otherwise be illegal, that state has provided that individual with a license. Therefore, the distinction between certification and licensure needs to be recognized by the medical director of any EMS agency or system.

Each state has its own requirements for obtaining and maintaining licensure. In the case of “certified providers,” states may consider allowing for reciprocity from another state, or from the National Registry of EMTs. This acknowledgment of like qualifications is strictly a matter of the states and their regulatory structure for EMS. At the time of this writing, the National Registry certification is accepted as proof of initial qualifications and/or continued certification in 46 states in the United States (nonregistry states include Illinois, New York, North Carolina, and Wyoming) (Figure 13-1).

Nurse practitioners, physician assistants, respiratory therapists, nurses, and physicians who are not EMS trained may also be found working in the prehospital environment, as part of either a disaster relief effort or an interfacility transport effort.^7,8 Those who serve on a specialty transport service team are typically trained and supported in their specific role on the team. There is no universal standard or training curriculum that covers these providers specifically. Each program and/or system typically provides this training.