EMS Education Pipeline

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National Highway Traffic Safety Administration (NHTSA) staff prepared this summary document on the
status of the Emergency Medical Services (EMS) education pipeline during a series of recent conference
calls with EMS stakeholder organizations. Included is a list of national, state, and local considerations
for EMS stakeholders. These considerations do not necessarily reflect official policy positions of the
organizations that participated during the conference calls. This document is intended to serve as an
informational resource for EMS stakeholders. This summary does not establish legal requirements or
obligations, and its content does not necessarily reflect agency recommendations or policy.

Contributors to its content included representatives from the National Registry of Emergency Medical
Technicians (NREMT), the National Association of EMS Educators (NAEMSE), the Committee on
Accreditation for the EMS Professions (CoAEMSP), the Commission on Accreditation for Pre-Hospital
Continuing Education, the National Association of State EMS Officials, the International Association of
Fire Chiefs, the American Ambulance Association, the National Association of Emergency Medical
Technicians, the American College of Surgeons, and the Interstate Commission for EMS Personnel
Practice.

Challenges Facing EMS Education
Nationwide social distancing measures have led to closures, delays, and other impacts on the national
EMS education system. National, State, and local EMS organizations are collaborating to address these
challenges, but prolonged delays are likely in the education, certification, and licensing of tens of
thousands of entry-level EMS clinicians.

EMS Education Programs Closed
Community colleges, universities, fire academies, and other programs that provide EMS education
throughout the country closed in response to social distancing measures. Many of these institutions
created distance learning programs to help current students complete their didactic education.
However, not every EMS education program has the resources to support online or distance learning
alternatives.

To assist EMS education programs, NAEMSE has led a webinar series on transitioning to the online
classroom2 and is collaborating with NREMT to develop best practices for distance education.
EMS students must also complete in-hospital and pre-hospital clinical rotations to graduate.
Unfortunately, most clinical and field internship sites remain closed to students based on a combination
of factors, such as government restrictions and recommendations on traveling and social distancing, lack
of personal protective equipment (PPE) for students, or the decision of the clinical site to restrict
student access.

CoAEMSP acknowledged the need for its 706 accredited paramedic education programs to modify
current graduation requirements.

On April 5th, 2020, the CoAEMSP Board of Directors issued a
statement regarding Coronavirus Disease 2019 (COVID-19) to clarify that Paramedic educational programs may employ a broad array of approaches, including simulation, in determining competency in
didactic, laboratory, clinical, field experience, and capstone field internship.
Another option suggested by stakeholders for increasing the number of competent, entry-level EMS
clinicians to enter the workforce with advanced life support (ALS) skills may be allowing paramedic
students to graduate early and be tested as Advanced EMTs (AEMTs).

Testing and Certification Delayed
NREMT is the national certification agency for EMS clinicians. NREMT testing and certification (after
completion of approved education) is a requirement for EMS clinician licensure in most States. NREMT’s
cognitive (computer-based written) exam is administered by Pearson VUE. On March 17, 2020, Pearson
VUE closed most of its nearly 700 testing centers nationwide. Over the subsequent weeks,
approximately 450 of Pearson VUE’s testing centers have re-opened at reduced capacity, with more
projected to open in the future. Many testing sites remain closed under State government orders that
closed State colleges and universities. Allowing sites to remain open for the sole purpose of testing EMS
and other healthcare professionals would help alleviate the lack of testing capacity. Open testing centers
are operating at approximately 50% capacity due to social distancing measures.

NREMT is temporarily not requiring the psychomotor (hands-on skills) examination due to social
distancing guidelines. It is offering a provisional certification that requires only the successful completion of
the EMS education course and the cognitive exam. NREMT has accelerated plans for remote proctoring
of the cognitive exam, which will be available for the AEMT examination and the EMT examination in
May 2020. These emergency measures will help to continue certifying new EMS professionals.

Historically, the NREMT tests over 60,000 EMS clinicians in the spring season. NREMT projects that a
significantly lower number of EMS clinicians will be tested this year due to the cancellation of EMS
education courses. Consequently, local EMS agencies will face a severe workforce supply shortage
within the next three months.

Recertification Deadlines Extended
NREMT has approved a 90-day extension on EMS certifications that were due to expire on March 31,
2020, and waived continuing education requirements for face-to-face instruction. States are beginning
to modify relicensing requirements in line with NREMT’s actions.

Specialty certification courses (such as Cardio Pulmonary Resuscitation, Pediatric Advanced Life Support,
Pre-Hospital Trauma Life Support, Advanced Cardiac Life Support, etc.) are often required as part of EMS
education, certification, licensure, or affiliation. Many specialty certification course providers have
created online courses for didactic materials, and either waived hands-on skills requirements or
provided guidance on safely facilitating in-person instruction. Most have also extended or waived
current expiration dates.

Licensure Modifications Underway
State EMS offices license EMS clinicians, regulate local EMS agencies, and support EMS system
development. Many State EMS staff are currently deployed to state operations centers supporting the
COVID-19 response, including guiding statewide efforts to support crisis standards of care (CSC) planning
for EMS. Multiple States have temporarily waived or modified licensure policies to streamline licensure.

Emergency Medical Service (EMS) Education Pipeline
Twenty States are accepting NREMT provisional certification as a condition of licensure; however, some
States4 have reported that their laws and rules prohibit issuing licenses to holders of the NREMT
provisional certification.

A few states require fingerprinting and a criminal background check as a condition for licensure;
however, social distancing measures and public building closures have made fingerprinting services
largely unavailable. Some States5 are offering provisional licensure that defers a criminal background
check until the public health emergency ends. Employers cannot assume a provisional licensee had a
background check and may now need to do this as part of their hiring process. States are also
reactivating expired licenses within specified time frames.

Twenty States are members of the Interstate EMS Licensure Compact (Compact), which was formally
activated in response to COVID-19. The Compact will enable interstate recognition of EMS clinician
licensure between member States. However, the Compact does not address practice by EMS clinicians in
non-traditional settings, such as hospitals. Many States6 grant physicians authority to delegate certain
aspects of medical practice, which may give hospitals flexibility to use EMS personnel in an expanded
clinical role.

Service Impact
In the United States, more than 18,200 EMS agencies, staffed by a total licensed workforce of more than
1.03 million EMS clinicians, provide ubiquitous 24/7 coverage of the entire Nation. In 2019, these EMS
agencies responded to more than 28.5 million 911 dispatches.

Stakeholders have reported an average 30 percent decline in EMS transports in areas not yet severely
impacted by the public health emergency, which they attribute to less public willingness to be
transported to hospitals. This decline in EMS transports has led to a decline in insurance reimbursement
revenue9 accompanied by an anticipated decline in State and local tax revenue. As a result, EMS
stakeholders have reported widespread hiring freezes and potential future furloughs and layoffs.
Despite the need for 24/7 service, stakeholders anticipate that the inability to hire, coupled with
workforce supply shortages (attributed to the shutdown of EMS education programs), will lead to
prolonged EMS staffing shortfalls. In some cases, these staffing shortfalls may take effect as COVID-19
peaks locally resulting in potentially insufficient staffing to respond to an expected surge of EMS calls.
As components of the workforce pipeline partially resume operations, employers will face additional
challenges, such as delays in fingerprint-based background checks and remedial education and testing
for provisionally certified and licensed EMS personnel.

The long-term impact of system accommodations (e.g., deferred background checks, proctored exams,
provisional certification and licensing) is unknown. In addition, there is also growing concern that the
pandemic may increase EMS workforce turnover.
State and Local Considerations for EMS Stakeholders
Based on the issues and challenges discussed above, stakeholders may consider the following
measures at the State and local levels:
1. Enable EMS clinicians with a NREMT provisional certification to pursue provisional State
licensure.
2. Enable EMS clinicians with expired licenses to pursue provisional State licensure.
3. Prioritize the reopening of EMS clinical skills labs when reopening educational institutions.
4. Encourage EMS education programs to provide distance learning resources to all students. Front-load didactic education for EMS students until clinical skills labs, clinical internships, and field
internships can resume.
5. Enable States, colleges, and educational programs to allow modified approaches to clinical skills
labs, clinical internships, and field internships, when they can be conducted safely.
6. Encourage the sharing of best practices by State and local authorities.
7. Encourage collaboration between educational programs to develop online education
capabilities.
8. Permit public and private education testing centers to administer the NREMT examination
within local jurisdictions, while following strict social distancing protocols.
9. Explore the ability to verify course completion and/or testing paramedic students at the AEMTlevel,
provided the state has approved an AEMT course.

National Considerations for EMS Stakeholders
In addition, stakeholders may consider the following measures at the national level to the extent
permitted by applicable law:
1. Permit fingerprinting centers to open to support criminal background checks for EMS clinicians
as a condition of licensure or employment. Explore other innovative solutions for conducting
criminal background checks.
2. Continue convening national EMS organizations to facilitate collaborative and innovative
problem-solving. Engage additional stakeholders, such as the Accreditation Council for Graduate
Medical Education, to coordinate healthcare education efforts.
3. Consider, as essential critical infrastructure workers, those workers involved in the certification,
licensing, and credentialing of EMS personnel and other healthcare workers.
4. Consider, as essential critical infrastructure workers, those workers supporting public and
private education testing centers for EMS personnel and other healthcare workers.
5. Share EMS educational best practices nationally.
6. Support technology for EMS education programs to conduct remote training, high-fidelity
simulation and other tools for effective training while also supporting social distancing.