January 20, 2005

Ms. Amy Starchville
National Association of State EMS Directors
201 Park Washington Court
Falls Church, VA 22046-4527

RE: Request for Comments on the National EMS Scope of Practice Model

Dear Amy:

We appreciate the hard work that the Scope of Practice work group put into the project and thank them for their willingness to allow our comments for consideration. The American Ambulance Association (AAA) remains committed to the improvement of emergency medical services and fully understands the importance of this process as one of the critical steps in implementing the EMS Agenda for the Future. Therefore, we take the opportunity to comment on this very important document with great thought and care as we represent the interests and needs of our members and most importantly the patients they serve.

The American Ambulance Association is the primary trade association representing providers of emergency and non-emergency care and medical transportation services. The AAA membership is comprised of over 600 ambulance service providers across the United States that participate in serving more than 75% of the U.S. population. AAA members employ nearly 100,000 EMT’s and paramedics who respond to approximately ten million requests for ambulance services each year. The AAA was formed in 1979 in response to the need for improvements in medical transportation and emergency medical services. The Association serves as a voice and clearinghouse for ambulance service providers who view pre-hospital care not only as a public service but also as an essential part of the total public heath care system. We pride ourselves on addressing issues that are critical to our members which operate in both rural and urban environments and are comprised of private, public, fire and hospital-based entities.

Our overarching concern is that the Scope of Practice (SoP) draft is being developed in a way that does not consider the practical impacts on our educational and provider agencies and ultimately the general public we are to serve. While the EMS Agenda for the Future was developed on the basis of a systems approach, we believe the SoP has not incorporated this core concept. We strongly suggest that an impact analysis be conducted on those aspects of the SoP that are deemed to require the greatest amount of change or pose likely disruptions to the current delivery of EMS, especially, but not limited to, the rural areas of America. We also believe many of the questions and concerns voiced by the EMS community concerning this document can and should be addressed through the use of evidence based findings.

We are thoroughly committed to the advancement of improved quality of EMS care and delivery as our first and foremost priority. The process of performance and quality improvement requires a patient and studied approach that can responsibly project any untoward impacts to the current quality of care enjoyed by communities throughout the nation. In that regard, there are numerous elements to the current draft with which we take exception and concern over unintended consequences. We believe that corrective action must occur in future development forums prior to advancing this important initiative and request your serious consideration as to the following:

  • Discussions with members of the work group and other interested parties have indicated this initiative to be a long-term implementation. We believe many people found that information to be poorly articulated in the draft document. We strongly suggest the inclusion or reference to a projected implementation plan which includes sentinel events that must occur prior to full realization of the SoP.
  • While “grandfathering” might be considered an implementation tactic and therefore not one of the core components of the SoP, we believe some discussion in regard to the impact on existing workforce would be helpful for those who will most likely be affected by proposed changes.
  • We recommend a comprehensive survey to appropriate oversight agencies heads, such as the State EMS Directors, to establish an inventory of current certification levels along with the perceived scope of practices associated with those levels. We believe this process will strongly support the development of an impact analysis as stated above.
  • We are concerned that certain assumptions in v.1 were made without reference to evidence based analysis. While current clinical practices may be incorporated into a revised document, we ask that all future additions or modifications to the SoP be based on evidence based findings or supported by clinical studies literature (i.e. the OPAL study).
  • We believe the SoP should establish a floor for cognitive and knowledge based skills relative to the different levels of certification/licensure and avoid the assignment of specific skills in the SoP document. This should allow the greatest opportunity for standardization.
  • The practical skill requirement should therefore be driven at the local level as enabled by the medical community through approval of clinical protocols.
  • References to specific devices (i.e. epi-pens, mast suits, etc.) should be avoided due to the rapid emergence of new technologies and devices that can be used to deliver the care specified by local protocol.
  • We believe the SoP should support a national standardization of certification and/or licensure that will facilitate more expeditious reciprocity for those persons moving from state to state, thereby creating a more attractive career path and increasing retention in the industry. This feature alone can help mitigate the current and longer-term staffing shortages currently being experienced by many providers.
  • The SoP draft seems to advocate an extension of the training hours required to meet each of the EMT levels. We must express the concerns raised by both urban and rural providers on the impact that a heightened training regime will have on the ability to staff both full-time and volunteer ambulances throughout the country. While perhaps inappropriately named, we believe the “Intermediate” level of EMS provider should be integrated into this process. Including an “Intermediate” level will not only provide relief for rural and volunteer EMS agencies but will enhance opportunities for those seeking a career in EMS -particularly if each of the levels are treated as building blocks toward a paramedic certification rather than stand-alone modules.
  • With the increased training requirements reflected in associate and bachelor degree programs, we believe it is important to understand the affect on current training institutions. What will be the impact on free-standing programs and will therefore be adequate educational institutions with proper funding prepared to meet the new educational demands that emerge from the final process? Again, we believe an impact analysis by a well-chartered group can flesh out these issues.
  • We take exception to the creation of Advanced Practice Paramedic (APP) as defined in the document. The reasons for the creation of such a certification level seem to be far-reaching and only vaguely connected. We suggest the SoP allow for “specialty” adjunct training that can satisfy certain needs as reflected in the document (i.e., paramedics stationed on off-shore drilling platforms, mass event medical coverage, etc). Further, we believe the educational requirement necessary for a paramedic to advance to the APP certification would severely constrain a local medical community from implementing creative and innovative integrated delivery systems that allow for referral/transport to alternative health care facilities. We believe the Specialty Care Transport level of service recently approved by the Centers for Medicare and Medicaid Services (CMS) is a good indication at how the funding mechanisms for EMS will accept sub-specialty certifications.
  • Over the past few years, the AAA has led the EMS community in pressing CMS for implementation of condition codes specific to ambulance services as a core component of the Medicare Ambulance Fee Schedule. The condition codes were implemented on January 3, 2005 and will provide greater clarification relative to the level of service necessary as determined by CMS. We believe the SoP should carefully crosswalk condition codes to the skill sets related to the delivery of BLS, ALS-1, ALS-2 and SCT levels of care as now constituted and recognized by CMS. Failure to do so may result in a revenue reduction for all provider types and add further confusion during the claim review process at CMS.
  • We appreciate the discussion related to the expansion of EMS providers into basic preventive health measures (i.e. inoculations, etc) as benefiting our local communities. For example, by including injections in SoP, we believe the federal government will favorably reimburse ambulance providers for providing these essential public health services.
  • We are intrigued by the inclusion of IV and ET monitoring as a basic EMT level skill. We believe careful consideration and study should be given to the consequences of essentially advocating the transport of patients at the BLS level when invasive life support measures are in place. We believe this applies to inter-facility transport as well as transfer of “911” patients to a BLS level ambulance once ALS procedures have been initiated by ALS level personnel at the scene. We also believe this is contrary to current and acceptable medical practices.
  • While outpatient services have grown exponentially over the past 20 years, most communities seem to be married to the preconception that patients accessing health care via 911 must be transported to a hospital emergency department by statute. We believe the SoP revisions should consider the opportunity for a given medical community to adopt innovative patient destination procedures.
  • We agree that the public needs to be able to identify and recognize EMS providers as true professionals. Redefining levels of providers will fall short of this objective and may in fact compound the confusion. A common term that recognizes all providers, regardless of skill set, is paramount to the advancement of the EMS profession and should be considered in the SoP.

While this list is certainly not exhaustive, we ask that the timelines for the various phases of this project be expanded, well defined, and thoroughly communicated. It is imperative that all stakeholders continue to have an opportunity to provide input and share their expertise. The American Ambulance Association is committed to a high level of involvement in this process and look forward to future meetings.

We again thank you for your invitation to respond and stand ready and willing to help in the continued improvement of our EMS systems nationwide. Please do not hesitate to contact our Vice President of Government Affairs, Tristan North, at (703) 610-9018 with any questions or comments.

Sincerely,

Robert Garner
President