Iowa Emergency Medical Care Provider
Iowa Department of Public HealthBureau of Emergency and Trauma ServicesIowa Emergency Medical Care ProviderScope of PracticeSeptember 2019“Protecting and Improving the Health of Iowans”LUCAS STATE OFFICE BUILDING321 East 12th StreetDES MOINES, IOWA 50319-0075(515) 281-0620(800) 728-3367https://idph.iowa.gov/BETS/EMSScope of Practice – Defined parameters of various duties or services that may be provided by anindividual with specific credentials. Whether regulated by rule, statute, or court decision, itrepresents the limits of services an individual may legally perform.
ContentsIntroduction . 2Background . 2Overview of the EMS Profession . 2The Evolution of the EMS Agenda for the Future . 4National EMS Educational Standards . 5Interdependent Relationship Between Education, Certification, Licensure, andCredentialing . 7Medical Supervision. 8Pilot Project . 8Scope of Practice versus Standard of Care. 8Description of Iowa EMS Provider Levels . 9Legacy Levels . 9Emergency Medical Responders (EMR) . 9Emergency Medical Technician (EMT) . 10Advanced Emergency Medical Technician (AEMT) . 11Paramedic (PM) . 11Endorsement Level . 12Scope of Practice . 13Assisting with a Skill or Procedure Outside of an Individual’s Scope of Practice . 13Blood Testing Devices . 13Airway/Ventilation/Oxygenation . 14Cardiovascular/Circulation . 15Splinting/Spinal Motion Restriction (SMR)/Patient Restraint . 15IV Initiation/Monitoring/Fluids . 15Medication/Administration Routes . 16Miscellaneous . 17Iowa Department of Public Health – September 20191
IntroductionThe Iowa Emergency Medical Care Provider Scope of Practice (September 2019)identifies the psychomotor skills and knowledge necessary for the minimum competenceof each identified level of state certified EMS provider. Assurance of competency is bycompletion of an EMS educational program and certifying examinations adhering toestablished national standards. EMS providers must be educated and verifiably competentin the minimum cognitive, affective, and psychomotor skills needed to ensure safe andeffective practice at that level. Eligibility to practice is dependent on education, statecertification, and credentialing by the physician medical director. Certified EMSProviders at each level are responsible for all knowledge, judgments, and skills at theirlevel and all levels preceding their level.For the purposes of this document “Scope of practice” is a description of the distinctionbetween certified Iowa EMS providers and the lay public. It describes the authorityvested by Iowa in individuals that are certified as EMS providers. In general, the scope ofpractice focus is on activities regulated by law (for example, starting an intravenous line,administering a medication, etc.). This includes technical skills and procedures that, ifdone improperly, represent a significant hazard to the patient and therefore must beregulated for public protection. Scope of practice establishes which activities, skills, andprocedures that would represent illegal activity if performed without certification.The Iowa Department of Public Health has the statutory authority (Iowa Code Chapter147A) and responsibility to regulate EMS within its borders and to determine the scopeof practice of State-certified EMS personnel.BackgroundThe Iowa Emergency Medical Care Provider Scope of Practice (June 2019) is based onthe National EMS Scope of Practice Model produced by the National Association of StateEMS Officials (NASEMSO) with support from the US Department of Transportation,National Highway Traffic Safety Administration (NHTSA), Office of EmergencyMedical Services (OEMS) and released in September 2018. The National EMS Scope ofPractice Model is a consensus-based document that was developed to improve theconsistency of EMS personnel licensure levels and nomenclature among States. Thewidespread use and adoption of the previous version of the National EMS Scope ofPractice Model by most states suggests that it is an accepted national standard.Overview of the EMS ProfessionThe National EMS Scope of Practice Model provides a resource for defining the practiceof Emergency Medical Services (EMS) personnel. EMS clinicians are unique health careprofessionals in that they provide medical care in many environments, locations, andsituations. Much of this care occurs in out-of-hospital settings with little onsitesupervision. Physician medical directors provide medical oversight to ensure andmaintain safe EMS practices. This medical oversight is occasionally performed in-personby medical directors in the field or through electronic communications, but moreIowa Department of Public Health – September 20192
commonly accomplished through protocol development and quality improvementfounded on evidence-based treatment standards and resources such as this National EMSScope of Practice Model. EMS personnel are not independent clinicians, but are expectedto execute many treatment modalities based on their assessments and protocols inchallenging situations. EMS personnel must be able to exercise considerable judgment,problem-solving, and decision-making skills.In the vast majority of communities across the nation, residents call for EMS by dialing9-1-1 when emergency medical care is needed, and the appropriate resources aredispatched. EMS personnel respond and provide care to the patient in the setting in whichthe patient became ill or injured, including the home, field, recreational, work, andindustrial settings. Many of these are in high-risk situations, such as on highways andfreeways, violent scenarios, and other unique settings.Many EMS personnel provide medical transportation services for patients requiringmedical care while en-route to or between medical facilities, in both ground and airambulance entities. These transport situations may originate from emergency scenes, ormay be scheduled transports moving patients from one licensed facility to another. Thecomplexity of care delivered by EMS personnel can range from very basic skills toexceptionally complex monitoring and interventions for very high acuity patients.Medical care at mass gatherings (e.g., concerts or sporting events) and high-risk activities(e.g., fireground operations, or law enforcement tactical operations) are a growingexpectation of EMS personnel. EMS personnel sometimes serve in an emergencyresponse or primary care role combined with an occupational setting in remote areas.EMS personnel also work in more traditional health care settings in hospitals, urgent carecenters, doctor’s offices and long-term care facilities. Finally, EMS personnel areinvolved in numerous community and public health initiatives, such as working withhealth care systems to provide non-emergent care and follow up to certain patientpopulations as well as providing immunizations, illness and injury prevention programs,and other health initiatives.EMS is a local function and organized in a variety of ways. These include agencies thatare volunteer, career, or a combination; agencies that are operated by government, healthcare system, or private entities; and agencies that are stand-alone EMS, fire-based or lawenforcement-based. Common models are municipal government (fire-based or thirdservice) or a contracted service with a private (profit or nonprofit) entity. Multiple levelsof licensure exist for EMS personnel nationally, each offering different levels of scopesof practice. EMS personnel provide medical care to those with emergent, urgent, and insome cases chronic medical needs. EMS is a component of the overall health care system,and delivers care as part of a system intended to reduce the morbidity and mortalityassociated with illness and injury. EMS care is enhanced through the linking with othercommunity health resources and integration within the health care system.Iowa Department of Public Health – September 20193
The Evolution of the EMS Agenda for the FutureThe original National EMS Scope of Practice Model was developed in 2007 as one partof the NHTSA’s commitment to its EMS Agenda for the Future1 (EMS Agenda).Released in 1996, the EMS Agenda established a long-term vision for the future of EMSin the United States:“EMS of the future will be community-based health management that is fullyintegrated with the overall health care system. It will have the ability to identifyand modify illness and injury risks, provide acute illness and injury care andfollow up, and contribute to treatment of chronic conditions and communityhealth monitoring. This new entity will be developed from redistribution ofexisting health care resources and it will be integrated with other health careprofessionals and public health and safety agencies. It will improve communityhealth and result in a more appropriate use of acute health care resources. EMSwill remain the public’s emergency medical safety net.”As a follow up to the EMS Agenda, the EMS Education Agenda for the Future: A SystemsApproach2 (Education Agenda), released in 2000, called for the development of a systemto support the education, certification and licensure of entry-level EMS personnel thatfacilitates national consistency:“The Education Agenda established a vision for the future of EMS education, andcalled for an improved structured system to educate the next generation of EMSpersonnel. The Education Agenda built on broad concepts from the 1996 Agendato create a vision for an educational system that will result in improved efficiencyfor the national EMS education process. This was to enhance consistency ineducation quality ultimately leading to greater entry-level graduate competence.”The Education Agenda proposed an EMS education system with five dynamic andintegrated components: National EMS Core Content, National EMS Scope of PracticeModel, National EMS Education Standards, National EMS Certification, and NationalEMS Education Program Accreditation.12EMS Agenda for the Future, NHTSA, August 1996EMS Education Agenda for the Future: A Systems Approach, NHTSA, 2000Iowa Department of Public Health – September 20194
The National EMS Core Content3, released in 2004, defined the domain of out of hospitalcare. The 2007 National EMS Scope of Practice Model divided the core content intolevels of practice, defining the minimum corresponding skills and knowledge for eachlevel. Our nation has made great progress in implementing these documents over thepreceding decade.The development and publication of the 2007 National EMS Scope of Practice Modelrepresented a transition from the historical connection between scope of practice and theEMS National Standard Curricula. The National EMS Scope of Practice Model is aconsensus document, guided by data and expert opinion that reflects the skillsrepresenting the minimum competencies of the levels of EMS personnel.The National EMS Education Standards4, led by the National Association of EMSEducators (NAEMSE), replaced the NHTSA National Standard Curricula at all licensurelevels. The National EMS Education Standards define the competencies, clinicalbehaviors, and judgments that must be met by entry-level EMS personnel to meetpractice guidelines defined in the National EMS Scope of Practice Model. Content andconcepts defined in the National EMS Core Content are also integrated within theNational EMS Education Standards.National EMS Educational StandardsThe National EMS Education Standards comprise four components:1. Competency - This statement represents the minimum competency required for entrylevel personnel at each licensure level.2. Knowledge Required to Achieve Competency - This represents an elaboration of theknowledge within each competency (when appropriate) that entry-level personnel wouldneed to master in order to achieve competency.3. Clinical Behaviors/Judgments - This section describes the clinical behaviors andjudgments essential for entry-level EMS personnel at each licensure level.4. Educational Infrastructure - This section describes the support standards necessary forconducting EMS training programs at each licensure level.Each statement in the National EMS Education Standards presumes that the expectedknowledge and behaviors are within the scope of practice for that EMS licensure level, asdefined by the National EMS Scope of Practice Model. Each competency applies topatients of all ages, unless a specific age group is identified.The National EMS Education Standards also assume there is a progression in practicefrom the Emergency Medical Responder level to the Paramedic level. That is, licensedpersonnel at each level are responsible for all knowledge, judgments, and behaviors attheir level and at all levels preceding their level. For example, a Paramedic is responsiblefor knowing and doing everything identified in that specific area, as well as knowing anddoing all tasks in the three preceding levels. The descriptors used to illustrate the34National EMS Core Content, NHTSA, July 2005National EMS Education Standards, NHTSA, January 2009Iowa Department of Public Health – September 20195
increasing complexity of knowledge and behaviors through the progression of licensurelevels originate, in part, from the National EMS Scope of Practice Model. These termsreflect the differences in the breadth, depth, and actions required at each licensure level.The depth of knowledge is the amount of detail a student needs to know about aparticular topic. The breadth of knowledge refers to the number of topics or issues astudent needs to learn in a particular competency. For example, the Emergency MedicalResponder needs to have a thorough understanding (depth) about how to safely andeffectively use the bag valve mask; however, the EMR is taught a limited number ofconcepts (breadth) surrounding management of a patient’s airway.To describe the intended depth of knowledge of a particular concept within a providerlevel, the National EMS Education Standards uses the terms simple, fundamental, andcomplex. This terminology better illustrates the progression of the depth of knowledgefrom one particular level to another. For example, the EMR’s depth of knowledge forbleeding control is simple while the EMT’s depth of knowledge for bleeding control isfundamental.To describe the intended breadth of knowledge of a concept within a provider level, theNational EMS Education Standards uses the terms simple, foundational, andcomprehensive. This terminology also better illustrates the progression of the breadth ofknowledge from one particular level to another. For example, the EMT’s breadth ofknowledge for cardiovascular disorders is foundational while the Paramedic’s breadth ofknowledge for cardiovascular disorders is comprehensive.Iowa Department of Public Health – September 20196
Interdependent Relationship Between Education, Certification, Licensure, andCredentialingThe National EMS Scope of Practice Model establishes a framework that ultimatelydetermines the range of skills and roles that an individual possessing a State EMS licenseor certification is authorized to do on a given day, in a given EMS system. It is based onthe notion that education, certification, licensure, and credentialing represent fourseparate but related activities.Education includes all of the cognitive, psychomotor, andaffective learning that individuals have undergone throughout theirlives. This includes entry-level education, continuing professionaleducation, formal and informal learning. Clearly, manyindividuals have extensive education that in some cases exceedstheir EMS skills or roles.Certification is an external verification of the competencies thatan individual has achieved and typically involves an examinationprocess. While certification exams can be set to any level ofproficiency, in health care they are typically designed to verifythat an individual has achieved minimum competency to assuresafe and effective patient care.Licensure5 represents legal authority granted to an individual by the State to performcertain restricted activities. Scope of practice represents the legallimits of the licensed individual’s performance. States have a varietyof mechanisms to define the margins of what an individual is legallypermitted to perform. This authority granted by the state is definedas licensure, but some states still use “certification” to describe thesame granting of authority to practice for EMS personnel. In thesecases, this state authority should not be confused with certificationto verify competency as described in the preceding paragraph.Throughout this document, licensure will refer to the authority ofthe State to grant an individual the ability to practice at a certain level of EMSpractitioner, whether or not a State refers to this process as certification.Credentialing is a clinical determination that is the responsibility ofa physician medical director. It is the employer or affiliatingorganization’s responsibility to act on the clinical credentialingstatus of EMS personnel in making employment and deploymentdecisions.Iowa uses “Certification” as the authority granted by the State to legally perform EMS, Iowa Codechapter 272C and Iowa Code chapter 147A5Iowa Department of Public Health – September 20197
Medical SupervisionEMS medical directors are expected to provide appropriate supervision in the interest ofpublic safety and are obligated to revoke or restrict local credentialing as appropriate. Anauthorized Iowa EMS medical director may choose to limit the skills or proceduresperformed by an Iowa Emergency Medical Care Provider but cannot authorize a providerto perform skills or procedures outside or beyond the provider’s established scope ofpractice.Pilot ProjectIn accordance with IAC 61-131, an EMS medical director and service program mayapply to the department for pilot project(s) on a limited basis if they wish to considerskills or procedures currently beyond an Iowa EMS provider’s scope of practice.Application form for EMS pilot project(s) can be obtained by contacting the Bureau ofEmergency and Trauma Services.Scope of Practice versus Standard of CareScope of practice does not define a standard of care, nor does it define what should bedone in a given situation (i.e., it is not a practice guideline or protocol). Scope of practicedoes define what skills or procedures are legally permitted for some or all of the certifiedindividuals at that identified level, not what must be done to provide patient care.Iowa Department of Public Health – September 20198
Description of Iowa EMS Provider LevelsLegacy LevelsFirst Responder (1979) (FR)This EMS provider level identifies individuals who successfully completed a program oftraining that used, as a minimum, the 1979 FR national standard curriculum (NSC) andsuccessfully completed the department’s testing requirements at the time of initialcertification. Individuals certified at this level have an Iowa EMS certification numberidentified with the letter “F”. Initial certification at this level is no longer available.Providers who maintain this legacy level certification must operate within the scope ofpractice of an EMR.First Responder – Defibrillation (FR-D)This EMS provider level identifies individuals who successfully completed a program oftraining that used, as a minimum, the 1979 FR national standard curriculum and the AEDsupplemental curriculum, and successfully completed the department’s testingrequirements at the time of initial certification. Individuals certified at this level have anIowa EMS certification number identified with the letter “G.” Initial certification at thislevel is no longer available. Providers who maintain this legacy level certification mustoperate within the scope of practice of an EMR.Emergency Medical Technician – Defibrillation (EMT-D)This EMS provider level identifies individuals who successfully completed a program oftraining that used, as a minimum, the 1984 EMT-A national standard curriculum (NSC)and the AED supplemental curriculum, and successfully completed the department’stesting requirements at the time of initial certification. Individuals certified at this levelhave an Iowa EMS certification number identified with the letter “D”. Initial certificationat this level is no longer available. Providers who maintain this legacy level certificationmust operate within the scope of practice of an EMT.Emergency Medical Responders (EMR)The EMR is an out of hospital practitioner whose primary focus is to initiate immediatelifesaving care to patients while ensuring patient access to the emergency medicalservices system. EMRs possess the basicknowledge and skills necessary to providelifesaving interventions while awaitingadditional EMS response and rely on an EMSor public safety agency or larger sceneresponse that includes other higher-levelmedical personnel. When practicing in lesspopulated areas, EMRs may have a low callvolume coupled with being the only carepersonnel for prolonged periods awaiting arrival of higher levels of care. EMRs mayassist, but cannot be the highest-level person caring for a patient during ambulancetransport. EMRs are often the first to arrive on scene. They must quickly assess patientneeds, initiate treatment, and request additional resources. EMRs function as part of aIowa Department of Public Health – September 20199
comprehensive EMS response, community, health, or public safety system with clinicalprotocols and medical oversight. EMRs perform basic interventions with minimalequipment to manage life threats, medical, and psychological needs with minimalresources until other personnel can arrive. EMRs are an important link within the 9-1-1and emergency medical services systems. The focused and limited scope of this levelmakes it suitable for employee cross training in settings where emergency medical care isnot the EMRs primary job function. Examples include firefighters, law enforcement,lifeguards, backcountry guides, community responders, industrial workers and similarjobs. EMRs advocate health and safety practices that may help reduce harm to the public.This Iowa EMS provider level identifies individuals who successfully completed aprogram of training that used, as a minimum, the 2005 National Education Standards forthe EMR and successfully completed the department’s testing requirements at the time ofinitial certification or completed the FR to EMR transition requirement. Individualscertified at this level have an Iowa EMS certification number identified with the letters“EMR.”Emergency Medical Technician (EMT)The primary focus of the EMT is to provide basic emergency medical care andtransportation for critical and emergent patientswho access the emergency medical system. Thisindividual possesses the basic knowledge and skillsnecessary to provide patient care andtransportation. EMTs function as part of acomprehensive EMS response, under medicaloversight. EMTs perform interventions with thebasic equipment typically found on an ambulance.The EMT is a link from the scene to the emergency health care system. EMTs function aspart of a comprehensive EMS response, community, health, or public safety system withdefined clinical protocols and medical oversight. EMTs perform interventions with thebasic equipment typically found on an ambulance to manage life threats, medical, andpsychological needs. EMTs are an important link within the continuum of the emergencycare system from an out of hospital response through the delivery of patients to definitivecare. The majority of personnel in the EMS system are licensed at the EMT level. TheEMT plays many important roles and possesses the knowledge and skill set to initiallymanage any emergency until a higher level of care can be accessed. In areas whereAEMT or Paramedic response is not available, the EMT may be the highest level of EMSpersonnel a patient encounters before reaching a hospital. EMTs advocate health andsafety practices that may help reduce harm to the public.This EMS provider level identifies individuals who successfully completed a program oftraining that used, as a minimum, the 2005 National Education Standards for the EMTand successfully completed the department’s testing requirements at the time of initialcertification, transition from EMT-I 1985 , or completed the EMT-B to EMT transitionrequirements. Individuals certified at this level have an Iowa EMS certification numberidentified with the letters “EMT”.Iowa Department of Public Health – September 201910
Advanced Emergency Medical Technician (AEMT)The AEMT is a health professional whose primary focus is to respond to, assess andtriage non-urgent, urgent, and emergent requests formedical care. AEMTs apply basic and focused advancedknowledge and skills necessary to provide patient careand/or medical transportation, and facilitate access to ahigher level of care when the needs of the patient exceedthe capability level of the AEMT. The additionalpreparation beyond EMT prepares an AEMT to improvepatient care in common emergency conditions for whichreasonably safe, targeted, and evidence-based interventions exist. Interventions within theAEMT scope of practice may carry more risk if not performed properly thaninterventions authorized for the EMR/EMT levels. With proper supervision, AEMTs mayserve as a patient care team member in a hospital or health care setting to the full extentof their education, certification, licensure, and credentialing. In a community setting anAEMT might visit patients at home and make observations that are reported to a higherlevel authority to help manage a patient’s care. AEMTs function as part of acomprehensive EMS response, community, health, or public safety system with medicaloversight. AEMTs perform interventions with the basic and advanced equipmenttypically found on an ambulance. AEMTs perform focused advanced skills andpharmacological interventions that are engineered to mitigate specific life-threateningconditions, medical, and psychological conditions with a targeted set of skills beyond thelevel of an EMT.AEMTs function as an important link from the scene into the health caresystem. The learning objectives and additional clinical preparation for AEMTs exceed thelevel of an EMT. In areas where Paramedic response is not available, the AEMT may bethe highest level of EMS personnel a patient encounters before reaching a hospital.AEMTs advocate health and safety practices that may help reduce harm to the public.This EMS provider level identifies individuals who successfully completed a program oftraining that used, as a minimum, the 2005 National Education Standards for the AEMTand successfully completed the department’s testing requirements at the time of initialcertification. Individuals certified at this level have an Iowa EMS certification numberidentified with the letters “AEMT.”Paramedic (PM)The paramedic is a health professional whose primary focus is to respond to, assess, andtriage emergent, urgent, and non-urgent requests for medical care, apply basic andadvanced knowledge and skills necessary todetermine patient physiologic, psychological, andpsychosocial needs, administer medications,interpret and use diagnostic findings to implementtreatment, provide complex patient care, andfacilitate referrals and/or access to a higher level ofcare when the needs of the patient exceeds thecapability level of the paramedic. Paramedics oftenIowa Department of Public Health – September 201911
serve as a patient care team member in a hospital or other health care setting to the fullextent of their education, certification, licensure, and credentialing. Paramedics may workin community settings where they take on additional responsibilities monitoring andevaluating the needs of at-risk patients, as well as intervening to mitigate conditions thatcould lead to poor outcomes. Paramedic
Iowa Department of Public Health Bureau of Emergency and Trauma Services Iowa Emergency Medical Care Provider Scope of Practice September 2019 "Protecting and Improving the Health of Iowans" LUCAS STATE OFFICE BUILDING 321 East 12th Street DES MOINES, IOWA 50319-0075 (515) 281-0620 (800) 728-3367 https://idph.iowa.gov/BETS/EMS
Iowa Chapter, American Academy of Pediatrics Iowa Dental Association Iowa Department of Public Health Iowa Health Care Association Iowa Hospital Association Iowa Medical Society Iowa Nurses Association Iowa Pharmacy Association Iowa Veterinary Medical Association Iowa‘s Statewide Epidemiology Education and Consultation Program State Hygienic .
c. Commitment to Iowa Trauma System and EMS activities, for example Iowa Trauma Coordinators, American College of Surgeons (ACS), Iowa Chapter Committee on Trauma, Iowa Chapter of American College of Emergency Physicians (ACEP), Iowa Emergency Medical Service Association (IEMSA),Trauma System Advisory Council (TSAC), System Evaluation Quality
Agricultural Biotechnology Stewardship Technical Committee (ABSTC), Iowa Corn Growers Association (ICGA), the Iowa Chapter of the American Society of Farm Managers and Rural Appraisers (ASFMRA), Iowa Farm Bureau Federation (IFBF), Iowa Independent Crop Consultants Association, Iowa Institute for Cooperatives (IIC), Iowa Soybean Association (ISA),
This Provider Manual was created to assist you and your office staff with providing services to our members, your patients. As a provider, you agree to use this Provider Manual as a reference pertaining to the provision of medical services for members of AmeriHealth Caritas Iowa. This Provider M
AERLP Description Created by Iowa legislature in May 1996 1997 Iowa Code, Section 476.46 Amendment to the 1990 Iowa Energy Efficiency Act Funded via Iowa’s investor-owned utilities Competitive application process Eligibility All individuals and groups except Iowa’s gas and electric utilities that are not required to be rate regulated
Iowa Department of Public Health Text4baby Iowa State Contact 515-778-2212 Kelly.Schulte@idph.iowa.gov Let’s work together to promote this terrific resource to pregnant women and new mothers in Iowa! Approximately 1.8% of estimated pregnant women and new moms in Iowa have enrolled in Text4baby since its launch.
Lenox Neighborhood Center Lions Club—Iowa Falls, Iowa Loaves and Fishes—Story City, Iowa Lords Cupboard—Fort Dodge, Iowa Lords Cupboard—Jewell, Iowa . St. Joseph’s Community Schools, New
found in API RP 500, API RP 505 and NFPA 497 are examples of the direct example approach method. This approach utilizes engineering judgment to determine the extent of the hazardous area classification. The diagrams and the boundary distances utilized are selected based on the type of installation, volume and properties of the hazardous gases/vapors. The second ANSI method, less commonly used .
