A Note On The Scope Of Practice Change For The Indiana Advanced EMT

January 20, 2017

Those of us on the Indiana EMS Commission made a decision today that affects the scope of practice for Indiana Advanced EMTs.

Anyone who was involved in Indiana EMS just a few years ago will remember the transition from having two mid-level certifications (Emergency Medical Technician - Basic Advanced and Emergency Medical Technician - Intermediate) to a single mid-level prehospital caregiver, the Advanced EMT. This occurred chiefly due to the transition from the old DOT curricula to the new national EMS educational standards (NES), but there were also many discussions (and arguments) regarding appropriate length of programs, needed clinical hours and contacts and if there was any connection of these certification levels to improved outcomes.

It was a long year of debating and trying to do the right thing for the people in the communities here in Indiana. The end result, the new Advanced EMT was still given some additional abilities above what the NES curricula allowed at the national level. One of those additional skills was a continuation of several components of ECG interpretation (not all) and manual defibrillation (rather than the use of an automated external defibrillator).

The Advanced EMT exam for Indiana was destined for National Registry due to the unparalleled work that goes into their exams, however that exam did not cover Indiana's desired ECG component. A separate test was developed and was administered and available at several sites throughout the state. Pass rates on the Registry exam were one thing, but the pass rate on the separate ECG test has been less than favorable.

Why?

It could be many things... variances in the interpretation of the curricula... variances in instructors and what was delivered... some have even been taught things that were not in the ECG curricula in the first place.

In all, there are about 500 of this certification level certified in Indiana today. In the last year there have only been a little over 70 added to make up that 500. Many are reporting that they cannot pass the additional test.

As a Commission, we were faced with the fact that we had a curricula that had been applied inconsistently in some cases, a test that was extremely hard to pass, and the ever present elephant in the room... the fact that since cardiac medications were removed from this level by the NES that cardiac monitoring with ECG interpretation and accompanying manual defibrillation really have no patient outcome impact.

An automated external defibrillator will perform the only proven outcome driven intervention as easily as a regular monitor with manual defibrillation capability.

So... in the course of discussing options, the following was decided:

• ECG Interpretation and Manual Defibrillation will no longer be taught in the Indiana Advanced EMT course.
• Those individuals who have already successfully passed the Indiana Cardiology Test (ECG), in addition to the Advanced EMT exam (NR), will be allowed to continue to monitor ECG rhythms within the curricula and provide manual defibrillation until 12/31/2017. After that date ECG Monitoring and Manual Defibrillation will no longer be allowed at that level.
• The Indiana Cardiology Test (ECG) is abolished.
• This does not affect existing rules regarding the acquisition AND transmission of 12-lead ECGs.

These changes only affect the Advanced EMT level practitioners. This change moves us closer to the NES which allows for a national test to be used to determine certification competency.

Most of all, this acknowledges the practice of evidence-based medicine.

This decision may not be a popular one and was reached only after lively discussion mainly centered around affecting patient outcomes. The Commission's purpose is to create systems of care for Indiana. There is an ethical obligation to assure that this is done with quality and the end result in mind... patient lives.

There will be more information released on this topic soon.

EMS Commission meetings and decisions often center around change. We are currently looking at CEU requirements due to changes at the national level that could offer some applicable education offerings and consistency with Registry.

We also noted today that there is a large number of quality educational offerings occurring in the state during 2017.

Change is often hard. Understand that the changes the Commission makes are those that we feel will support outcomes.

As for myself as the Chairman, I wanted to get a public explanation out as soon as possible as was done with the National Registry decision last year.

Communication of the thought process behind decisions is crucial to understanding. If you are correctly informed, you have the facts. I would encourage those who are affected by this decision to understand that this does not lessen your abilities to provide positive outcomes. It just further defines a skill set so that what you do perform is known to have impact when combined with the overall Advanced EMT skillset.

The Indiana EMS Commission and the citizens of this state appreciate the efforts of every caregiver... EMR... EMT... Advanced EMT... and Paramedic.

One of my favorite quotes was said a few years back at a national EMS conference: "EMS must stop defining itself by the skills it performs and start defining itself by the outcomes it provides."

This is the future we owe our patients. Skills do not define us. Lives saved do.